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Based on hospital policy reviews, closed medical record reviews, staff and physician interviews, the hospital staff failed to comply with 42 CFR 489.24.

The Findings include:

1. The hospital's dedicated emergency department (DED) failed to provide stabilizing treatment within its' capacity and capabilities after a medical screening examination (MSE) determined the presence of an emergency medical condition (EMC) for 1 of 1 sampled DED patients discharged with an ongoing EMC (#7).

~cross refer to 489.24(d)(1-3) Stabilizing Treatment - Tag A2407

2. The hospital's dedicated emergency department (DED) failed to ensure an appropriate transfer for 1 of 10 sampled DED patients (#7) that were transferred with an emergency medical condition by failing to ensure a physician certified the medical benefits of transfer outweighed the risks to the patient; obtaining the patient's consent for and/or refusal for transfer; ensure and document the receiving facility had space and qualified personnel available and agreed to accept the patient; ensure copies of all pertinent medical records available at the time of transfer were sent to the receiving hospital; and failed to ensure the transfer was effected through qualified personnel and transportation equipment.

~cross refer to 489.24(e)(1)-(2) Appropriate Transfer - Tag A2409

Based on hospital policy reviews; closed medical record reviews; hospital staff, contracted Mobile Crisis Management staff, physician assistant and physician interviews the hospital's dedicated emergency department (DED) failed to provide stabilizing treatment within its' capacity and capabilities after a medical screening examination (MSE) determined the presence of a psychiatric emergency medical condition (EMC) for 1 of 1 sampled DED patients discharged with an ongoing EMC (#7).

The findings include:

Review of current hospital policy "Emergency Medical Screening, Treatment, Transfer and on-call Roster Policy" (revised 07/12/2011) revealed "...C. Stabilization and Treatment Beyond the Capability of the Emergency Department (Procedure) 1. A patient experiencing an emergency medical condition must be stabilized prior to being discharged or transferred. (Points to Remember) 1. A patient is considered to be stabilized when the treating physician has determined with reasonable clinical confidence that the patient's emergency medical condition has been resolved. (Procedure) 2. The Emergency Department physician is responsible for the general care of all patients presenting to the Emergency Department until....the patient is discharged or transferred. ...(Procedure) 7. After being informed of the risks and benefits of treatment and the risks of refusing treatment, if a patient refuses to accept treatment that has been recommended to stabilize an emergency medical condition, reasonable steps shall be taken to obtain the patient's signature and the refusal on the Release of Responsibility for Discharge Form (A-34). (Points to Remember) 7. The refusal should be documented in the medical record. ...(Procedure) 9. A patient may be discharged after the emergency medical conditions has been resolved or after determination has been made that the patient is stable for discharge. (Points to Remember) 9. Stable for discharge means that continued care including diagnostic work up and/or treatment can be safely performed on an outpatient basis, or later on an inpatient basis, provided the patient is given a plan for appropriate follow up care with discharge instructions. ..."

Review of current hospital policy "Management of Mental Health and Substance Abuse Patients with Suicide Precautions Orders" (revised April 2011) revealed "...Policy: Any patient who is emotionally or mentally disturbed will be evaluated and treated in the Emergency Department for any medical condition and referred to the appropriate agency for definitive treatment of the emotional or mental disturbances. Any patient known or suspected to be suicidal will be assessed by the physician, PA (Physicians' Assistant), or NP (Nurse Practitioner) and a referral will be made for a mental health risk assessment by mental health staff if the physician deems appropriate. Based on the risk assessment, the patient may be discharged home for outpatient mental health follow-up, the patient may be transferred to a psychiatric facility or the patient may be admitted for medical stabilization. ...The final disposition of the patient is the responsibility of the physician. ..."

Review of current hospital policy "Triage/Primary Assessments/Fast Track Determination" (revised November 2009) revealed "...Policy: All patients that present to the Emergency Department (ED) will be assessed by a registered nurse (RN) and assigned an Emergency Severity Index (ESI) level according to the patient classification listed below: ...2. Level 2: Significant risk of loss of life or limb. ..." Review of the Triage Grid Five Level System "(Hospital Name) Fast Track Determination" form attached to the policy for "Medical Complaints" revealed "Level 2 Emergent....Acute Psychosis/suicidal ideation or homicidal ideation... ."

Hospital A closed medical record review on 10/16/2012 for Patient #7 revealed a 33 year old male who presented ambulatory via private transportation to the DED on 09/27/2012 at 1243. The patient was triaged at 1300 by a Registered Nurse (RN #1). Review of triage nurse documentation revealed a chief complaint of "Suicidal Ideations." Review revealed "Associated Sxs (symptoms)/Pertinent History PT (patient) PRESENTS TO ED WITH SUICIDAL IDEATIONS, PT TEARFUL REPORTING HAS BEEN OFF MEDS X3 MONTHS DUE TO NOT HAVING MONEY TO BUY THEM. PT WAS INPATIENT AT (Hospital B name) IN MAY FOR SAME AND DOING GOOD WHEN ON MEDS PER FEMALE VISITOR. PT ASKED IF HE HAS A PLAN AND STATES, 'I WANT TO HANG MYSELF'. PT COOPERATIVE AND POLITE. PT DENIES HOMICIDAL IDEATIONS OR ILLICIT DRUG USE. DOES ADMIT DRINKS ALCOHOL." Review revealed a past medical history (PMH) of Manic Depressive; Bipolar Disorder; and Schizophrenia. Review revealed the patient's current medications as Lithium (anti-manic), Neurontin (anti-convulsant), Seroquel (anti-psychotic), Paxil (selective serotonin reuptake inhibitor), Ambien (sedative-hypnotic). Review revealed the patient was assessed as alert and oriented with a Glasgow Coma Scale (scale used for measuring level of consciousness) of 15 (normal). Review revealed the patient's vital signs were assessed as: temperature (T) 98.1 degrees Fahrenheit; heart rate (HR) 118; blood pressure (BP) 142/88; respiratory rate (RR) 22; oxygen saturation (O2 Sat) 98% on room air. Review revealed a pain assessment was performed using a numerical pain scale with "No Pain" documented. Review revealed the patient was assigned category "4 Level - Non-(urgent)" (Level 1 most severe, Level 5 least severe). Review of nursing documentation by RN #1 at 1326 revealed "PA (physician assistant)....AT BEDSIDE FOR PT EVAL (evaluation)"; at 1432 "VITALS OBTAINED AND WNL (within normal limits). PT ADMITTING TO THIS RN THAT HE SMOKES A JOINT EVERY NOW AND THEN AND DID SOME COCAINE MONDAY. PT SAYING, 'I JUST DON'T WANT TO LIE TO YALL I WANTED TO LET YOU KNOW'."; at 1532 "MOBILE CRISIS (MC) [a contracted psychiatric/mental health evaluation service] CONTACTED FOR REFERRAL. PT INFO GIVEN...."; at 1617 "(name) WITH MC AT BEDSIDE SPEAKING WITH PT"; at 1628 "PT REPORTING IS BECOMING AGITATED BECAUSE HE WANT TO SMOKE. ..."; at 1724 "PT TELLING THIS NURSE HE IS GOING TO WALK HIS GIRLFRIEND OUT TO CAR AND WILL BE BACK. PT THEN SAYING 'I PROMISE I WON'T GO ANYWHERE. I CAME FOR HELP AND I WANT HELP'."; at 1739 "PT BACK IN ROOM."; at 1757 "(MC staff name) AT BEDSIDE SPEAKING WITH PT."; and at 1815 "PT DC'D (discharged) TO GIRLFRIEND WHO IS TAKING PT STRAIGH [sic] TO (Hospital B name) EVAL (evaluation) AND TX (treatment). PT THANKFUL FOR CARE PROVIDED. AMB (ambulatory) TO ER LOBBY IN NAD (no acute distress) WITH GIRLFRIEND."

Review of MSE documentation by PA #1 at 1315 revealed "History of Present Illness (HPI) 33 Year Old M (male) Patient Presents with Suicidal Ideations with Plan for seevral [sic] days. The Onset is Gradually worsening sx (symptoms) since running out of medications 2-3 months ago. The symptoms are No Pain. Additional Symptoms or Pertinent History also involve Depressed mood. Furthermore, the Patient/Family Denies Acute medical symptoms. Patient states exacerbating Factors that occur are No medications." Review of "Review of Systems (ROS)" documentation revealed "...Psych(iatric) HPI..." Review revealed a check mark in a box adjacent to "All other ROS negative." Review revealed a check mark in a box adjacent to "Vital Signs/Triage/Nursing Notes Reviewed and Agree." Review of "Past Medical History" documentation revealed a check mark in a box adjacent to "Psychiatric." Review of "Social History" documentation revealed a check mark in a box adjacent to "ETOH (alcohol)" and "Smoking." Review of "Family History (FMHx)" documentation revealed a check mark in a box adjacent to "Past Family History reviewed and not relevant No Significant FMHx." Review of "Physical Exam" documentation revealed "General Appearance Awake A&Ox3 (alert and oriented times person, place, time) HEENT (head, ears, eyes, nose, throat) PERRL (pupils equal round reactive light) EOMI (extra-ocular movements intact) Moist Mucous Membranes No icterus Chest RRR (regular rate rhythm) No M (murmur) Lungs CTA (clear to auscultation) No Ret (retractions) Chest Wall NT (nontender) Abdomen No Pulsating Masses BS (bowel sounds)-NL (normal) /No Bruits Tenderness-None....Extremities Throughout all extremities Appearance Normal CBR (capillary blood refill) < (less than)2 sec (seconds) Active ROM (range of motion)-Full Tenderness-None Neuro Major Muscle Groups 5/5 Gross Sensory Intact Gait Normal Skin No pallor/rashes warm & dry Back NT no CVAT (costovertebral Angle Tenderness), Back Flexion 90 Neck NT Full ROM No JVD (jugular vein distention)...." Review of "Repeat or Additional Clinical Notes" revealed documentation at 1331 "Affect depressed." Review revealed PA #1 ordered the following diagnostic studies for Patient #7: complete blood count (CBC), Basic Metabolic Panel (BMP), ETOH (alcohol) level, Urine Toxicology panel and urinalysis. Review of the urine toxicology panel results revealed Patient #7 tested positive for cocaine and THC (Marijuana). Review revealed the ETOH level was less than 3.0 (Reference Range <3.0 milligrams/deciliter). Review revealed at 1434 PA #1 ordered Ativan 2 milligrams (mg) orally, administered by RN #1 at 1501 and at 1636 Nicotine Patch 21 mg, administered by RN #1 at 1636. Review revealed an order at 1458 by PA #1 for "Cleared for mental health evaluation."

Review of a MCM (Mobile Crisis Management) Assessment dated 09/27/2012 (not timed) by MCM Staff #1 revealed "...PRESENTING PROBLEM: (Current Symptoms, Precipitating Events, Situational Stressors) Consumer presents in ER with suicidal ideations and a plan to hang himself. He has been diagnosed with bipolar disorder and schizophrenia with paranoia and has been without medication for several months." Review of a "SUICIDE RISK ASSESSMENT" revealed the following "Risk Factors" documented: Suicidal Behaviors (history of prior attempts, aborted attempts, self-injurious behaviors); Family History (completed suicide or attempts, Axis I diagnosis requiring hospitalization) and Childhood trauma (parental loss, sexual/physical abuse or neglect). Review of the "Suicide Inquiry" section revealed documentation of suicidal ideation within the last 48 hours, in the past month, and is the worst ever. Review of the "Has Suicide Plan" section revealed "Plans to hang himself" and the "plan is lethal" and "has availability to carry out plan." Review of the "Suicidal Behaviors" section revealed documentation "He was in process of hanging himself last week when his fiance walked in and stopped him. Further review revealed documentation of a history of aborted attempts and rehearsals. Review of the "Suicidal Intent" section revealed documentation "He intends to harm himself but states it is voices encouraging him to do so" Further review revealed "Believes plan is lethal (i.e. plan will cause more than self-injury)." Review of the "Risk Level and Intervention" section revealed documentation Patient #7 was assessed as a "High" risk level. Review of the "Risk/Protective Factors" section revealed "Has psychiatric diagnosis with severe symptoms or acute precipitating factors; protective factors not relevant." Review of the "Suicidality" section revealed "Potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal." Review of the "Recommended Interventions" revealed "Inpatient admission with suicide precautions is recommended unless there is a significant change to reduce risk. Develop crisis plan." Review of substance abuse documentation revealed a history of Marijuana use (09/26/2012), Cocaine use on 09/24/2012, and Alcohol use (09/26/2012). Review of "Social History" documentation revealed "(Current family structure and support network, Hx of trauma or abuse, Recent losses or stressors) Consumer lives with his fiance in XYZ County. He states he was sexually molested by his maternal grandfather from ages 6-12 years and did not tell anyone until he was 30 years old. At age 16, his brother's wife was killed in a car accident and consumer was in the car. At age 17, his brother committed suicide by hanging himself and consumer found the body. At age 20, his other brother's wife died and left them all to care for a 6-month old baby. Consumer states that he bottled up all these feelings, but is sure these events play a role in his feelings and behaviors now." Review revealed the patient is non-compliant with his current medications of Lithium, Neurontin, Seroquel, Paxil, and Ambien. Review of "Mental Status" documentation revealed the patient was assessed as oriented to person, place, time, and situation; mood/affect was depressed; behavior was calm and cooperative; appearance was unkept; eye contact was good; motor activity was unremarkable; speech was rapid; perceptual disturbances (hallucinations) included auditory and visual; thought content was concrete; thought process was attentative; insight was aware of self, problem acknowledged; acceptance of problem. Review revealed "Comments: Consumer is calm and cooperative, but states he often hears his deceased brother's voice encouraging him to 'do it' and join him. He is somewhat fidgety, but anxious for help." Review revealed a diagnostic impression(s) of Axis I: Bipolar Disorder NOS and Schizophrenia, Paranoid Type. Review of "Intervention" documentation revealed "Interviewed consumer in ER with his fiance present. Consumer endorses suicidal ideation and states it is getting worse. He attempts to self-medicate with marijuana and beer, but that has not been successful. He was an inpatient at (Hospital B) in June and says that greatly helped him. However, he stopped taking his medications because he couldn't afford them, and has gone downhill steadily. ...Consumer states that he is having visual and auditory hallucinations and most often hears his deceased brother talking to him and he also sees him. Consumer is anxious to get help he needs, fearful that he might not be able to fight off the feelings of suicide. His fiance found him last week with the rope around his neck and was able to talk him out of it. -Recommended treatment is in-patient, for which all agree. -Began the process of referral and placement. -called (Hospital C); they have beds and referral will be faxed. -Called (Hospital B)-no beds....Talked with consumer. He wishes to go directly to (Hospital B) because he is familiar with the doctor and is comfortable there. Advised that a placement was not guaranteed, but would probably be better from their (Hospital B) ER and he is a resident of that county. Consumer left with fiance to go directly to (Hospital B)."

Continued review of MSE documentation by PA #1 revealed "Repeat or Additional Clinical Notes" at 1813 revealed "No Sx(s) (symptoms) or Objective findings that are life or limb threatening. Medically Screened and Stable for disposition (Transfer) from the ED." Review revealed a diagnosis by PA #1 of "Suicidal Ideation with Plan" and "Depression" with a secondary diagnoses of "Psychiatric." Review revealed at 1516 documentation by PA #1 the patient's "Condition" was "Good" and at 1813 documentation of the patient's "Disposition" as "Discharge Psychiatric Facility." Review revealed documentation of a co-signature (not dated or timed) by Physician A (on-duty supervising attending physician on 09/27/2012).

Review of a "Discharge Instructions" form dated 09/27/2012 at 1813 revealed "Suicidal Ideation with Plan" and "Depression" documented as the diagnoses for Patient #7. Further review revealed "You have been evaluated today by a healthcare provider practicing Emergency Medicine. In most cases follow-up care is recommended with your regular Doctor, HMO (health management organization) or Clinic within 2 days....Call for appointment as soon as possible. IDENTIFY yourself as an ER Patient. If you don't have a doctor or need a specialist follow-up with Physician/Specialist (left blank) Address (left blank) Phone (left blank) Additional Instructions: If the symptoms worsen or new symptoms develop return to the Emergency Department (ED) immediately. Call your doctor for additional questions. ED phone number:....Eastpointe Crisis Hotline: (number)." Review revealed the handwritten signatures of PA #1, RN #1, and Patient #7 on the form. Review revealed no documentation Patient #7 was given discharge instructions to leave the DED of Hospital A and go directly to the DED of Hospital B.

Hospital B closed medical record review on 10/29/2012 for Patient #7 revealed a 33 year-old male who presented ambulatory via private transportation to the DED on 09/27/2012 at 1912 (59 minutes after discharge from Hospital A's DED). Review revealed an arrival complaint of "Psychiatric Emergency Suicidal Thoughts and a Plan." Review revealed at 1944 the patient was placed into treatment room ED05 and triaged by a Registered Nurse. Review revealed at 1945 the patient was placed on suicide monitoring and was assessed as "...Affect: Congruent with mood; Anxious; Sad/depressed: Behavior: Cooperative; Mood: Depressed; Guilt Feelings; Actions Taken: Continued Established Plan of Care; Observation Q (every) 15 minutes; MD Notified; Sleep Status: Awake." Review of triage nursing documentation at 1952 revealed "Pt (patient) was placed in #5 with sig (significant) other at bedside. Pt changed out into paper scrubs and room made safe to accommodate suicidal pt. As pt was changing into scrubs he informed nurse that he had been at (Hospital A name) ER (emergency room) and was dc (discharged) from there and told he needed to come to our ER (Hospital B) for placement so he didn't have to stay in their (Hospital A) ER for 2-3 days waiting for placement. He was also told not to tell anyone that (she), the crisis worker, had told him this instruction. NSS (Nursing Supervisor) made aware and (Hospital A name) contacted to confirm instructions." Review revealed the patient was assigned a triage acuity level of 2 (1 most severe, 5 least severe). Review of nursing documentation at 1955 revealed "Psychosocial Assessment Psychosocial - Meets Psychosocial Standard: No; Emotional State/Behavior: Calm; Cooperative; Anxious; Self-Perception: VerbDepr (verbalized depression); VerbSuic (verbalized suicidal ideation); Support System Present: Yes Suicide Risk Assessment - Have you had thoughts of harming/killing yourself in past month?: Yes (pt attempted to hang self 3 weeks ago but girlfriend discovered him before he was able to complete the act); Do you have a plan? Yes (pt has plan to hang himself with the means to do so); Do you have the means/items to carry out your plan?: Yes." Review of nursing documentation revealed Patient #7 was provided suicide monitoring every 15 minutes (+/-) until admission to Hospital B's inpatient psychiatric unit on 09/29/2012 at 1457 (43 hours 45 minutes after presentation to Hospital B's DED).

Review of MSE documentation dated 09/27/2012 at 2021 by Physician B revealed "HPI Comments: Patient is a 33 yo (year old) WM (white male) with a H/O (history of) depression, bipolar disorder, and paranoid schizophrenia, who has been off his medications for the past 2 months. He presents today with c/o (complaints of) worsening depression and suicidal ideations/gestures. His wife (girlfriend) caught him trying to hang himself 3 weeks ago, but he talked her out of calling authorities. The patient admits to hearing voices including the voice of his deceased brother, who also committed suicide. The patient was seen and evaluated at (Hospital A name) earlier today, and was discharged and instructed to go to (Hospital B name) because the patient expressed some interest in coming here because Dr. (Psychiatrist name) is here. The history is provided by the patient. Patient is a 33 yrs (years) male presenting with: Suicidal Ideations This is a recurrent problem. Episode onset: 1 week ago; worse over past 2 days. The problem occurs constantly. The problem has been gradually worsening.....Exacerbated by: Off psych meds for past 2 months. Nothing relieves the symptoms. He has tried nothing for the symptoms. ...Review of Symptoms....Psychiatric/Behavioral: Positive for suicidal ideas. ...Physical Exam: Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. No distress. ...Psychiatric: Appears depressed." Review of physician's orders revealed the patient was ordered a urine drug screen, complete blood count with differential, basic metabolic panel, ethanol level, and thyroid stimulating hormone level, and electrocardiogram (EKG). Review of test results revealed the patient was positive for cocaine and cannabinoids in the urine. The ethanol level was less than 3 (reference range 0-10 mg/dl). Review revealed a Telepsych (telepsychiatric) consult was ordered. Review revealed "Emergency Department Course: Lab studies reviewed. Telepsych consult pending. Further evaluation, treatment, and disposition endorsed to Dr. (Physician C) at shift change. Diagnosis: 1. Depression 2. Suicidal ideation/gesture." Review of continued MSE documentation by Physician C on 09/28/2012 at 0754 revealed "The patient was checked out to me for follow up by Dr. (Physician B) at the beginning of my shift at 0730. Present with depression....and suicidal ideations/gesure [sic]. He is under INC [sic] (involuntary commitment) papers. ...Plan: Psych consultation pending. 1930 The patient is stable and medically cleared for Psych evaluation. ...The medication recommended per psych consult started. Psychiatric disposition pending. The patient will be check out to Dr. (Physician B) for further care till disposition. ..."

Review of "Affidavit and Petition for Involuntary Commitment" form dated 09/27/2012 (not timed) signed by Physician B (Hospital B) revealed "I, the undersigned affiant, being first duly sworn, and having sufficient knowledge to believe that the respondent is a proper subject for involuntary commitment, allege that the respondent is a resident of, or can be found in the above named county, and is (Check all that apply) "X" in a box adjacent to "1. mentally ill and dangerous to self or others or mentally ill and in need of treatment in order to prevent further disability or deterioration that would predictably result in dangerousness,....The facts upon which this opinion is based are as follows:....(handwritten) Patient has a lengthy history of depression, bipolar disorder, and paranoid schizophrenia. He has been off his meds for the past 2 months. He presents to the ER complaining of worsening depression and suicidal ideation/gestures. His significant other caught him trying to hang himself 3 weeks ago, but he convinced her not to contact the authorities."

Review of "Findings and Custody Order Involuntary Commitment" form dated 09/27/2012 at 2215 signed by a magistrate revealed "...The Court finds from the petition in the above matter that there are reasonable grounds to believe that the facts alleged in the petition are true and that the respondent is probably: (Check all that apply) with an "X" marked in the box adjacent to "1. Mentally ill and dangerous to self or others or mentally ill and in need of treatment in order to prevent further disability or deterioration that would predictably result in dangerousness. ..."

Review of a Psychiatry History & Physical Note dated 09/30/2012 at 1200 by a Psychiatric Nurse Practitioner revealed "Chief Complaint: 'suicidal thoughts' HIP: 33 year old male admitted after having suicidal ideation with plan to hang himself. Has history of Bipolar Disorder and ran out of medications 2 months ago. Having increased mood lability with depressive symptoms. Having increased sadness, hopelessness, poor energy, poor appetite with decreased eating and weight loss, poor concentration and suicidal ideations. Having auditory hallucination of one voice, brother whom is deceased, telling him to hurt himself. Patient found deceased brother 15 years ago after he committed suicide. Anniversary date of this was July. Depressive symptoms have persisted after anniversary time. Increased mood lability. Having poor sleep, racing thoughts, flight of ideas, and increased irritability. Visual hallucinations of brother. Brought to ER by girlfriend who was concerned patient's safety. ...Assessment/Plan/Decision Making: Axis I: Bipolar Disorder, most recent episode mixed, severe with psychotic features...Polysubstance Dependence....Axis IV: Chronic mental illness, noncompliance....Recommendations: Psychoeducation and medication management. ..."

Review of a Psychiatry Discharge Summary dated 10/08/2012 at 1311 by a Psychiatrist revealed "...Course of Treatment in Hospital: The patient was admitted to the inpatient psychiatric unit after a complete physical and psychological evaluation. Medications were adjusted by starting haldol and remeron in addition to celexa. Medications were tolerated well. Patient has been able to care for self and participate in unit activities. Denies suicidal and homicidal ideations. No signs of self injurious behavior. Agrees to stay safe after discharge. ..." Review revealed the patient was discharged from Hospital B's inpatient psychiatric unit on 10/07/2012 (10 days after presentation to Hospital B's DED and discharge from Hospital A's DED).

Interview on 10/17/2012 at 0914 with PA #1 (Physician Assistant) revealed he was on-duty when Patient #7 presented to the DED of Hospital A on 09/27/2012. Interview revealed he was the provider who evaluated Patient #7. Interview revealed he remembers the patient because the hospital did a RCA (root-cause-analysis) on the patient. Interview revealed the RCA was performed because the patient left the hospital (Hospital A) and went to another hospital. Interview revealed he found out later that the patient went to (Hospital B name). Interview revealed he does not know if the patient was admitted or not, but he "assumed" Patient #7 was admitted. Interview revealed he reviewed the nursing notes and interviewed the patient (on 09/27/2012). The patient was having suicidal ideation and had a "vague plan." Interview revealed he felt the patient did not have a plan to hang himself because the patient came to the ED voluntarily and he was calm and cooperative. Interview revealed he did not feel the patient was going to hurt himself because the patient came voluntarily for help and was not under involuntary commitment petition. Interview revealed the patient had an unremarkable physical exam. The patient tested positive for cocaine and marijuana in his urine. Interview revealed he examined the patient, reviewed the labs, and cleared the patient for mental health evaluation. Interview revealed the patient was "medically cleared." Interview revealed the patient was anxious and he ordered Ativan and a Nicotine patch. Interview revealed a mobile crisis management staff member (MCM Staff #1) came to the ED to evaluate the patient psychologically. Interview revealed the MCM Staff evaluates the patient and helps with recommendations for dispositions. Interview revealed the MCM Staff are not employees of the hospital. Interview revealed the provider in consultation with the MCM staff member determines the disposition of the patient. Interview revealed MCM staff cannot discharge patients from the ED. Ordinarily, the MCM staff member verbally communicates/discusses their findings and case with the provider. Interview revealed he is not generally given a written consult note to review. Interview revealed "I know they have an assessment several pages long." Interview revealed the patient was awake and alert, and oriented X3 (person, place, time) with no signs of psychosis. The patient was calm and cooperative with a depressed affect. Interview revealed "not much information was relayed to me" by the MCM staff member. Interview revealed Patient #7 had "no sense of immediately going to do something to himself." Interview revealed he "knew the patient needed to be cared for in some type of facility." Interview revealed the intent was for "the patient to get inpatient psychiatric care." Interview revealed he had no idea where the patient would be placed or the mode of transportation. Interview revealed generally the MCM staff member makes arrangements with the accepting facility. Interview revealed when the MCM staff find a placement they usually inform the provider. Interview revealed the MCM staff will talk to their counter part at the receiving facility. Interview revealed the providers do not normally talk provider to provider with the accepting facility. Interview revealed he felt the patient needed to go to a facility for inpatient admission and not to be discharged from the ED. Interview revealed Patient #7 "had a serious psychiatric problem." Interview revealed he believed the patient would not commit suicide. Interview revealed "absolutely" a psychiatric condition can be an emergency medical condition. Interview revealed "potentially" the patient had a EMC. Interview revealed "If not the patient would have been appropriate for outpatient care." Interview revealed "I felt like the patient was reasonably stable to be transferred to an inpatient facility but not stable to be discharged." Interview revealed he did not review the MCM Assessment note completed by MCM Staff #1 after her evaluation of Patient #7 on 09/27/2012. Interview revealed he was unaware the patient was in the process of hanging himself last week when his fiance walked in and stopped him; unaware of the patient having auditory and visual hallucinations of his deceased brother; unaware of the patient's social history of his brother committing suicide by hanging; and unaware the patient had been identified as high risk for suicide with a recommendation for inpatient admission with suicide precautions as documented in the MCM Assessment by MCM Staff #1. Interview revealed "I did not talk to (MCM Staff #1 name) or review her documentation." Interview revealed he did not give an order for the patient to be discharged and go by private vehicle to Hospital B. Interview revealed the expectation was for the patient to be transferred. Interview revealed the patient's mental health evaluation had been performed and he was told the patient was going to another facility with his girlfriend. Interview revealed he was asked to change the patient's disposition in the computer from a transfer to a discharge by the nurse (RN #1). Interview revealed he did not communicate directly with (MCM Staff #1 name), he was advised by the nurse (RN #1). Interview revealed his decision was made based on "incomplete information" and if he had known about the previous hanging attempt and hallucinations the patient would have been an involuntary commitment. Interview revealed an "assumption" was made based on evaluation from Mobile Crisis (MCM Staff #1), the patient's risk was not high. Interview revealed he was made aware transport was to take place by the patient's girlfriend. Interview revealed based on the interactions with the patient and the patient was calm and cooperative at that moment transport by private vehicle with the girlfriend was appropriate. Interview revealed after review of the MCM assessment documentation (on 10/17/2012) the patient would have been involuntarily committed. Interview revealed the patient would have been transported by law enforcement or ambulance if under involuntary commitment petition. Interview revealed the physician's certification for transfer forms are completed prior to the patient's departure from the ED because the provider must reevaluate the patient prior to departure and also to complete paperwork when provided the information of when and where the patient is going. Interview revealed a physician's certification form was not completed for Patient #7. Interview revealed he does not know if the patient was explained the risk or benefits of transfer. Interview revealed he does not know if any ED medical records accompanied the patient when he was discharged for the accepting facility. Interview revealed he did not know if a physician accepted the patient nor if the accepting facility had space available at the time of discharge. Interview revealed he "feels the breakdown occurred with not getting all information from the crisis worker prior to discharge." Interview revealed he did not dis

Based on policy reviews, closed medical record reviews, staff and physician interviews the hospital's dedicated emergency department (DED) failed to ensure an appropriate transfer for 1 of 10 sampled DED patients (#7) that were transferred with an emergency medical condition by failing to ensure a physician certified the medical benefits of transfer outweighed the risks to the patient; obtaining the patient's consent for and/or refusal for transfer; ensure and document the receiving facility had space and qualified personnel available and agreed to accept the patient; ensure copies of all pertinent medical records available at the time of transfer were sent to the receiving hospital; and ensure the transfer was effected through qualified personnel and transportation equipment.

The findings include:

Review of current hospital policy "Emergency Medical Screening, Treatment, Transfer and on-call Roster Policy" (revised 07/12/2011) revealed "...C. Stabilization and Treatment Beyond the Capability of the Emergency Department (Procedure) 1. A patient experiencing an emergency medical condition must be stabilized prior to being discharged or transferred. (Points to Remember) 1. A patient is considered to be stabilized when the treating physician has determined with reasonable clinical confidence that the patient's emergency medical condition has been resolved. (Procedure) 2. The Emergency Department physician is responsible for the general care of all patients presenting to the Emergency Department until the patient's private physician or an on-call physician assumes that responsibility or the patient is discharged or transferred. ...(Procedure) 7. After being informed of the risks and benefits of treatment and the risks of refusing treatment, if a patient refuses to accept treatment that has been recommended to stabilize an emergency medical condition, reasonable steps shall be taken to obtain the patient's signature and the refusal on the Release of Responsibility for Discharge Form (A-34). (Points to Remember) 7. The refusal should be documented in the medical record. ...(Procedure) 9. A patient may be discharged after the emergency medical conditions has been resolved or after determination has been made that the patient is stable for discharge. (Points to Remember) 9. Stable for discharge means that continued care including diagnostic work up and/or treatment can be safely performed on an outpatient basis, or later on an inpatient basis, provided the patient is given a plan for appropriate follow up care with discharge instructions. ...D. On-Call Rotation Responsibilities ...(Procedure) 2. Transfer arrangements with the hospital that can provide the speciality service shall be made when the speciality service is not available. (Points to Remember) 2. Patients shall be transferred in accordance with this policy and procedure. ...E. Patient Transfers to A Medical Facility ...(Procedure) 2. Appropriate steps shall be taken and treatment provided to minimize the risks associated with transfer. (Points to Remember) 2. SRMC must provide the medical treatment necessary to stabilize the patient and reduce the risk of transfer within its capacity. The care and condition of the individual must be documented in the medical record. A copy of the medical record including test results, consent forms, and physician transfer certification must be provided to the receiving hospital. (Procedure) 3. When a patient requests a transfer, the physician shall discuss the risks associated with the transfer and the services that would be provided if the patient is not transferred. If the patient continues to request a transfer, reasonable steps must be taken to obtain written confirmation of this request from the patient. (Points to Remember) 3. If the patient requests the transfer against the advice of the physician, this shall be noted in the patient's transfer form. If the patient refuses to sign the form, all pertinent information shall be recorded in the patient's medical record. (Procedure) 4. When a physician initiates the transfer, the Emergency Department or on-call physician shall complete the Transfer Certification Form which must include the summary of the risks and benefits of transfer (Form A-262A). (Points to Remember) 4. Reasonable steps shall be taken to secure the written consent of the patient for the transfer. If the patient refuses to sign the form, all pertinent information shall be recorded in the medial record. If the patient refuses a transfer that is recommended by a physician, steps shall be taken to obtain this refusal in writing and the same shall be documented in the patient's medial record. (Procedure) 5. In all cases of patient transfer, consent of the receiving hospital and physician must be obtained and documented in the patient's medial record before the transfer. (Points to Remember) 5. This consent is to include that the receiving hospital has available space and qualified personnel to provide treatment to the patient. The patient's condition must be documented in the median record prior to transfer. ... (Procedure) 6. If a patient has been accepted for transfer but no bed is available or transport delays are expected or incurred, efforts should be made to obtain a bed at another facility. (Points to Remember) 6. Delays in transfer form the ED grater than twelve hours (or sooner if indicated by patient condition) should be communicated up the chain of command for assistance.... (Procedures) 7. Copies of the patient's medical record including, but not limited to, symptoms, preliminary diagnosis, treatment provided, test results, and informed written consent or transfer certification shall be sent with the patient to the receiving hospital. (Points to Remember) 7. EMTALA requires that the medical records containing the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide stabilizing treatment. (Procedure) 8. The transfer of a patient shall be carried out by qualified personnel using transportation equipment appropriate for the patient's medical condition. (Points to Remember) 8. The physician at the sending hospital has the responsibility of determining the appropriate mode, equipment, and attendants for the transfer. ...(Procedure) 10. The referring physician will specify on the transfer orders form (A-262) the medical records which should be copied and sent with the patient. (Points to Remember) 10. The staff member copying the record should check the appropriate areas on the transfer orders form verifying the record has been copied. Sign, date and time the form in the appropriate space. ...(Procedure) 13. The nurse caring for the patient at this facility should give a report to the nurse at the receiving facility prior to transport. ..."

Hospital A closed medical record review on 10/16/2012 for Patient #7 revealed a 33 year old male who presented ambulatory via private transportation to the DED on 09/27/2012 at 1243. The patient was triaged at 1300 by a Registered Nurse (RN #1). Review of triage nurse documentation revealed a chief complaint of "Suicidal Ideations." Review revealed "Associated Sxs (symptoms)/Pertinent History PT (patient) PRESENTS TO ED WITH SUICIDAL IDEATIONS, PT TEARFUL REPORTING HAS BEEN OFF MEDS X3 MONTHS DUE TO NOT HAVING MONEY TO BUY THEM. PT WAS INPATIENT AT (Hospital B name) IN MAY FOR SAME AND DOING GOOD WHEN ON MEDS PER FEMALE VISITOR. PT ASKED IF HE HAS A PLAN AND STATES, 'I WANT TO HANG MYSELF'. PT COOPERATIVE AND POLITE. PT DENIES HOMICIDAL IDEATIONS OR ILLICIT DRUG USE. DOES ADMIT DRINKS ALCOHOL." Review revealed a past medical history (PMH) of Manic Depressive; Bipolar Disorder; and Schizophrenia. Review revealed the patient's current medications as Lithium (anti-manic), Neurontin (anti-convulsant), Seroquel (anti-psychotic), Paxil (selective serotonin reuptake inhibitor), Ambien (sedative-hypnotic). Review revealed the patient was assessed as alert and oriented with a Glasgow Coma Scale (scale used for measuring level of consciousness) of 15 (normal). Review revealed the patient's vital signs were assessed as: temperature (T) 98.1 degrees Fahrenheit; heart rate (HR) 118; blood pressure (BP) 142/88; respiratory rate (RR) 22; oxygen saturation (O2 Sat) 98% on room air. Review revealed a pain assessment was performed using a numerical pain scale with "No Pain" documented. Review revealed the patient was assigned category "4 Level - Non-(urgent)" (Level 1 most severe, Level 5 least severe). Review of nursing documentation by RN #1 at 1326 revealed "PA (physician assistant)....AT BEDSIDE FOR PT EVAL (evaluation)"; at 1432 "VITALS OBTAINED AND WNL (within normal limits). PT ADMITTING TO THIS RN THAT HE SMOKES A JOINT EVERY NOW AND THEN AND DID SOME COCAINE MONDAY. PT SAYING, 'I JUST DON'T WANT TO LIE TO YALL I WANTED TO LET YOU KNOW'."; at 1532 "MOBILE CRISIS (MC) [a contracted psychiatric/mental health evaluation service] CONTACTED FOR REFERRAL. PT INFO GIVEN...."; at 1617 "(name) WITH MC AT BEDSIDE SPEAKING WITH PT"; at 1628 "PT REPORTING IS BECOMING AGITATED BECAUSE HE WANT TO SMOKE. ..."; at 1724 "PT TELLING THIS NURSE HE IS GOING TO WALK HIS GIRLFRIEND OUT TO CAR AND WILL BE BACK. PT THEN SAYING 'I PROMISE I WON'T GO ANYWHERE. I CAME FOR HELP AND I WANT HELP'."; at 1739 "PT BACK IN ROOM."; at 1757 "(MC staff name) AT BEDSIDE SPEAKING WITH PT."; and at 1815 "PT DC'D (discharged) TO GIRLFRIEND WHO IS TAKING PT STRAIGH [sic] TO (Hospital B name) EVAL (evaluation) AND TX (treatment). PT THANKFUL FOR CARE PROVIDED. AMB (ambulatory) TO ER LOBBY IN NAD (no acute distress) WITH GIRLFRIEND."

Review of MSE documentation by PA #1 at 1315 revealed "History of Present Illness (HPI) 33 Year Old M (male) Patient Presents with Suicidal Ideations with Plan for seevral [sic] days. The Onset is Gradually worsening sx (symptoms) since running out of medications 2-3 months ago. The symptoms are No Pain. Additional Symptoms or Pertinent History also involve Depressed mood. Furthermore, the Patient/Family Denies Acute medical symptoms. Patient states exacerbating Factors that occur are No medications." Review of "Review of Systems (ROS)" documentation revealed "...Psych(iatric) HPI..." Review revealed a check mark in a box adjacent to "All other ROS negative." Review revealed a check mark in a box adjacent to "Vital Signs/Triage/Nursing Notes Reviewed and Agree." Review of "Past Medical History" documentation revealed a check mark in a box adjacent to "Psychiatric." Review of "Social History" documentation revealed a check mark in a box adjacent to "ETOH (alcohol)" and "Smoking." Review of "Family History (FMHx)" documentation revealed a check mark in a box adjacent to "Past Family History reviewed and not relevant No Significant FMHx." Review of "Physical Exam" documentation revealed "General Appearance Awake A&Ox3 (alert and oriented times person, place, time) HEENT (head, ears, eyes, nose, throat) PERRL (pupils equal round reactive light) EOMI (extra-ocular movements intact) Moist Mucous Membranes No icterus Chest RRR (regular rate rhythm) No M (murmur) Lungs CTA (clear to auscultation) No Ret (retractions) Chest Wall NT (nontender) Abdomen No Pulsating Masses BS (bowel sounds)-NL (normal) /No Bruits Tenderness-None....Extremities Throughout all extremities Appearance Normal CBR (capillary blood refill) < (less than)2 sec (seconds) Active ROM (range of motion)-Full Tenderness-None Neuro Major Muscle Groups 5/5 Gross Sensory Intact Gait Normal Skin No pallor/rashes warm & dry Back NT no CVAT (costovertebral Angle Tenderness), Back Flexion 90 Neck NT Full ROM No JVD (jugular vein distention)...." Review of "Repeat or Additional Clinical Notes" revealed documentation at 1331 "Affect depressed." Review revealed PA #1 ordered the following diagnostic studies for Patient #7: complete blood count (CBC), Basic Metabolic Panel (BMP), ETOH (alcohol) level, Urine Toxicology panel and urinalysis. Review of the urine toxicology panel results revealed Patient #7 tested positive for cocaine and THC (Marijuana). Review revealed the ETOH level was less than 3.0 (Reference Range <3.0 milligrams/deciliter). Review revealed at 1434 PA #1 ordered Ativan 2 milligrams (mg) orally, administered by RN #1 at 1501 and at 1636 Nicotine Patch 21 mg, administered by RN #1 at 1636. Review revealed an order at 1458 by PA #1 for "Cleared for mental health evaluation."

Review of a MCM (Mobile Crisis Management) Assessment dated 09/27/2012 (not timed) by MCM Staff #1 revealed "...PRESENTING PROBLEM: (Current Symptoms, Precipitating Events, Situational Stressors) Consumer presents in ER with suicidal ideations and a plan to hang himself. He has been diagnosed with bipolar disorder and schizophrenia with paranoia and has been without medication for several months." Review of a "SUICIDE RISK ASSESSMENT" revealed the following "Risk Factors" documented: Suicidal Behaviors (history of prior attempts, aborted attempts, self-injurious behaviors); Family History (completed suicide or attempts, Axis I diagnosis requiring hospitalization) and Childhood trauma (parental loss, sexual/physical abuse or neglect). Review of the "Suicide Inquiry" section revealed documentation of suicidal ideation within the last 48 hours, in the past month, and is the worst ever. Review of the "Has Suicide Plan" section revealed "Plans to hang himself" and the "plan is lethal" and "has availability to carry out plan." Review of the "Suicidal Behaviors" section revealed documentation "He was in process of hanging himself last week when his fiance walked in and stopped him. Further review revealed documentation of a history of aborted attempts and rehearsals. Review of the "Suicidal Intent" section revealed documentation "He intends to harm himself but states it is voices encouraging him to do so" Further review revealed "Believes plan is lethal (i.e. plan will cause more than self-injury)." Review of the "Risk Level and Intervention" section revealed documentation Patient #7 was assessed as a "High" risk level. Review of the "Risk/Protective Factors" section revealed "Has psychiatric diagnosis with severe symptoms or acute precipitating factors; protective factors not relevant." Review of the "Suicidality" section revealed "Potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal." Review of the "Recommended Interventions" revealed "Inpatient admission with suicide precautions is recommended unless there is a significant change to reduce risk. Develop crisis plan." Review of substance abuse documentation revealed a history of Marijuana use (09/26/2012), Cocaine use on 09/24/2012, and Alcohol use (09/26/2012). Review of "Social History" documentation revealed "(Current family structure and support network, Hx of trauma or abuse, Recent losses or stressors) Consumer lives with his fiance in XYZ County. He states he was sexually molested by his maternal grandfather from ages 6-12 years and did not tell anyone until he was 30 years old. At age 16, his brother's wife was killed in a car accident and consumer was in the car. At age 17, his brother committed suicide by hanging himself and consumer found the body. At age 20, his other brother's wife died and left them all to care for a 6-month old baby. Consumer states that he bottled up all these feelings, but is sure these events play a role in his feelings and behaviors now." Review revealed the patient is non-compliant with his current medications of Lithium, Neurontin, Seroquel, Paxil, and Ambien. Review of "Mental Status" documentation revealed the patient was assessed as oriented to person, place, time, and situation; mood/affect was depressed; behavior was calm and cooperative; appearance was unkept; eye contact was good; motor activity was unremarkable; speech was rapid; perceptual disturbances (hallucinations) included auditory and visual; thought content was concrete; thought process was attentative; insight was aware of self, problem acknowledged; acceptance of problem. Review revealed "Comments: Consumer is calm and cooperative, but states he often hears his deceased brother's voice encouraging him to 'do it' and join him. He is somewhat fidgety, but anxious for help." Review revealed a diagnostic impression(s) of Axis I: Bipolar Disorder NOS and Schizophrenia, Paranoid Type. Review of "Intervention" documentation revealed "Interviewed consumer in ER with his fiance present. Consumer endorses suicidal ideation and states it is getting worse. He attempts to self-medicate with marijuana and beer, but that has not been successful. He was an inpatient at (Hospital B) in June and says that greatly helped him. However, he stopped taking his medications because he couldn't afford them, and has gone downhill steadily. ...Consumer states that he is having visual and auditory hallucinations and most often hears his deceased brother talking to him and he also sees him. Consumer is anxious to get help he needs, fearful that he might not be able to fight off the feelings of suicide. His fiance found him last week with the rope around his neck and was able to talk him out of it. -Recommended treatment is in-patient, for which all agree. -Began the process of referral and placement. -called (Hospital C); they have beds and referral will be faxed. -Called (Hospital B)-no beds....Talked with consumer. He wishes to go directly to (Hospital B) because he is familiar with the doctor and is comfortable there. Advised that a placement was not guaranteed, but would probably be better from their (Hospital B) ER and he is a resident of that county. Consumer left with fiance to go directly to (Hospital B)."

Continued review of MSE documentation by PA #1 revealed "Repeat or Additional Clinical Notes" at 1813 revealed "No Sx(s) (symptoms) or Objective findings that are life or limb threatening. Medically Screened and Stable for disposition (Transfer) from the ED." Review revealed a diagnosis by PA #1 of "Suicidal Ideation with Plan" and "Depression" with a secondary diagnoses of "Psychiatric." Review revealed at 1516 documentation by PA #1 the patient's "Condition" was "Good" and at 1813 documentation of the patient's "Disposition" as "Discharge Psychiatric Facility." Review revealed documentation of a co-signature (not dated or timed) by Physician A (on-duty supervising attending physician on 09/27/2012).

Review of a "Discharge Instructions" form dated 09/27/2012 at 1813 revealed "Suicidal Ideation with Plan" and "Depression" documented as the diagnoses for Patient #7. Further review revealed "You have been evaluated today by a healthcare provider practicing Emergency Medicine. In most cases follow-up care is recommended with your regular Doctor, HMO (health management organization) or Clinic within 2 days....Call for appointment as soon as possible. IDENTIFY yourself as an ER Patient. If you don't have a doctor or need a specialist follow-up with Physician/Specialist (left blank) Address (left blank) Phone (left blank) Additional Instructions: If the symptoms worsen or new symptoms develop return to the Emergency Department (ED) immediately. Call your doctor for additional questions. ED phone number:....Eastpointe Crisis Hotline: (number)." Review revealed the handwritten signatures of PA #1, RN #1, and Patient #7 on the form. Review revealed no documentation Patient #7 was given discharge instructions to leave the DED of Hospital A and go directly to the DED of Hospital B.

Review of Hospital A medical records failed to reveal any available documentation that PA #1 or Physician A completed a physician's certification for transfer form and/or certified that the medical benefits of transfer outweighed the risks to the patient; obtained the patient's consent for and/or refusal for transfer; ensured the receiving facility had space and qualified personnel available and agreed to accept the patient; copies of all pertinent medical records available at the time of transfer were sent to the receiving hospital; and the transfer was effected through qualified personnel and transportation equipment. Further review failed to reveal any documentation RN #1 called Hospital B to give a report at the time of discharge.

Hospital B closed medical record review on 10/29/2012 for Patient #7 revealed a 33 year-old male who presented ambulatory via private transportation to the DED on 09/27/2012 at 1912 (59 minutes after discharge from Hospital A's DED). Review revealed an arrival complaint of "Psychiatric Emergency Suicidal Thoughts and a Plan." Review revealed at 1944 the patient was placed into treatment room ED05 and triaged by a Registered Nurse. Review revealed at 1945 the patient was placed on suicide monitoring and was assessed as "...Affect: Congruent with mood; Anxious; Sad/depressed: Behavior: Cooperative; Mood: Depressed; Guilt Feelings; Actions Taken: Continued Established Plan of Care; Observation Q (every) 15 minutes; MD Notified; Sleep Status: Awake." Review of triage nursing documentation at 1952 revealed "Pt (patient) was placed in #5 with sig (significant) other at bedside. Pt changed out into paper scrubs and room made safe to accommodate suicidal pt. As pt was changing into scrubs he informed nurse that he had been at (Hospital A name) ER (emergency room) and was dc (discharged) from there and told he needed to come to our ER (Hospital B) for placement so he didn't have to stay in their (Hospital A) ER for 2-3 days waiting for placement. He was also told not to tell anyone that (she), the crisis worker, had told him this instruction. NSS (Nursing Supervisor) made aware and (Hospital A name) contacted to confirm instructions." Review revealed the patient was assigned a triage acuity level of 2 (1 most severe, 5 least severe). Review of nursing documentation at 1955 revealed "Psychosocial Assessment Psychosocial - Meets Psychosocial Standard: No; Emotional State/Behavior: Calm; Cooperative; Anxious; Self-Perception: VerbDepr (verbalized depression); VerbSuic (verbalized suicidal ideation); Support System Present: Yes Suicide Risk Assessment - Have you had thoughts of harming/killing yourself in past month?: Yes (pt attempted to hang self 3 weeks ago but girlfriend discovered him before he was able to complete the act); Do you have a plan? Yes (pt has plan to hang himself with the means to do so); Do you have the means/items to carry out your plan?: Yes." Review of nursing documentation revealed Patient #7 was provided suicide monitoring every 15 minutes (+/-) until admission to Hospital B's inpatient psychiatric unit on 09/29/2012 at 1457 (43 hours 45 minutes after presentation to Hospital B's DED).

Review of MSE documentation dated 09/27/2012 at 2021 by Physician B revealed "HPI Comments: Patient is a 33 yo (year old) WM (white male) with a H/O (history of) depression, bipolar disorder, and paranoid schizophrenia, who has been off his medications for the past 2 months. He presents today with c/o (complaints of) worsening depression and suicidal ideations/gestures. His wife (girlfriend) caught him trying to hang himself 3 weeks ago, but he talked her out of calling authorities. The patient admits to hearing voices including the voice of his deceased brother, who also committed suicide. The patient was seen and evaluated at (Hospital A name) earlier today, and was discharged and instructed to go to (Hospital B name) because the patient expressed some interest in coming here because Dr. (Psychiatrist name) is here. The history is provided by the patient. Patient is a 33 yrs (years) male presenting with: Suicidal Ideations This is a recurrent problem. Episode onset: 1 week ago; worse over past 2 days. The problem occurs constantly. The problem has been gradually worsening.....Exacerbated by: Off psych meds for past 2 months. Nothing relieves the symptoms. He has tried nothing for the symptoms. ...Review of Symptoms....Psychiatric/Behavioral: Positive for suicidal ideas. ...Physical Exam: Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. No distress. ...Psychiatric: Appears depressed." Review of physician's orders revealed the patient was ordered a urine drug screen, complete blood count with differential, basic metabolic panel, ethanol level, and thyroid stimulating hormone level, and electrocardiogram (EKG). Review of test results revealed the patient was positive for cocaine and cannabinoids in the urine. The ethanol level was less than 3 (reference range 0-10 mg/dl). Review revealed a Telepsych (telepsychiatric) consult was ordered. Review revealed "Emergency Department Course: Lab studies reviewed. Telepsych consult pending. Further evaluation, treatment, and disposition endorsed to Dr. (Physician C) at shift change. Diagnosis: 1. Depression 2. Suicidal ideation/gesture." Review of continued MSE documentation by Physician C on 09/28/2012 at 0754 revealed "The patient was checked out to me for follow up by Dr. (Physician B) at the beginning of my shift at 0730. Present with depression....and suicidal ideations/gesure [sic]. He is under INC [sic] (involuntary commitment) papers. ...Plan: Psych consultation pending. 1930 The patient is stable and medically cleared for Psych evaluation. ...The medication recommended per psych consult started. Psychiatric disposition pending. The patient will be check out to Dr. (Physician B) for further care till disposition. ..."

Review of "Affidavit and Petition for Involuntary Commitment" form dated 09/27/2012 (not timed) signed by Physician B (Hospital B) revealed "I, the undersigned affiant, being first duly sworn, and having sufficient knowledge to believe that the respondent is a proper subject for involuntary commitment, allege that the respondent is a resident of, or can be found in the above named county, and is (Check all that apply) "X" in a box adjacent to "1. mentally ill and dangerous to self or others or mentally ill and in need of treatment in order to prevent further disability or deterioration that would predictably result in dangerousness,....The facts upon which this opinion is based are as follows:....(handwritten) Patient has a lengthy history of depression, bipolar disorder, and paranoid schizophrenia. He has been off his meds for the past 2 months. He presents to the ER complaining of worsening depression and suicidal ideation/gestures. His significant other caught him trying to hang himself 3 weeks ago, but he convinced her not to contact the authorities."

Review of "Findings and Custody Order Involuntary Commitment" form dated 09/27/2012 at 2215 signed by a magistrate revealed "...The Court finds from the petition in the above matter that there are reasonable grounds to believe that the facts alleged in the petition are true and that the respondent is probably: (Check all that apply) with an "X" marked in the box adjacent to "1. Mentally ill and dangerous to self or others or mentally ill and in need of treatment in order to prevent further disability or deterioration that would predictably result in dangerousness. ..."

Review of a Psychiatry History & Physical Note dated 09/30/2012 at 1200 by a Psychiatric Nurse Practitioner revealed "Chief Complaint: 'suicidal thoughts' HIP: 33 year old male admitted after having suicidal ideation with plan to hang himself. Has history of Bipolar Disorder and ran out of medications 2 months ago. Having increased mood lability with depressive symptoms. Having increased sadness, hopelessness, poor energy, poor appetite with decreased eating and weight loss, poor concentration and suicidal ideations. Having auditory hallucination of one voice, brother whom is deceased, telling him to hurt himself. Patient found deceased brother 15 years ago after he committed suicide. Anniversary date of this was July. Depressive symptoms have persisted after anniversary time. Increased mood lability. Having poor sleep, racing thoughts, flight of ideas, and increased irritability. Visual hallucinations of brother. Brought to ER by girlfriend who was concerned patient's safety. ...Assessment/Plan/Decision Making: Axis I: Bipolar Disorder, most recent episode mixed, severe with psychotic features...Polysubstance Dependence....Axis IV: Chronic mental illness, noncompliance....Recommendations: Psychoeducation and medication management. ..."

Review of a Psychiatry Discharge Summary dated 10/08/2012 at 1311 by a Psychiatrist revealed "...Course of Treatment in Hospital: The patient was admitted to the inpatient psychiatric unit after a compete physical and psychological evaluation. Medications were adjusted by starting haldol and remeron in addition to celexa. Medications were tolerated well. Patient has been able to care for self and participate in unit activities. Denies suicidal and homicidal ideations. No signs of self injurious behavior. Agrees to stay safe after discharge. ..." Review revealed the patient was discharged from Hospital B's inpatient psychiatric unit on 10/07/2012 (10 days after presentation to Hospital B's DED and discharge from Hospital A's DED).

Interview on 10/17/2012 at 0914 with PA #1 (Physician Assistant) revealed he was on-duty when Patient #7 presented to the DED of Hospital A on 09/27/2012. Interview revealed he was the provider who evaluated Patient #7. Interview revealed he remembers the patient because the hospital did a RCA (root-cause-analysis) on the patient. Interview revealed the RCA was performed because the patient left the hospital (Hospital A) and went to another hospital. Interview revealed he found out later that the patient went to (Hospital B name). Interview revealed he does not know if the patient was admitted or not, but he "assumed" Patient #7 was admitted. Interview revealed he reviewed the nursing notes and interviewed the patient (on 09/27/2012). The patient was having suicidal ideation and had a "vague plan." Interview revealed he felt the patient did not have a plan to hang himself because the patient came to the ED voluntarily and he was calm and cooperative. Interview revealed he did not feel the patient was going to hurt himself because the patient came voluntarily for help and was not under involuntary commitment petition. Interview revealed the patient had an unremarkable physical exam. The patient tested positive for cocaine and marijuana in his urine. Interview revealed he examined the patient, reviewed the labs, and cleared the patient for mental health evaluation. Interview revealed the patient was "medically cleared." Interview revealed the patient was anxious and he ordered Ativan and a Nicotine patch. Interview revealed a mobile crisis management staff member (MCM Staff #1) came to the ED to evaluate the patient psychologically. Interview revealed the MCM Staff evaluates the patient and helps with recommendations for dispositions. Interview revealed the MCM Staff are not employees of the hospital. Interview revealed the provider in consultation with the MCM staff member determines the disposition of the patient. Interview revealed MCM staff cannot discharge patients from the ED. Ordinarily, the MCM staff member verbally communicates/discusses their findings and case with the provider. Interview revealed he is not generally given a written consult note to review. Interview revealed "I know they have an assessment several pages long." Interview revealed the patient was awake and alert, and oriented X3 (person, place, time) with no signs of psychosis. The patient was calm and cooperative with a depressed affect. Interview revealed "not much information was relayed to me" by the MCM staff member. Interview revealed Patient #7 had "no sense of immediately going to do something to himself." Interview revealed he "knew the patient needed to be cared for in some type of facility." Interview revealed the intent was for "the patient to get inpatient psychiatric care." Interview revealed he had no idea where the patient would be placed or the mode of transportation. Interview revealed generally the MCM staff member makes arrangements with the accepting facility. Interview revealed when the MCM staff find a placement they usually inform the provider. Interview revealed the MCM staff will talk to their counter part at the receiving facility. Interview revealed the providers do not normally talk provider to provider with the accepting facility. In