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Based on interview, record review, and review of a facility policy, it was determined the facility failed to ensure five (5) of twenty (20) sampled patients (Patient #1, Patient #2, Patient #16, Patient #18, and Patient #19) who presented to the facility's (Facility #1) Emergency Department (ED) with an Emergency Medical Condition were transferred to another hospital for stabilizing medical/psychiatric treatment that could not be provided by the facility.

Findings include:
Refer to C2407.

Based on interview, record review, and review of a facility policy, it was determined the facility failed to ensure five (5) of twenty (20) sampled patients (Patient #1, Patient #2, Patient #16, Patient #18, and Patient #19) who presented to the facility's (Facility #1) Emergency Department (ED) with an Emergency Medical Condition were transferred to another hospital for stabilizing medical/psychiatric treatment that could not be provided by the facility. Patients #1, #2, #16, #18, and #19 presented to the facility with behavioral health complaints. The facility obtained a Mental Inquest Warrant (MIW) (a court order for an individual to be involuntarily admitted for psychiatric treatment) for Patients #1, #2, #16, #18, and #19. Facility physicians completed a Medical Screening Exam for each patient and documented that the patients were "medically" stable and were being transferred to another facility for an evaluation/treatment of their behavioral health condition. However, despite having an MIW for the patients and despite the physician's documentation that the patients were being transferred, a review of the patients' discharge documentation revealed the patients were "transferred" to a Community Mental Health Center (CMHC) (an outpatient facility that provides mental health services) for evaluation/treatment. The facility failed to ensure an appropriate transfer was arranged for the patients to ensure that the patients received stabilizing medical treatment for their behavioral health emergency medical conditions.

The findings include:

Review of the facility's policy entitled "Emergency Medical Treatment and Active Labor Act, (EMTALA)," undated, revealed all patients were entitled to receive an appropriate medical screening examination within the capability of the facility's Emergency Department. If the patient was determined to suffer from an emergency medical condition, the patient must be offered medical treatment as necessary to stabilize that condition within the capabilities of the facility. A patient may not be transferred or discharged in an unstable condition unless the patient or authorized person makes a written request for transfer or discharge or the attending physician or Emergency Department physician certifies that the medical benefits to be gained by transfer to another facility outweigh the risks of transfer. Patients who are transferred are provided medical supervision as warranted by their condition. Continued review of the policy revealed an emergency medical condition was defined as a condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the patient in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. If the patient was found to be suffering from an emergency medical condition, the patient was entitled to either such further medical examination and treatment as may be required to stabilize the condition or for an appropriate transfer to another facility. Stabilizing treatment was defined as such medical treatment as may be necessary to assure within reasonable medical probability that no material deterioration of the condition was likely to result or occur during or from the transfer.

Review of the facility policy entitled "Safety Precautions for the Suicidal Patient," dated September 2018, revealed all patients presenting for care in the ED would be screened and/or assessed for suicidal ideations and safety precautions would be taken as needed to prevent harm. Continued review of the policy revealed a minimal screening would be performed with the first patient contact and the tool is entitled "Ongoing Suicide Assessment." Any single positive response in the Moderate or High risk categories or a chief complaint of suicidal ideations will prompt a Registered Nurse (RN) or physician to immediately perform the "Columbia-Suicide Severity Rating Scale (C-SSR). Affirmative responses to questions #3, #4, and #5 on the C-SSR would result in the implementation of suicide precautions.

1. a. Review of the medical record for Patient #1 revealed the patient presented to the ED via law enforcement officer on 02/10/19 at 11:53 AM with complaints of "medical clearance, patient stated to officer [he/she] was going to kill [himself/herself]." Further review of the record revealed nursing staff triaged Patient #1 at 11:53 AM and the patient admitted to using "meth last night." Nursing staff documented that Patient #1 was screened for vaccines, advanced directives, and social history. Further review revealed nursing staff documented on 02/10/19 at 2:23 PM the Discharge Disposition was "Home Continuity of Care document given to patient, patient ambulated off the unit accompanied by Law Enforcement, transported by police. Patient is stable." Continued review of the medical record revealed the C-SSR was conducted and Patient #1 was rated as a "low" risk. There was no other nursing documentation found in the medical record.

A review of the physician's assessment dated 02/10/19 at 12:18 PM, revealed Patient #1's chief complaint was "suicidal ideation" and the law enforcement officer stated the patient was "on the phone with dispatch since around one or two am" stating that "[he/she] wanted to harm [himself/herself]." The patient reportedly had no history of suicidal ideation and the duration is noted to be "today" with the timing noted as "constant." The physician documented the Diagnosis for Patient #1 was "Suicidal Ideation" and the Plan was "patient states [he/she] does not know why [he/she] was on the phone all night but says [he/she] is afraid of [his/her] parents, ...of the officer that brought [him/her] to the ER." The physician also documented another law enforcement officer stated "the patient would be taken to a [Community Mental Health Center (CMHC)] to be evaluated and decide where the patient needs to be sent for further evaluation and treatment." The physician documented Patient #1 was "medically cleared to be taken by the county police officer to the [CMHC]."

Continued review of the medical record revealed the physician had ordered Patient #1 to be discharged on 02/10/19 at 1:58 PM and the Discharge Disposition was "court/law enforcement." The follow-up appointment and care was for the patient to follow-up with psychiatric experts as needed. Patient #1's condition was "good, the patient will be taken by the county police officer to the [CMHC] for evaluation" and the primary diagnosis was "suicidal ideation."

There was no documented evidence that the facility provided or arranged for a transfer of the patient to a medical facility for stabilizing treatment of the patient's condition.

1. b. Review of medical records revealed Patient #1 returned to the ED on 02/19/19 at 7:12 PM via private vehicle with Family Member #1. Nursing staff triaged Patient #1 at 7:12 PM and documented the "chief complaint" as "suicidal ideation." Nursing staff documented the Secondary complaint as "patient ambulatory to ED from [privately owned vehicle] with [Family Member #1] who reports she received a phone call from patient asking for help." RN #1 documented "Patient reports [he/she] wants to kill [himself/herself] before they get a chance to kill [him/her] first." RN #1 completed the "Ongoing Suicide Assessment and documented Patient #1 was a "moderate risk" based on the Suicide Risk Assessment and/or clinical judgement. Continued review of the nursing notes revealed RN #1 documented at 7:57 PM "Trial Commissioner here to sign 72 hour hold paperwork." Continued review of the nursing notes revealed RN #1 documented at 8:10 PM "Patient #1 was discharged ambulatory with law enforcement officers in stable condition. No noted changes while in ED. Patient being transported to CMHC for evaluation. Family Member #1 to meet law enforcement officers at CMHC."

A review of Physician #1's assessment dated 02/19/19 at 8:00 PM revealed the physician documented the patient's "chief complaint" as "suicidal thoughts." The physician documented that the patient was uncooperative and information was provided by a family member. Physician #1 documented "patient refuses to sign consent for evaluation or treatment. Uncooperative when approached for history. History of multiple recent evaluations for similar complaints." Physician #1 diagnosed the patient with "Acute Suicidal Ideation, History of Substance Abuse."

Continued review of Patient #1's medical record revealed staff also documented that the patient's "disposition" was "other type facility" and "transported to [CMHC] per law enforcement." RN #1 documented Patient #1's condition was "stable." RN #1 documented "paper discharge instructions not applicable."

There was no documented evidence in the medical record of the "Verified Petition for Involuntary Hospitalization" for Patient #1.

In addition, there was no documented evidence that the patient's transfer was arranged to ensure the patient received stabilizing medical treatment to treat the patient's suicidal ideation/attempt.

Interview with RN #1 on 05/21/19 at 11:33 AM revealed she provided care to Patient #1 on the second visit to the ED on 02/19/19. RN #1 stated the patient was very paranoid and she remembered the patient's behavior escalating while in the ED. RN #1 stated that Patient #1's disposition was to the CMHC and once the patient discharged or transferred there, the facility had no idea what happened to the patient. RN #1 stated it was not really a transfer, because it was an outpatient facility and they did not keep the patient.

Interview with Physician #1 on 05/21/19 at 1:35 PM revealed he provided care to Patient #1 on 02/19/19. Physician #1 stated when the patient refused to sign the consent and would not answer questions the only thing left for him to do was contact the Trial Commissioner to obtain a mental health warrant (MIW) to hold the patient. Physician #1 stated it was very "concerning" to him that patients left the ED with a MIW and then he never knew what happened to them. Physician #1 stated he was concerned enough about "these types of patients" to have a MIW placed on them and then they left the facility for a lower level of care to have someone else who is not a medical physician decide whether or not the patient needs further treatment.

Interview with Family Member #1 on 05/22/19 at 10:23 AM revealed that she took Patient #1 to the ED on 02/19/19 requesting their assistance with her son/daughter. Family Member #1 stated when law enforcement officers transported Patient #1 to the CMHC, the CMHC stated there was nothing they could do for Patient #1 because Facility #1 had not "medically cleared" Patient #1. Family Member #1 stated she took Patient #1 home that night and the patient stayed the night in the basement with a hammer because he/she was so afraid. Continued interview revealed Family Member #1 transported Patient #1 on 02/20/19 to another acute care facility ED where they provided stabilizing medical treatment and the patient was diagnosed with Psychotic Disorder and was then transferred to a Psychiatric Hospital for continued treatment.

Review of the medical record for Patient #1 from Facility #2 revealed the facility admitted the patient on 02/21/19 at 4:47 PM with a chief complaint of a "psych mental health breakdown." Review of the ED physician documentation revealed Patient #1 became combative in the ED and had to be chemically restrained with Haldol (a medication used to treat psychosis) and Ativan (a medication used to treat anxiety). Patient #1 remained in Facility #2's ED the entire night and was "transferred to [psychiatric hospital] for evaluation" on 02/22/19. Facility #2 diagnosed Patient #1 with "Unspecified Psychosis not due to Substance or known Psychological Disorder."

2. Review of the medical record for Patient #2 revealed the patient arrived at the facility on 02/14/19 at 4:12 PM, with a chief complaint of "suicidal ideation." Nursing staff documented Patient #2 was brought to the ED with family with a request to be taken to a psychiatric hospital. Nursing staff conducted the "Ongoing Suicide Assessment" with risk factors documented as verbalizes suicidal thoughts or feelings, and suicidal ideations repetitive or persistent with high level of frustrations. Patient #2 was a "Moderate risk for suicide based on the suicide risk assessment and/or clinical judgement." There was no documented evidence in the medical record nursing staff completed the C-SSR and followed the protocol per facility policy. Nursing staff documented they contacted "dispatch to notify of patients threats" at 4:20 PM. Nursing staff documented at 4:29 PM Patient #2 placed in trauma room, in gown with clothes removed and backpack to nurses station, and the physician in to evaluate the patient. Nursing staff documented at 4:31 PM Patient #2 was resting on stretcher and family at bedside. At 5:09 PM, it was documented that the patient was impatient and wanting to know what was taking so long. Continued review of nursing documentation revealed at 5:27 PM the "[Trial Commissioner] present and MIW signed", at 5:29 PM Patient #2 was outside the facility with law enforcement officer present. And at 5:34 PM, the patient was back to the room resting on a stretcher in a gown waiting on transfer to CMHC. Nursing staff documented at 6:23 PM that law enforcement was here for transport, and the patient dressed and at 6:26 PM Patient #2 discharged with law enforcement for transport to CMHC. Patient #2's condition was documented as "stable at time of departure."

Continued review of nursing documentation revealed Patient #2's discharge disposition was "court/law enforcement, continuity of care document given to patient." ED discharge at 02/14/19 at 6:26 PM. Patient #2's condition was documented as "stable" and it was noted "to [CMHC] via [law enforcement]."

A review of Physician #2's assessment dated 02/14/19 at 4:57 PM revealed Patient #2's chief complaint was "suicidal ideation." The physician documented Patient #2 presented with suicidal ideation with a plan for three days. Patient #2 was going to hang himself/herself with a history of schizophrenia, prior suicide attempts, and prior psychiatric hospitalizations. The physician diagnosed Patient #2 with "suicidal ideation with a plan to fill out a mental health petition."

There was no documented evidence in the medical record of the "Verified Petition for Involuntary Hospitalization" for Patient #2.

There was no documented evidence that the facility provided or arranged for a transfer of the patient to a medical facility for stabilizing treatment of the patient's condition.


3. Review of the medical record for Patient #16 revealed the patient arrived at the facility on 02/11/19 at 10:22 PM and was triaged at 10:22 PM. According to the triage assessment, the patient arrived via Emergency Medical Services (EMS) and was accompanied by Law Enforcement. The documentation stated the patient was having a "psychotic episode." Further review revealed the facility completed an "Ongoing Suicide Assessment" at 8:22 PM that revealed Patient #16 had no risk for suicide. Continued review revealed at 10:44 PM "lab in room to draw blood" and at 10:50 PM the physician in to evaluate Patient #16. Nursing staff documented at 11:30 PM that Patient #16 was resting quietly in the treatment room with no distress. Nursing staff notified the "trial commissioner to come to [facility] for a 72 hour hold" at 11:58 PM and on 02/12/19 at 12:06 AM the trial commissioner here to sign papers for a 72 hour hold.

Further review revealed nursing staff documented on 02/12/19 at 12:36 AM Patient #16's discharge disposition was "other type facility." Nursing staff documented Patient #16 was discharged with law enforcement and was being transported to the CMHC for further evaluation.

A review of Patient #16's physician assessment dated 02/11/19 at 10:30 PM revealed Patient #16 "arrives to the ED per [EMS] and [law enforcement], patient is having a psychotic episode." The physician documented police were called to the patient's residence and Patient #16 was "out of control" and "talking out of [his/her] head." The physician documented Patient #16 had a history of psychosis in the past and has been hospitalized in the past for psychotic episodes. The physician diagnosed Patient #16 with "Uncontrollable Behavior" and the Plan was to "transfer to [CMHC] by local law enforcement."

Further review of the medical record revealed a "Verified Petition for Involuntary Hospitalization" for Patient #16. The physician had documented she was a Qualified Mental Health Professional and that Patient #16 had a mental illness. The physician also documented he believed Patient #16 was a person with a mental illness because the patient had uncontrollable behavior, delusions, and hallucinations.

There was no documented evidence that the facility provided or arranged for a transfer of the patient to a medical facility for stabilizing treatment of the patient's condition.

4. Review of the medical record for Patient #18 revealed the patient presented to the ED on 04/05/19 at 8:28 PM with a chief complaint of "suicidal ideation." Nursing staff documented Patient #18 presented with a family member and stated the patient had been depressed and feeling hopeless and has attempted suicide in the past. Nursing staff completed the "Ongoing Suicide Assessment" and assessed Patient #18 to be "moderate risk" for suicide based on the suicide risk assessment and/or clinical judgement. Nursing staff also completed the "Adult SAD person scale" (a clinical assessment tool for medical professionals to determine suicide risk) and Patient #18 was assessed to have a risk assessment score of a "5" which indicated, "consider for hospitalization or at least very close follow-up." Nursing staff completed the C-SSR and at 8:28 PM placed Patient #18 on suicidal precautions and the patient was placed on 1:1 staff observation. Nursing staff documented at 8:58 PM the physician was in the room for evaluation. Nursing staff documented at 9:00 PM patient wanting to leave and becoming very aggressive. The police were called at 9:03 PM and law enforcement arrived at the facility. Patient #18 was discharged with law enforcement. Nursing staff documented that the trial commissioner was contacted at 9:59 PM for a 72 hour hold, and arrived at the facility at 8:05 PM.

Further review revealed nursing staff documented on 04/05/19 at 10:45 PM that Patient #18's discharge disposition was "other type facility" with "continuity of care document given to patient." Nursing staff documented Patient #18 "ambulated off the unit accompanied by law enforcement transported by police" and patient transported to [CMHC] per [law enforcement] for further [evaluation.]"

A review of Patient #18's physician assessment dated 04/05/19 at 9:03 PM revealed Patient #18's chief complaint was "suicidal ideation." Patient #18 stated "Yes, I want to kill myself." Patient reported being excessively down depressed and hopeless the past two weeks and reported suicidal intent. The duration was noted to be one half hour and today, timing constant, and severity was noted as "severe." The physician did not document a diagnosis for Patient #18, but documented the condition as "fair" and the disposition as "to send the patient to [CMHC] for evaluation with law enforcement officer."

Further review of the medical record revealed a "Verified Petition for Involuntary Hospitalization" for Patient #18. The physician had documented he was a Qualified Mental Health Professional and that Patient #18 had a mental illness. The physician also documented he believed Patient #18 was a person with a mental illness because "the patient stated he/she had "severe recurrent depression (not in treatment) with suicidal intent, with previous history of suicide attempt." The physician documented that the following facts indicated belief that Patient #18 was a danger or threat of danger to self, family or others because "patient informed [his/her] cousin that [he/she] feels hopeless, nothing to live for, wants to kill [himself/herself]."

There was no documented evidence that the facility provided or arranged for a transfer of the patient to a medical facility for stabilizing treatment of the patient's condition.

5. Review of the medical record for Patient #19 revealed the patient presented to the ED on 04/14/19 at 9:35 AM with a chief complaint of "attempted suicide by cutting wrist." Nursing staff documented that Patient #19 ambulated to the room and the patient cut both wrist with a razor blade, but the incisions were not bleeding at this time. Patient #19 was tearful and asking for help. Patient #19 also stated that he/she had attempted suicide by taking pills and cutting multiple times over the past five years. There was no documented evidence nursing staff completed the "Ongoing Suicide Assessment." Nursing Staff completed the C-SSR and Patient #19 answered yes to all questions. Continued review of the nursing documentation revealed the physician was at the bedside suturing Patient #19's left wrist at 11:40 AM, at 11:50 AM four (4) sutures placed in left wrist with antibiotic ointment applied and area bandaged. Nursing staff documented at 12:15 PM that Patient #19 was resting quietly with no complaints voiced. Documentation further revealed that at 12:50 PM the trial commissioner was signing the 72 hour hold papers, and at 1:11 PM dispatch was notified of patients need for transport. Nursing staff provided written discharge orders and prescription given for Patient #19 at 1:12 PM.

Further review revealed nursing staff documented on 04/14/19 at 4:20 PM Patient #19 discharge disposition was "other type facility" with "continuity of care document given to patient." Nursing staff documented Patient #19 "ambulated off the unit accompanied by law enforcement transported by police" and patient "discharged to [CMHC] with police officer."

A review of Patient #19's physician assessment dated 04/14/19 at 10:21 PM revealed Patient #19's chief complaint was "depression, tried to commit suicide." The physician documented Patient #19 has a long history of depression, poorly treated, poor social support, had an agreement with his/her significant other and attempted to commit suicide by cutting both of his/her wrists. Patient #19 requested help. The physician documented Patient #19's condition duration was noted to be one (1) hour, the timing constant and the severity was noted to be moderate. The physician diagnosed Patient #19 with "Suicidal Ideation and attempt with a plan to "transfer to [CMHC] in police custody for evaluation and treatment."

Further review of the medical record revealed a "Verified Petition for Involuntary Hospitalization" for Patient #19. The physician had documented he was a Qualified Mental Health Professional and that Patient #18 had a mental illness. The physician documented that the following facts indicated belief that Patient #19 was a danger or threat of danger to self, family or others because "[he/she] is suicidal and attempted to kill [himself/herself] by cutting [his/her] wrists. [He/She] has a long history of depression not adequately treated. [He/She] has a seven (7) month old baby with no social support."

There was no documented evidence that the facility provided or arranged for a transfer of the patient to a medical facility for stabilizing treatment of the patient's condition.

Interviews with Registered Nurse (RN) #1 on 05/21/19 at 11:33 AM, RN #2 on 05/21/19 at 12:39 PM, and RN #3 on 05/21/19 at 1:05 PM revealed they worked as nurses in the ED. The RNs stated that when a patient presented with a psychiatric medical condition the patient was "transferred" to an outpatient facility, a CMHC, for an evaluation because the facility (Facility #1) did not have staff capable of evaluating/treating patients with suicidal ideation. Continued interviews revealed that normal procedure was to triage the patient, "medically clear" the patient, and then refer them to the outpatient community mental health center for an evaluation. However, the RNs stated they did not arrange for the patients' transfer or complete "transfer" paperwork for the patients because police officers "transferred" them to the outpatient facility.

Interview with the Director of Nursing (DON) on 05/21/19 at 1:55 PM revealed the facility only had the capability to complete a drug screen and a "medical workup" for patients who presented with a behavioral health concern, but did not have the means to provide a behavioral health assessment or treatment. The DON stated that when a patient presented with a behavioral health emergency, the facility's procedure was to contact Law Enforcement who transferred the patient to the local CMHC for an evaluation. According to the DON, police could not transport the patient unless the facility had obtained a MIW. The DON further stated that the CMHC arranged transportation from there if the patient needed to be admitted to a psychiatric hospital/unit. The DON stated the facility did not contact the CMHC and arrange for the patient to be transferred, and stated that technically the patient was being discharged from the facility when they were "transferred" to the CMHC.