HospitalInspections.org

Based on interview and medical record and document review, it was determined that in 1 of 20 medical records reviewed of patients who presented to the hospital emergency department requesting medical services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide stabilizing treatment to Patient #1.

Findings include:
1. See findings cited at 42 CFR 489.24 (d) (1-3)

Based on interview and record review, it was determined that the hospital failed to provide, within the capabilities of the staff and facilities available, stabilizing treatment for an emergency medical condition prior to discharge and /or transfer for 1 of 20 applicable patients (Patient #1). Findings include:

Per record review Patient #1 has a history of suicidal ideation (SI); auditory hallucinations; schizophrenia; schizoaffective disorder; overdoses; alcohol dependence; anxiety; substance use disorder; depression; depression, major, recurrent; insomnia; lesion of brain; major depressive disorder; panic disorder with agoraphobia; psychosis; unspecified psychosis not due to a substance or known physiological condition; ADHD (Attention Deficit Hyperactivity Disorder); and self-inflicted injuries, including several overdoses between 8/2012 - 5/2014. Patient # 1 was seen in the emergency department (ED) on the following dates:

4/2021 ED Insomnia
3/2022 ED Substance Use Disorder
7/2022 ED Opioid Abuse
6/2023 Auditory Hallucinations and SI (admitted to psychiatric unit)
9/24/23 Auditory Hallucinations and SI

Per Patient #1's record, on 6/3/2023 they presented to the ED via EMS, with the chief complaint of auditory hallucinations and the voices increased when they were alone and decreased with the presence of a parent. ED note dated 6/3/23 at 15:29 (3:59 PM) revealed under "History of Present Illness", "Patient reports auditory hallucinations stating roughly 1.5 months ago. [pronoun omitted] has been hearing voices that often tell [pronoun omitted] to hurt [pronoun omitted] self. These hallucinations are constant." ......."[pronoun omitted] denies SI. ......."also has had issues with "staring off into space." [pronoun omitted] reports occasionally drinking a glass of wine. [pronoun omitted] denies substance abuse but has relapsed several times previously." In this document under "Highlights of Physical Examination" reveals, "The patient is generally well appearing, appears stated age. Able to follow commands and regards examiner appropriately, speaking full and fluent sentences. Normal midrange pupils. Unlabored respiratory effort. 2+exposed skin. Appropriate thought content and insight, flat affect."

ED note dated 6/3/2023 at 16:26 (4:26 PM) they stated, "hallucinations are causing [pronoun omitted] to have suicidal thoughts".

Patient #1 saw a crisis clinician for an initial assessment that is dated 6/3/2023 at 21:52 (9:52 PM) that revealed the following:

"Client presents with complaints of auditory hallucinations that have exacerbated symptoms of anxiety and depression. [pronoun omitted] drove to a secluded location, wrote a suicide note, and put a gun to [pronoun omitted] head yesterday with intent to die. [pronoun omitted] daughter and fear of death deterred [pronoun omitted] from completing suicide. [pronoun omitted] worries how long [pronoun omitted] will be able to tolerate the AH (auditory hallucinations) without intervention. The risk of suicide remains high. CC (crisis counselor) recommends IP (in patient) psychiatric hospitalization for medication management, crisis stabilization, and diagnostic clarity." Patient #1 stated a "firearm was in their vehicle and mother can help to place it safely". Patient #1 was admitted to the inpatient psychiatric unit for Depression from 6/5/23 - 6/8/23.

Throughout the ED visit notes Patient #1 is documented as "calm and cooperative".

Per record review, Patient #1 presented to the ED on 9/24/23 with auditory hallucinations, persecutory delusions, and suicidal ideation (SI). S/he was assessed at that time where they endorsed these symptoms. S/he was placed on 1:1 supervision and a referral was made for a crisis counselor assessment, which was completed. Due to risk for suicide and lack of ability to adequately access services at that time, a recommendation was made for inpatient admission for medication management, evaluation, stabilization, and safety. Patient #1 had initially agreed to this plan however, later changed her/his mind and wanted to go home. An ED psychiatrist assessed Patient #1 and determined her/him safe for discharge. Patient #1 was discharged and approximately 10 minutes after discharge was found by a passerby in his/her car deceased from a self-inflicted gun shot wound to the head.

Per record review, Patient #1 presented to the ED on 9/24/23 at 2353 hours (11:53 PM), with complaints of auditory hallucinations she/he had been on antidepressant medication in the past but had not been on anything for the past 5 months. She/he reported that the auditory hallucinations interfered with their ability to function on a daily basis and "If I focus on the voices, they tell me to hurt myself".

Per review of ED provider note dated 9/25/23 at 1:12 (AM) Patient #1 was recently noncompliant with her/his home antipsychotic medication over the past 3 weeks and was endorsing SI. They were maintained on 1:1 observation for safety. The provider documented that Patient #1 has a history of ongoing psychiatric disease, medication noncompliance which has impacted care and subsequent decision making. The provider documented in the HPI (history of present illness) that Patient #1 "has a history of schizophrenia and [pronoun omitted] symptoms have been significantly worsening over the last 3 months and have acutely worsened over the last month." ......."now having auditory hallucinations and persecutory delusions where [pronoun omitted] feels like people in [pronoun omitted] family or people [pronoun omitted] just met are following [pronoun omitted] or trying to hurt [pronoun omitted]. The patient endorses new symptoms of new intrusive thoughts and images. [pronoun omitted] is endorsing active SI and when asked about a plan [pronoun omitted] states that [pronoun omitted] hadn't developed any specific plans but is frequently getting intrusive images of [pronoun omitted] harming [pronoun omitted], such as shooting [pronoun omitted] in the head. The patient states that [pronoun omitted] has not been taking any medications for [pronoun omitted] schizophrenia for the last 3 weeks because for several months [pronoun omitted] was trying different combinations of medications for [pronoun omitted] schizophrenia without any significant improvement in [pronoun omitted] symptoms, so [pronoun omitted] stopped taking them altogether because [pronoun omitted] was not having any benefit from them. The patient currently lives alone." The ED physician stated that the patient's history was obtained from the "patient and the medical records", including Patient #1's "admission notes from June 2023 for psychosis with similar initial presentation. Patient was diagnosed with schizoaffective disorder at this time." A physical exam was done by the ED physician and the patient was noted to have a blood pressure of 153/102 and a pulse of 112 BPM (beats per minute). A systems assessment was done and all systems were within normal limits with the exception of "psych" which was documented as "Flat affect. Active SI. No HI [homicidal ideation]. Does not appear to be actively responding to internal stimuli."

Per review of an ED note dated 9/25/23 at 3:13 (AM), Patient #1 stated [pronoun omitted] is homeless living in a vehicle, have no family support.

Per review of the "Crisis Clinician Initial Assessment Note" dated 9/25/23 at 10:04 (AM) of the "Clinical Interpretation" revealed, " ... ....Diagnosis include social anxiety disorder, PTSD [Post Traumatic Stress Disorder], panic disorder with agoraphobia, and opioid use disorder. He is not living at home. Supported by a PCP (primary care physician) ... ....MAT (Medication Assisted Treatment program) and [business name omitted] Psychiatric Services. [pronoun omitted] was on Shep 6 [psychiatric unit] June 6-8/23 [2023]." "Ct [client] states [pronoun omitted] has been struggling with voices for about 5 months. [[pronoun omitted] told ED staff that if [pronoun omitted] focuses on them, they tell [pronoun omitted] to hurt [pronoun omitted]. [pronoun omitted] denies current plan or intent to hurt [pronoun omitted] or others, but does endorse wanting to die and having access to gun (at parents home in closet) and [pronoun omitted] medications ([pronoun omitted] stopped taking). [pronoun omitted] does not have a current therapist but plans to meet with [proper name omitted] at [business name omitted] Psychiatry on 9/29/23. [pronoun omitted] endorses that the voices are hard to ignore and often interfere with work, but [pronoun omitted] isn't sure. [pronoun omitted] has called out a few times lately." ... ...."[pronoun omitted] is choosing to live out of [pronoun omitted] car as this makes it more manageable." "[pronoun omitted] agreed to safety planning including allowing me to call mom to be sure the gun is secure and bring [pronoun omitted] meds in to us so they are not in [pronoun omitted] car. CC [Crisis Counselor] left message for mom ... ....". "[proper name omitted] has been experiencing an [sic] steady increase in auditory hallucinations causing an increasing interference in [pronoun omitted] daily life. While [pronoun omitted] does have a follow up with [pronoun omitted] outpatient psychiatrist, due to risk for suicide and lack of ability to adequately access services at this time, [proper name omitted] would best be served on psychiatric unit for medication evaluation, stabilization, and safety." At that time a referral was made by the Crisis Counselor to the inpatient psychiatric unit. The patient was in agreement with voluntary admission and a referral to the inpatient psychiatric unit was made. Later the patient said they did not want to do a voluntary admission but wanted to go home.

Per review of the "Emergency Department Emergency Psychiatry Assessment" conducted on 9/25/23 at 12:03 (PM) revealed the following note: "[pronoun omitted] endorses auditory hallucinations in the last 5 months that are near constant and distressing. [pronoun omitted] states the voices started out as the voice of [pronoun omitted] parents, then became everyone [pronoun omitted] met. The voices are "gang stalking [pronoun omitted]", telling [pronoun omitted] disparaging things about [pronoun omitted] and encourage suicidal actions. These voices had not occurred prior to this since [pronoun omitted] brain surgery. During [pronoun omitted] teenage years, [pronoun omitted] had a "psychotic break" that was mostly delusions and paranoia has followed [pronoun omitted], but was never quite this severe. [pronoun omitted] endorses persecutory delusions where [pronoun omitted] thinks people are out to get [pronoun omitted]." ... ...."[pronoun omitted] states the hallucinations did not stop even during [pronoun omitted] last hospitalization. [pronoun omitted] says [pronoun omitted] still hears the voices now during the encounter. [pronoun omitted] endorses distress from the voices and it interfering with [pronoun omitted] work, and passive SI daily of "wanting to be dead" so that [pronoun omitted] didn't have to deal with the voices. No current plan for suicide not [sic] but had plans in the past of overdosing and had attempted suicide in [pronoun omitted] adolescence. [pronoun omitted] also endorses depressive symptoms of low mood, anhedonia, as well as possible hypomania in the past-periods of decreased sleep, impulsivity, irritability, and social anxiety." ... .... "[pronoun omitted] also reports decreased PO [oral intake] (stress from voices, homeless and unable to cook). [pronoun omitted] is currently homeless and living in [pronoun omitted] car since August of this year. [pronoun omitted] was living with parents but left home following arguments with parents due to the voices becoming overwhelming. [pronoun omitted] says [pronoun omitted] parents are less supportive now because of "what [pronoun omitted] put them through." "[pronoun omitted] was referred to IOP [intensive outpatient program] following discharge at last hospitalization but did not follow through. Today, he prefers to go home, but will consider IOP too." The psychiatry note goes on to say, "On attending evaluation, [proper name omitted] is calm, well-related, and polite. [pronoun omitted] had previously reported to the medical student on the team that [pronoun omitted] was willing to be psychiatrically admitted (after declining admission when discussing with [crisis counselor]. When I bring this up, [pronoun omitted] tells that [pronoun omitted] "prefers to go home". We discuss [pronoun omitted] psychiatric symptoms, and I recommend admission as a means of more rapidly addressing [pronoun omitted] hallucinations but [pronoun omitted] declines this. Regarding suicidal ideation, [pronoun omitted] confirms [pronoun omitted] been having thoughts that [pronoun omitted] might be better off dead. [pronoun omitted] denies wanting to end [pronoun omitted] life or having any plan to kill [pronoun omitted]. Confirms [pronoun omitted] has a gun which is currently with [pronoun omitted] parents."

This note lists Patient #1's suicide risks under "Suicide Risk Assessment" and are documented as: Psychic distress, loss of pleasure/interest, insomnia, homelessness, poor social support. [pronoun omitted] Non-Modifiable Risk Factors include: Gender, marital status, and nationality, FH [family history] psychiatric illness, prior suicide attempt, discharge from psychiatric hospitalization in the last 3 months. [pronoun omitted] Overall Risk Rating included: Acute: moderate and Chronic: Moderate.

"Patient would benefit from a short inpatient hospitalization, also meets requirements for lower level of care. At this time [pronoun omitted] is involuntary for admission. Patient does not meet criteria for involuntary hold."

Per review of the discharge summary dated 9/25/2023 printed at 13:00 hours (1:00 PM) and provided to the patient revealed the patient was prescribed propranolol and risperidone and currently has an active order for Buprenorphine-naloxone (suboxone), lurasidone (Latuda) and naloxone (Narcan). Her/his discharge instructions provide medication administration directions, follow up appointment with adult neurology, information about the HAP (Health Assistance Program) and contact information, Suicide Prevention Hotline phone number, and a Vermont support line information and contact number. Discharge instructions were provided and included, "Stay with someone tonight that can make sure you are safe - if you feel unsafe at any time, return to the ED immediately".

Per review of ED events timeline, patient was discharged from the ED on 9/25/23 at 1329 hours (1:29 PM).

Per review of the "Investigative Report" from the Office of the Chief Medical Examiner (OCME) who stated, "Psychiatry released [pronoun omitted] for discharge and [pronoun omitted] stated [pronoun omitted] was going to [pronoun omitted] car to get some medications that [pronoun omitted] wanted disposed of. The nurse noticed that [pronoun omitted] had not returned and at that same time a female entered the ED upset stating that she walked past a car that had blood streaked on the window. ED staff went outside and found the decedent slumped to [pronoun omitted] left side with a gun in [pronoun omitted] lap and blood in car and on [pronoun omitted] body." 911 was called and both police and the fire department responded. The police removed the firearm before EMS (emergency medical services) assessed the patient. The patient was assessed and pronounced at the scene. Cause of death was determined to be "Self-inflicted gunshot wound to head". The OCME documented that camera footage was reviewed and showed that the patient entered [pronoun omitted] vehicle at 13:28 (1:28 PM) and was found by the female walking past at 13:38 (1:38 PM).

Per interview on 1/17/24 at 12:36 with the Director of Accreditation & Regulatory Affairs, confirmed facility awareness regarding the incident involving Patient #1. The facility performed a Root Cause Analysis (RCA). Based on the RCA the facility implemented the following: A prompt was added in the medical record to make sure the ED provider obtained collateral information related to access to firearms prior to discharge and when a patient requires mental health services in the ED, they could be seen by either the Crisis Center and/or the ED Psychiatry Service provider.

Interview conducted on 1/17/24 at 1:29 PM with the ED Division Chief Emergency Medicine, Director of Psychology Services of the ED, CMO (Chief Medical Officer) of Medical Staff, and the RN Nurse Manager of the ED and present was the Director of Acceditation & Regulatory Affairs, and two Accreditation & Regulatory staff members. A request for clarification regarding the gun that was discussed during the crisis counselor assessment revealed that there was one call made to the patient's mother and a message was left with no return call. The Director of Psychology Services of the ED confirmed there were no additional attempts to reach the patient's mother to confirm the gun was in her possession. The Director of Psychology Services of the ED confirmed that the treating psychiatrist prescribed a betablocker and risperidone to treat the patient's symptoms. S/he confirmed that these medications would take time to provide relief of symptoms and would not provide immediate relief. S/he stated that the patient requested to be discharged, and s/he did not meet the criteria for an emergency admission due to the State of Vermont statute that requires a patient to be an imminent risk/danger to him/herself or others. The survey team asked if AMA (Against Medical Advice) had been considered for this patient as s/he was declining recommended inpatient admission, the Director of Psychology Services of the ED stated that this was not considered a "case of AMA".

The Director of Psychology Services of the ED stated that the patients partner provided collateral information, however upon further clarification of who the patients partner was s/he stated they thought there was a partner involved but stated they had not reviewed the patients record prior to this interview. It was confirmed that the patient did not have a partner or an accompanying person during this visit. The Director of Psychology Services of the ED stated that the patient's actions were taken into consideration, s/he was calm and cooperative throughout all interactions with the ED staff, provided credible information, and could make their own decision thus showing capacity. The fact that the patient sought help on her/his own showed self-preservation, s/he had no specific plan, although the patient did mention to the ED provider on 9/25/23 at 1:12 AM s/he "hadn't developed any specific plans but is frequently getting intrusive images of harming themselves, such as shooting themselves in the head."

During this interview the survey team asked about EMTALA (Emergency Medical Treatment and Active Labor Act) training and how often it is provided. The Chief Medical Officer of Medical Staff stated EMTALA training is mandatory at onboarding for all staff, for nurses it is an annual mandatory training, and for physicians it is done periodically after onboarding, and it varies based on need.

Per interview on 1/17/24 at 4:30 PM with the Division Chief Emergency Medicine and the Director of Psychiatry Services confirmation of the patient's Emergency Medical Condition (EMC) was confirmed by the Division Chief Emergency Medicine of the ED and the Director of Psychiatry Services of the ED as auditory hallucinations and SI. After the patient's 13 hour stay the team determined the patient no longer had an emergency medical condition. The Director of Psychiatry Services of the ED went on to say that the treating psychiatrist went by her/his assessment, the patient's presentation, knowledge, and expertise and had s/he felt uncomfortable with discharging the patient s/he would have tried to involuntarily admit the patient. The Division Chief Emergency Medicine of the ED again explained that the Vermont State Law is very different than in other states and stated, "if this patient had presented to the ED in NY the same way, it would have been different".

The survey team mentioned the clinician note dated 9/25/23 at 1:12 AM that stated, "the patient's history was obtained from the "patient and the medical records", including Patient #1's "admission notes from June 2023 for psychosis with similar initial presentation". The survey team asked how this information was utilized to assist the clinical team specific to not involuntarily admitting this patient, since s/he had similar presentation and was involuntarily admitted at that time. The Director of Emergency Medicine stated that when a patient presents with a cardiac issue the hospital physicians treat it as a new event and do not rely on previous visits to the ED for similar presentation to treat the patient.

The above documentation demonstrates that the patient had an Emergency Medical Condition that warranted stabilization. S/he presented to the ED with auditory hallucinations, persecutory delusions, suicidal ideation, was homeless and living in her/his car, had a history of non-compliance with medications, prior history of a suicide attempt as well as several overdoses, lack of follow through with accessing psychiatric care, and prior psychiatric hospitalizations for similar presentation. In the crisis counselor note dated 9/25/23 at 10:04 AM it was documented, "due to risk for suicide and lack of ability to adequately access services at this time, [proper name omitted] would best be served on psychiatric unit for medication evaluation, stabilization, and safety." At the time of this evaluation, the patient confirmed that s/he had a gun, but it was locked up in a closet at her/his mother's house, the crisis counselor requested permission to call the patient's mother to confirm. A call was placed to the patient's mother; however, she did not answer the phone and a message was left. There were no other attempts made to contact the mother to confirm this, as stated by the Director of Psychiatry Service of the ED on 1/17/24 at 1:29 PM. The patient told the treating psychiatrist that s/he wanted to go home and to honor patients' autonomy s/he was discharged at 1:29 PM. The OCME "Investigative Report" stated, "Cameras outside showed that [pronoun omitted] entered [pronoun omitted] vehicle at 13:28 (1:28 PM) and was found by female walking past at 13:38 (1:38 PM)". The cause of death was a self-inflicted gunshot wound to the right side of the patient's head.

Per review of the hospital policy "EMTALA - Medical Screening Examination & Stabilization Policy" - effective 1/1/2024, it read, "Stable for Discharge: An individual is considered stable for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his or her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions. For the purpose of discharging an individual with psychiatric condition(s), the individual is considered to be stable when they are no longer considered to be an acute threat to themselves or others.

Under "DEFINITIONS" is listed "Emergency Medical Condition means: "A medical condition manifesting itself by acute symptoms of sufficient severity (including pain, psychiatric disturbances and/or symptoms of intoxication) such that the absence of immediate medical attention could reasonably be expected to result in:
a. Placing the health of the individual (or, with respect to pregnant women, the health of woman or her unborn child) in serious jeopardy,
b. Serious impairment of bodily functions, or
c. Serious dysfunction of any bodily organ or part

Stabilization of Psychiatric Emergencies: If an individual is expressing suicidal or homicidal thoughts or gestures and it is determined that they present an imminent danger to themselves or others, they are deemed to have an "emergency medical condition." Such an individual is stable when they are protected or prevented from injuring or harming themselves or others."