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Based on review of Medical Staff Bylaws, medical record review and interviews the hospital failed to ensure that an appropriate medical screening examination was provided for a patient who presented to the hospital's Dedicated Emergency Department (DED) for a psychiatric evaluation on 09/12/2021, Patient #2.

The findings include:

1. The hospital failed to ensure that an adequate medical screening examination was provided for a patient (Patient #2) who presented to the hospital's DED for a psychiatric evaluation on 09/12/2021.

~cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

Based on review of Medical Staff Bylaws, medical record review and interviews the hospital failed to ensure that an appropriate medical screening examination was provided for a patient (Patient #2) who presented to the hospital's Dedicated Emergency Department (DED) for a psychiatric evaluation on 09/21/2021.

The findings included:

Review of Medical Staff Bylaws reviewed 01/19/2021 revealed, "...On-Call Coverage After initial examination, an Emergency Department practitioner ... may determine that the patient requires specialty consultation. Consulting practitioners ... on-call must be available to respond, either by telephone or in person, within approximately thirty (30) minutes..."

Closed medical record review conducted on 11/15/2021 revealed Patient #2 was a 35-year-old male who presented to Hospital A's DED by law enforcement on 09/12/2021 at 0343 requiring a psychiatric evaluation under Involuntary Commitment (IVC). Patient #2's vital signs at 0349 were: blood pressure (BP) 133/93, pulse (P) 91, respirations (R) 20, pulse oximetry (SPO2) 99 % on room air, and temperature (T) 97.7. Review of the Affidavit and Petition for Involuntary Commitment sworn/affirmed to the Rutherford County Magistrate on 09/12/2021 [untimed] revealed, "...THE RESPONDENT HAS BEEN DIAGNOSED AS SCHIZOPHRENIC AND BI-POLAR IN THE PAST. HE HAS BEEN PRESCRIBED MEDICATION BUT HAS STOPPED TAKING IT. HE APPEARS TO BE LOSING RATIONAL JUDGEMENT. HE HAS BEEN LIVING IN THE WOODS, WAS WEARING CLOTHES THAT WERE STUCK TO HIM FROM LONG TERM WEAR WITHOUT CHANGING, AS WELL AS LONG TERM NEGLECT OF PERSONAL HYGIENE. HE MUST BE MADE TO TAKE A SHOWER AS HE SEES NO NEED IN KEEPING HIMSELF CLEAN. HE APPEARS TO BE EXTREMELY PARANOID AND DELUSIONAL. HE IS HEARING VOICES AND TALKING TO HIMSELF. HE WAS OBSERVED TELLING THE VOICES TO SHUT UP WHILE BECOMING ANGRY, CURSING AND SPITTING. HE IS NOT EATING REGULARLY, AND GOES DAYS WITHOUT SLEEPING. HE HAS MADE COMMENTS THAT HE HAS BOMBS ON HIS PERSON WHEN ALL HE HAS ARE BATTERIES. HE HAS MADE THE STATEMENT 'I'M GOING TO KILL EVERYONE OF THEM THAT WALK INTO THE ROOM'. IT IS NOT CLEAR TO WHOM HE IS REFERRING. HE IS SUSPECTED OF BEING ON METHAMPHETAMINE AND HEROIN. IN THE PAST FEW HOURS HE SHAVED HIS HEAD, AN ACT HE HAS NEVER BEFORE DONE. IN HIS CURRENT STATE HE APPEARS TO BE INCAPABLE OF TAKING CARE OF HIMSELF, AND IS A DANGER TO HIMSELF OR OTHERS..." Review of a Note written by Registered Nurse (RN) #1 on 09/12/2021 at 0426 revealed, "PT BROUGHT IN BY LEO [Law Enforcement Officer] ON IVC. PT [patient] IS OBVIOUSLY UNDER THE INFLUENCE OF SUBSTANCES. PT REFUSING TO ANSWER MOST QUESTIONS. HE DOES DENY SI/HI [Suicidal Ideation/Homicidal Ideation] and AVH [Auditory Visual Hallucinations]. PT IS MUMBLING TO SELF ABOUT WANTING TO BE LOVED, FRATERNIZING WITH MARRIED WOMEN AND PEOPLE NOT KEEPING THEIR WORD. PER OFFICER THAT BROUGHT PT IN, PT WAS SITTING INFRONT [SIC] OF AN OPEN WINDOW ACTIVELY SHOOTING UP METHAMPHETAMINE. PT HAS RAMBLING SPEECH WITH FLIGHT OF IDEAS AND LOOSE ASSOCIATIONS. PT MAKES LITTLE TO NO EYE CONTACT. PT LABS ARE PENDING." Review of an ED (Emergency Department) Provider Note written by Medical Doctor (MD) #2 on 09/12/2021, "...Time seen by Provider: 09/12/2021 03:53 ... PATIENT IS A 35-YEAR-OLD GENTLEMAN BROUGHT IN BY [NAMED POLICE DEPARTMENT] FOR IVC EVALUATION. PATIENT'S SISTER TOOK OUT THE IVC PAPERWORK. PER THE PAPERWORK PATIENT IS A SCHIZOPHRENIC WITH BIPOLAR DISEASE IS NOT COMPLIANT [SIC] WITH HIS MEDICATIONS. HE HAS BEEN USING DRUGS ONCE AGAIN AND HAS BEEN HOMELESS AND LIVING IN THE WOODS. PATIENT RECENTLY HAS BEEN USING METH AS WELL AS HEROIN. PATIENT HAS BEEN MUTTERING ABOUT BOMBS AND TRACKING DEVICES IN HIS BODY. HE ALSO HAS NOT BEEN BATHING OR TAKE [SIC] CARE OF HIMSELF. WHEN THE POLICE DEPARTMENT WENT TO PICK PATIENT [SIC] HE WAS ABOUT TO INJECT HIMSELF WITH SOME METH. PATIENT CURRENTLY DENIES ANY SUICIDAL HOMICIDAL IDEATION BUT HE IS HAVING RAMBLING THOUGHTS AND VERBALIZATIONS. PATIENT IS ALSO SOMEWHAT INCOHERENT WITH HIS THOUGHT PATTERNS. PATIENT WILL BE EVALUATED BY PSYCHIATRY TO DETERMINE WHETHER NOT [SIC] HIS IVC NEEDS TO BE UPHELD ... PMH [Past Medical History] Respiratory: Asthma ... Medication ... ALBUTEROL ... Claritin ... Review of Systems 10 Systems Reviewed: All systems are negative unless marked otherwise ... Psychiatric: Anxiety, Paranoia, Visual Hallucinations, Auditory Hallucinations. Negative: Thoughts of Hurting Yourself or Others. Physical Exam ... Psychiatric: Appropriate Affect, Normal Behavior, Calm Demeanor, Cooperative, Judgement/Insight Intact ... Reevaluation ... Improved (PATIENT HAS BEEN EVALUATED BY PSYCHIATRY. [NAMED PHYSICIAN] HAS BEEN CONTACTED AND FEELS PATIENT MAY BE DISCHARGED SAFELY SINCE HE CONTINUES TO DENIES [SIC] SUICIDAL HOMICIDAL IDEATION AND RECOMMENDS FOLLOW-UP FOR OUTPATIENT DRUG REHAB.) ... Discharge Diagnosis (1) IVC EVALUATION Status: Acute (2) Bipolar 1 disorder Status: Acute (3) Methamphetamine abuse Status: Acute ... Referrals: [2 Named Local Outpatient Services] Discharge Instructions Instructions: Alcohol and Drug Addiction, Finding Treatment, Methamphetamine Abuse, Complications Additional Instructions: PLEASE FOLLOW-UP WITH YOUR PRIMARY CARE PHYSICIAN OR THE UNASSIGNED PHYSICIAN GIVEN TO YOU IN YOUR DISCHARGE INSTRUCTIONS IN THE NEXT FEW DAYS. IF YOUR SYMPTOMS DO WORSEN FEEL FREE TO RETURN TO THE EMERGENCY ROOM FOR RE-EVALUATION. FOLLOW-UP WITH YOUR MENTAL HEALTH PROVIDER IF YOU START THINKING HURTING HERSELF [SIC] OR OTHERS THEM [SIC] PLEASE RETURN TO THE EMERGENCY ROOM FOR FURTHER EVALUATION STOP USING DRUGS. Follow-up [Patient #2 Named] has been referred to the following clinics/specialists for follow-up care: ADATC [Alcohol and Drug Abuse Treatment Center - address and phone number] Follow-Up Plan: 2-3 Days [Named Local Psychiatric Service with address and phone number] Follow-Up Plan: 2-3 Days..." Laboratory studies performed on Patient #2 during the DED admission were: Acetaminophen level, alcohol level, Complete Metabolic Profile, Complete Blood Count, Urine Drug Screen, Salicylate level, Thyroid Stimulating Hormone level, Urinalysis, and a Coronavirus screen. The only clinically significant result noted was a positive result for amphetamines and marijuana on the Urine Drug Screen. Review of a note written by RN #1 on 09/12/2021 at 0532 revealed, "Spoke with Dr. [Named Psychiatrist] re [reference] pt presentation and agrees that IVC may be overturned and pt DC'd [discharged]." Review of an Attestation Statement & Referral Form electronically signed on 10/14/2021 at 1147 by Psychiatrist #4 revealed, "I have read the Regional Assessment & Referral Form and have discussed with the psychiatric Nurse / Social Worker / ED Provider the disposition of the patient." Review of a note written on 09/12/2021 at 0719 by Registered Nurse (RN) #3 revealed, "...Disposition of Patient Discharge ... Discharge Instructions Given To Patient Verbalized understanding of Discharge Instructions Accompanied By/Driver Yes ... Method of Departure Ambulation..." Review revealed no evidence of any repeat vital signs prior to Patient #2's discharge.

Patient #2 returned to Hospital A's DED under IVC on 09/12/2021 at 1909. Patient #2's vital signs at 1943 were: BP 124/79, P 101, R 18, SPO2 99 % on room air, and T 98.3. Review of the Affidavit and Petition for Involuntary Commitment sworn/affirmed to the Rutherford County Magistrate on 09/12/2021 [untimed] revealed, "...The facts upon which this opinion is based are as follows ... respondent is hearing voices. has [sic] to run tv loud to drown out the sound. this [sic] afternoon has been in middle [sic] of road without shirt or shoes uttering sounds that no one can understand. thinks [sic] that the two batteries are bombs that he can blow things with them [sic]. saying [sic] I got to kill them all ... screaming at the TV and the floor. family [sic] not able to provide safe living environment. respondent [sic] can not [sic] perform daily living skills..." Review of a Provider Note written by Nurse Practitioner (NP) #5 on 09/16/2021 at 0123, and co-singed by MD #2 on 09/20/2021 at 1938 revealed, "...Time Seen by Provider: 09/12/2021 19:43 ... Patient is a 35-year-old male who presents emergency room (sic) complaining of being under an IVC order for aggressive behavior at home, screaming and yelling at the TV and at the floor. Patient was seen yesterday (sic) for bizarre behavior, positive for marijuana and methamphetamines. Patient is ambulatory in the emergency room without assistance awake and alert x3, patient denies suicidal and homicidal ideation. Patient was assessed by (MD #2 and RN #1 Named). Patient is stable for discharge, IVC order was overturned. Patient is denying rehab for substance abuse ... Review of Systems ... Psychiatric: None ... Psychical Exam Findings ... Psychiatric: Appropriate Affect, Euthymic, Normal Behavior, Calm Demeanor ... Discharge Diagnosis (1) Marijuana abuse ... (2) IVC EVALUATION ... (3) Methamphetamine abuse ... Referrals: (Named Outpatient Service) 2-3 Days..." The same labs listed in the initial visit were repeated with no change in results. Review of a note written by Psychiatrist #4 on 09/14/2021 at 1244 revealed, "This note is regarding the patient's 1st encounter on September 12, 2021, when he was brought to the emergency room around 4:30 a.m. on involuntary commitment. At that time the patient was triaged by the psychiatric nurse, (RN #1 Named) who subsequently contacted me regarding the patient being there and wondered about whether the patient needs to have his involuntary commitment up held. Due to nature of his presentation and the patient denying any suicidal or homicidal ideations I suggested that the patient does not need an extensive psychiatric evaluation, and if he is medically cleared that he can be discharged. I talked to (RN #1 Named) at 5:30 a.m., the patient was subsequently discharged under the discretion of the attending provider, (MD #2 Named)." Patient #2 refused to sign his provided discharge instructions on 09/12/2021 at 2116. Patient #2 was discharged on 09/12/2021 at 2252 by RN #6. Review revealed no evidence of any discharge vital signs.

Patient #2 presented to Hospital B's DED on 09/13/2021 at 0000 by private vehicle. Patient #2's vital signs were: BP 125/84, P 90, R 20, SpO2 97% on room air, and T 97.3. Review of a Provider Note written by MD #7 on 09/13/2021 at 0034 revealed, "...35-year-old male with past medical history of schizophrenia presenting to the ED with his sister for psychiatric evaluation. Patient is not forthcoming with history, states he has 'been through this so many times in [Hospital A] County.' Apparently he was IVC by his sister in [Hospital A] County twice in the last couple of days for decompensated schizophrenia and was reportedly seen by the psychiatrist in their emergency department and IVC was lifted and he was discharged. His sister states he is completely unstable, she actually has not seen him in about 8 months and he is off all medications, is actively hallucinating, talking about killing people with acid because they are hurting children all of which is related to paranoia and delusions. She is happy to IVC and [sic] again and will do so if we do not plan to hold him as she is concerned that he was inappropriately released earlier today. Apparently it was recommended that she bring the patient to him [sic] [Hospital B Named County] for reevaluation. At this time patient denies any acute medical complaints, headache, chest pain, cough, shortness of breath or elsewise, denies SI, HI, AVH but does seem to be responding to internal stimuli and is quite agitated ... Physical Exam ... Psychiatric: Significant psychomotor agitation, seems to be responding to internal stimuli, actively talking about doctors harming children ... Assessment/Plan 35-year-old male with past medical history of schizophrenia presenting to the ED with his sister for psychiatric evaluation. I would agree with the sister's assessment the patient seems decompensated and likely warrants inpatient stabilization. He is denying SI, HI or active hallucinations at this time but seems to clearly be responding to internal stimuli and does in front of me talk about doctors harming children which I think seems unlikely reality. Patient sister, [Named with phone number], is a hospice nurse and seems quite reliable and is planning to IVC him if we do not hold him. I explained to her that I would place him on an ED hold and will proceed with psychiatric evaluation and if felt appropriate will IVC him on RN [sic]. We will proceed with medical screening labs, have talked with psychiatric clinician they will evaluate the patient. Unfortunately when he was told that he was going to be held for psychiatric evaluation he became more agitated and required IM injections of medications. Laboratory studies reviewed and overall reassuring, mild nonspecific transaminitis [elevated levels of certain liver enzymes]. Patient is medically cleared, await psychiatric evaluation and disposition. He is now resting comfortably after medications ... The nature of this patient's critical illness/condition is: Acute decompensated schizophrenia resulting in agitation and need of IM medications..." Review of an assessment written by Licensed Clinical Social Worker [LCSW] #8 at 09/13/2021 at 0110 revealed, "...[MD #7 Named] calls to refer 35 year old male with a history of schizophrenia. He is unstable. He has not had medication in over 8 months. Patient has been missing for about 8 months. Sister brought him in. He is reacting to intrrnal [sic] stimuli. Patient hasn't slept in weeks. Patient is medically clear and will be seen by the next available Clinician ... Current Presentation : PC [Psychiatric Consult] located at [Named Area Hospital] met with Patient in BH Hall 01 at [Hospital B Named] ED via telehealth technology. Patient is yelling and threatening techs and security upon my arrival. Patient agrees to speak with PC and other members of the team leave out to the hallway for Patient privacy. Patient is angry. He is yelling incoherently about being forced to give up his parental rights. Patient is able to report that he has been evaluated and released 3 times in the past 2 days. Patient denies suicidal ideation, he denies homicidal ideation but starts talking about children and the was [sic] and multiple subjects about Navy Seals and then his ex-girlfriend taking him to court. He is angry and refuses to answer questions which he feels he has answered multiple times for other people today. He asks PC to be direct. Patient reports he has been working construction, he then goes off on a tangent about being in charge of the jobsite. He then talks about being in 2nd grade and having a very high IQ, but being penalized for being smart. He then talks about going to prison for 'that bitch'. He states 'I got to see my son for one week', 'then they took me to prison' Patient is not able to explain why he went to prison. He does state 'I went to [Named] Prison, maximum security' Patient ignores PC and has aa [sic] conversation with himself. He then stops and looks at the camera. He looks as though he is going to fall asleep, then jumps up and starts talking about his family being irraticated [sic]. Patient presents responding to internal stimuli. He is holding conversations with himself. He has a flight of ideas. He is not able to stay focused on one subject. Patient is paranoid [sic] about giving information about his family. He yells 'i'm not going to sign those papers to give up my parental rights' He then refuses to explain further, saying 'that's a private manner' Patient is in need of stabilization. By report he has not slept, he is missing some front teeth. He denies drug or alcohol use. He accuses someone, possibly the mother of his child, of poisoninghim [sic] at one point. Patient is not stable. He is a danger to himself and others outside of the hospital setting ..." Review of a note written by LCSW #8 on 09/13/2021 at 0158 revealed, "[MD #7 Named] orders PC to contact Patient's sister for collateral information due to Patient no [sic] being able to provide information ... contacted [Sister Named], patient's sister and previous caregiver. She reports that Patient was diagnosed with schizophrenia at age 21 by RHA [Unknown], she reports they also said he was manic depressive. He was seen by RHA and took medication for about 6 months when he decided he didn't need it anymore. Since that time patient has been in jail and prison multiple time for drug, assaults, and attempted homicide. Patient was released from prison 2 years ago aftr [sic] serving 2 +years for strangling his son's mother with a phone cord. [Sister Named] reports that when Patietn [sic] was 12 years old he was riding in the back of a pickup truck and fell out, she reports he wa sin [sic] the hospital for several weks [sic], his brain swelled and he developed seizures. His parents were somewhat neglectful and did not follow up to find out if Patient has a TBI [Traumatic Brain Injury] from that accident. [Sister Named] reports that she and her siblings were taking care of Patient, each taking turns until he went missing 8 months ago. He went to Ellenboro and follow [sic] the leader of the New World order [Unknown Organization]. Patient is dangerous when he is angry. He can be a sweet loving person too when he is stable. [Sister Named] is looking into guardianship of the Patient..." Patient #2 was also evaluated by a Psychiatrist who concurred with the previous assessments and Patient #2's IVC was ultimately carried out. Patient #2 was transferred to an area inpatient psychiatric facility on 09/13/2021 at 1908.

Staff interview conducted on 11/16/2021 at 0910 with Hospital A's Chief Nursing Officer (CNO) revealed MD #2 was out of the country and unavailable for interview.

Staff interview conducted on 11/16/2021 at 0928 with RN #6 revealed she didn't "particularly" remember Patient #2 however she remember the situation because he had been seen twice in the same day. RN #6 recalled Patient #2's sister had IVC'ed him. Interview revealed RN #6 was not Patient #2's primary nurse, but she was the Team Lead for the shift (Patient #2's second admission). Interview revealed per record review RN #6 did discharge Patient #2. RN #6 did not recall any "out of the ordinary behavior" upon his discharge and did not recall if he was alone at discharge. Interview revealed normally if a patient's IVC is overturned local police will transport the patient home, however RN #6 did not recall the circumstances of Patient #2's transport home. Interview revealed the time discrepancy between Patient #2 refusing to sign his discharge papers at 2116 and his discharge from Hospital A's electronic medical record system at 2252 was "probably because we were busy, and I just didn't take him out of the system until 2252." Interview revealed Psychiatrists do not physically come in to see patients at Hospital A, instead relying on DED nurse and provider reports to reach their recommendations.

Telephone interview was conducted with RN #1 on 11/16/2021 at 0943. Interview revealed RN #1 did not recall Patient #2 "at all." Interview revealed RN #1 has been employed at Hospital A's DED for approximately 3.5 years, however prior to employment in Hospital A's DED she was an inpatient psychiatric nurse for approximately 10.5 years. Interview revealed when Psychiatry performs consults for the DED they communicate with nursing staff and the DED provider after reviewing DED documentation and make their recommendations.

Telephone interview was conducted with Nurse Practitioner (NP) #5 on 11/16/2021 at 1000. Interview revealed NP #5 did not communicate with Patient #2's sister prior to deciding the DED disposition for the 2nd visit on 09/12/2021. Interview revealed NP #5 did not know if MD #2 communicated with Patient #2's sister prior to deciding the DED disposition during Patient #2's initial visit on 09/12/2021. Interviews revealed patient families' often want patients IVC'ed for drug rehabilitation without other psychiatric co-morbidities. Interview revealed if a patient exhibits no signs or symptoms of hallucinations, psychosis, suicidal or homicidal ideation, which Patient #2 did not; a patient cannot be forced into drug rehabilitation. Interview revealed Patient #2 was not interested in rehabilitation. Interview revealed in other states patients can be involuntarily committed for drug rehabilitation however North Carolina has no such laws. Interview confirmed Psychiatrist #4 was consulted via telephone and he recommended the IVC be rescinded, and Patient #2 was safe for discharge.

Telephone interview was consulted with Psychiatrist #4 on 11/16/2021 at 1300. Interview revealed Psychiatrist #4 never examined Patient #2 for either admission on 09/12/2021. Interview revealed he communicated with RN #1, MD #2 and NP #5 on the DED admissions, and recommended that if Patient #2 was medically cleared, he could be safe for discharge. Interview revealed it was reported that Patient #2 verbalized no suicidal or homicidal ideation and displayed no psychotic behavior. Interview revealed Hospital A has a Behavioral Health unit, however it does not provide drug rehabilitation, detoxification, or substance abuse services. Interview revealed Patient #2 verbalized no interest in such services, so he was not appropriate for transfer to another facility. Interview revealed if a patient was not IVC'ed a transfer cannot be forced, and "no facility would accept a patient not willing for rehab or detox treatment any way." Interview clarified the initial note on the 1st 09/12/2021 dated in October was resulted from Psychiatrist #4 "catching up" with documentation.