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Based on document review and staff interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided an appropriate medical screening examination. (A-2406)

An immediate jeopardy (IJ) investigation was conducted on 12/18/23 through 12/21/2023 for complaint #IL00166368/2311496. The immediate jeopardy began on 10/30/23, due to Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided an appropriate medical screening examination (MSE).

Based on document review and staff interview, it was determined that in 1 of 20 (Pt #1) Emergency Department (ED) records reviewed, the Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided an appropriate medical screening examination (MSE). Subsequently, Pt. #1 was found deceased by suicide within 12 hours of discharge from the hospital emergency room.

Findings include:

1. Pt #1's medical record was reviewed throughout the survey (12/18/23 thru 12/21/23). Pt #1 presented to the Emergency Department (ED) on 10/30/23 at 12:21 AM. Pt #1's chief complaint was "Depressed and Suicidal Thoughts and Psychiatric Evaluation Requested."
The triage note at 12:21 AM states, "patient was brought in today via police due to suicidal threats over the phone. Patient stated that he was going to go into his garage and "kick the bucket out from under him". Pt #1 has a history of Alcohol Abuse, Drug Abuse, Depression, Anxiety, Previous suicide attempt (13 years ago), and is currently on Ambien and Xanax. A Patient Safety Screener questionnaire was completed as follows:
1. In the past 2 weeks, have you felt down, depressed, or hopeless? Pt #1 answered "YES"
2. Over the Past 2 weeks, have you had thoughts of killing yourself? Pt# 1 answered "NO"
3. In your Lifetime, have you ever attempted to kill yourself? Pt #1 answered "YES"
3a. If yes, When did this happen? Pt #1 answered "more than 6 months ago"

Pt #1's physical assessment noted that pt #1 came in "without any problems with HPD (Havana Police Department), The patient is denying any suicidal ideations or homicidal threats ... ...appears in no acute distress." The Nursing Progress Note at 1:23 AM on 10/30/23 noted, " The patient is wanting to leave and go home and go to bed. The Patient reports he was just messing with people and things have got out of control. Nurse explained to patient that if he is doing this for attention he go his parents attention. The patient reports he has been more depressed with all the stuff going on. The patient was given resources to call but reports HE IS NOT GOING TO NEED THEM. The patient states "just give me phone and cloths so I can get home and go to bed." The patient states, "I would rather be in jail then in here."
The Physician Clinical Report was reviewed and on 10/30/23 at 12:21 am, under History of Present Illness states, "Chief Complaint: DEPRESSED AND SUICIDAL THOUGHTS and PSYCHIATRIC EVALUATION REQUESTED. This started today. (Patient reportedly made suicidal comments at home ... ... .....He had reportedly made a comment that he had a rope and was going to kill himself. Patient then later came in voluntarily with law enforcement ... ... ... ...On questioning, the patient denies suicidal ideation. Lives alone ... ... ... ... ...The patient has experienced situational problems. Recent drug use and alcohol consumption. Has been depressed and had suicidal thoughts."
Under Past History : " Depression. Prior Suicide Attempt"
Under Progress and Procedures: Course of Care: "Patient has overall quite poor insight. Thinks it is annoying that everyone is telling him to be positive. I do not believe he is actively suicidal at this time but rather depressed and likely made passive suicidal comments, which he chalked up to "bad humor" Patient would like to discharge. He was provided the number for mobile Mental Health. His mother was waiting for him in the parking lot and gave him a ride home. He proceeded to flip us off on camera once outside the facility."
Clinical Impression: Recurrent moderate major depressive disorder with psychosis. No suicidal attempt. Probable suicidal ideation."
The record lacked evidence that a Psychiatric evaluation was ordered, that a Suicide Risk Assessment was completed, and that discharge instructions were given per policy.

2. On 12/18/23 at approximately 10:00 AM the policy, "Triage & Registration of Patients in the Emergency Department (revised 2003)" was reviewed. The policy stated "1. Triage. 1.1 Patient who present with the emergencies triaged as a Level 1 (EMERGENT) shall bypass triage office and be escorted to treatment area for immediate medical screening and stabilization. 1.2 All other patients who will be escorted to triage office and have an initial triage assessment completed. 1.2.1 Triage is completed by Emergency Room Personnel ... .....2.1.1 Medical Screening will not be delayed to obtain insurance information or verify existing coverage as part of reasonable registration."

3. On 12/19/23 at approximately 1:15 PM, the policy, "Discharge of Patient from ED (revised 2016)" was reviewed. The policy stated, " It shall be the responsibility of emergency room personnel to discharge patients from the emergency room as ordered by physician. The discharge could be admitting patient to regular room (med/surg), transferring patient to another facility, discharge patient home ... ...4. Discharging Patient home. 4.2 ... ...A discharge timeout will be conducted in which the instructions are to be reviewed by the nurse and the physician together prior to giving them to the patient."

4. On 12/18/23 at approximately 10:30 AM, the ED patient log was reviewed. Pt #1 was on the ED log indicating Pt #1 presented to the ED on 10/30/23 at 12:21 AM with a chief complaint of "Suicidal." The log stated "Acuity Level: 3" (low acuity), Providers: E #5, E #4 Diagnosis: Depression, Suicidal Ideation Discharge Disposition: Discharge, Discharge Date/Time: 10/30/23 at 1:44 AM."

5. On 12/21/23 at 11:45 AM, the Preliminary Coroners report was reviewed and noted, "Date: 10/30/23... Time pronounced: 12:24 P.M. ... Autopsy: NO .....Medical History: Deceased was found hanging by his neck in his garage. He used an orange air compressor hose. He was found by Sheriff 's Deputy. Deputy had talked to Pt #1 in the night and told him that he would check in on him at lunchtime. Pt #1 had been discharged from MDH (Mason District Hospital), in Havana, at 1:41 a.m. on 10/30. He had denied suicidal thoughts and refused to take a phone number for the Suicide Hotline. From speaking to Pt #1's father, he had requested that MDH hold Pt #1 longer than they did."

6. On 12/18/23 at approximately 3:00 PM, an interview was conducted with the Director of ER & EMS (E #2). E #2 stated "I review every ED chart on a daily basis. I reviewed this chart and I had concerns & questions regarding the documentation of E #5. Therefore, I asked the ED medical director (E #7) to review the chart on an informal basis. Based on his findings, if any, he would do a formal investigation. He did not advise me of his thoughts. Also, when I heard the patient was found deceased, I advised Risk Management. I do not know if this case was investigated or not by our facility. The "MD" discharge instructions could have been more detailed, for example: a) which # was the patient given to follow up? b) what discharge documents were given? c) as well as the "education portion" of the discharge was not found. For every diagnosis there should be a form of education provided. E #5 only gave instructions related to patient medications, not follow up care."

7. On 12/21/23 at approximately 12:10 PM, an interview was conducted with the Quality and Risk Manager (E #6). E #6 stated, " I am not aware that any investigation has been done. It would have been looked at during the November Admin Meeting, but it was canceled. The next one is in January and this case is on that agenda."