HospitalInspections.org

Based on interviews and record reviews, the facility failed to maintain an accurate central log (ED log), when one of 21 Patients (Patient 1) presented to the facility's Emergency Department (ED) under an involuntary (5150) hold in the presence of law enforcement, but the facility did not enter patient information into the ED log. This failure did not comply with Federal law and had the potential to result in delayed care and treatment for an emergency medical condition.

Findings:

On 4/13/21, at 8:25 a.m., Registered Nurse (RN) (Nurse A) stated in her interview, she spoke with two Sheriff Officers by the Ambulance Entrance door and discussed a patient for which the officers presented a 5051 form. Nurse A stated she did not see the patient and assumed the patient was in the Sheriff's vehicle. Nurse A stated the 5150 document indicated the patient was violent and broke a restraining order. Nurse A stated she told the officers being violent was a criminal act and not criteria to place someone under an involuntary hold, and she would provide a "jail clearance" for the patient and put the patient in the room if they had one available. Nurse A stated jail clearance meant the ED staff will triage the patient, and the ED Physician will perform a Medical Screening Examination (MSE). Nurse A stated she did not refuse to see the patient. Nurse A stated Nurse Manager B joined the conversation with the two Officers and similarly stated the officer's 5150 determination was inappropriate. Nurse A stated one of the Officers "ripped" the 5150 paperwork from Nurse Manager B, and the two officers left the ED. Nurse A stated the Officer told Nurse Manager B they were going to another hospital.

During an interview on 4/13/2, at 10:15 a.m., Nurse Manager B stated she recalled when the Sheriff's Officer presented a 5150 form for Patient 1. Nurse Manager B stated the officer's 5150 form was not written appropriately and the patient did not meet the criteria of a gravely disabled patient. Nurse Manager B stated the patient had violated a restraining order and refused to take her medications. When asking Nurse Manager B if the facility's nurses have the authority to question the validity of the law-enforcement-initiated 5150, she stated, they "certainly do" based on the hospital's policy and procedures that address patient rights.

During an interview on 4/13/21, at 11:15 a.m., Clerk I and Admitting Clerk J were asked about the incident involving the two Officers and a patient, from 3/12/21. Both Clerks stated they did not receive the patient's information, thus the patient's name and other information was not logged.

During an interview on 4/14/21 at 7:38 a.m., Nurse D was asked who had the authority to decide if law enforcement's 5150 determination was appropriate. Nurse D stated when a patient is brought in on a 5150 or for jail clearance, we cannot revoke the patient we must accept the patient. Triage is conducted and the MD must evaluate patients that come in for jail clearance, the officer must stay with the patient being cleared for jail, they are considered under arrest. Patients under a 5150 involuntary hold are triaged and assessed by the MD and must be cleared by Behavioral Health. Law enforcement usually stays until the patient is settled and they leave.

During an interview on 4/14/21 at 7:55 a.m., Physician E was questioned about the 5150 process, he stated, when an officer comes to the door and presents with a patient under a 5150 involuntary hold, we are to receive all patients and provide a medical screening. Physician E stated, "Yes, we are obliged" to see the patient.

During review of electronic correspondence with the complainant from 3/15/21, at 11:16 a.m., the complainant provided the original 5150 involuntary detention document for Patient 1, dated 3/12/21, at 7:19 a.m., which had been completed by law enforcement. The document indicated law enforcement had completed the form intending the facility to provide care and services to Patient 1 because the patient was "a danger to ... herself," as she had been walking outdoors in cold weather without appropriate clothing, had not been able to answer simple questions appropriately, had not been taking her medication, and was experiencing a manic episode. The form neither indicated Patient 1 was assaultive nor gravely disabled.

During a record review of the facility's ED Log on 4/13/21, Sampled Patients were selected based on the following criteria: individual who left without being seen, left against medical advice, transferred to other facilities, refused examination/treatment/transfer, and returned to the emergency department within 48 hours. The ED Log did not show any gaps or non-sequential entries. The ED Log did not indicate Patient 1 had presented to the facility's ED on 3/12/21.

The facility's policy and procedure titled, "Structure Standards ED," reviewed, 4/2018, indicated: All patients presenting to the ED will be entered into the central log ... ." The policy did not indicate encounters involving a patient and law enforcement, like that on 3/12/21, at 7:26 a.m., should not be documented in the ED log.

Review of the facility's policy and procedure titled "Psychiatric Crisis - 5150," dated, 2/2019, indicates: 5150 authorizes Emergency Department physicians and persons designated by the County (including peace officers and designated licensed psychiatrist) to take, or cause to be taken, a person into custody and placed in a designated facility. The Hospital Emergency Department physicians are credentialed by the Hospital Medical Staff to perform patient assessments and place 5150 holds and have completed all requirements established by the County for designation to perform this function. Patients presented by law enforcement to the Emergency Department for a Medical Screening Exam (MSE) after external placement of a 5150 hold: 1) The ER physician provides a medical screening examination if requested by the patient or would seem reasonably indicated or someone familiar with the patient condition.

Based on observation, interview, and record review, the facility failed to provide a Medical Screening Exam (MSE) to one of 21 patients (Patient 1), when the law enforcement brought Patient 1 (while under a 5150-hold, an involuntary hold that places a person in protective custody) to the facility's emergency department (ED) requesting emergency services, but facility staff did not perform a MSE on Patient 1. This failure did not comply with facility policy and did not facilitate the facility's duty to assess and/or stabilize patients presenting to the facility's ED with a potentially emergent psychiatric or medical condition.

Findings:

On 3/15/21, the California Department of Public Health (CDPH) received a complaint indicating a potential EMTALA (Emergency Medical Treatment & Labor Act) violation at the facility, on 3/12/21. The complainant stated Patient 1 was brought to the facility's ED under protective custody of law enforcement. The complainant stated law enforcement requested emergency care and services on Patient 1's behalf, but the facility refused.

During an observation and interview on 4/12/21, at 3:21 p.m., Nurse Manager B pointed to beds 3 and 4 in the facility's ED, and stated they were designated beds for patients needing supervision, including patients who presented to the ED under 5150 hold (a temporary, involuntary hold under California state law). Nurse Manager B stated the ED received 21 patients under 5150 hold, between 1/1/21 and 3/1/21. Nurse Manager B stated the facility's ED started receiving a greater number of patients under a 5150 hold when a local psychiatric facility stopped admitting patients without evidence of a negative PCR test (polymerase chain reaction, a molecular test that detects the presence of virus) for COVID-19.

During an interview on 4/13/21, at 8:25 a.m., Nurse A stated she recalled the incident on 3/12/21. Nurse A stated she spoke with Sheriff Deputies by the ED's ambulance door. Nurse A stated the deputies presented her with completed 5150-paperwork, which indicated the deputies had a patient in protective custody under a 5150 hold. Nurse A stated she did not see the patient and assumed the patient was in the Sheriff's vehicle. Nurse A stated the 5150 hold document indicated the patient was violent and broke a restraining order. Nurse A stated she told the deputies being violent was a criminal act, and she would provide a "jail clearance" for the patient. Nurse A stated the jail clearance meant the ED staff will triage the patient, and the ED Physician will perform a Medical Examination Exam (MSE). Nurse A stated she did not refuse to see the patient. Nurse A stated Nurse Manager B arrived in the ED and joined the conversation with the two deputies. Nurse A stated Nurse Manager B said the 5150 hold was not appropriate. Nurse A stated one officer then "ripped" the 5150 document from Nurse Manager B, and the two officers left. Nurse A stated the deputy told Nurse Manager B they are going to St. Joseph (SJE). Nurse A stated the facility made no copy of the 5150 paperwork provided by the officers.

Nurse A stated patients who presented to the ED under a 5150 involuntary hold were screened by an outlying psychiatric facility's staff, via telehealth, to determine if the patient's condition warranted admission to a psychiatric facility. Nurse A stated she believed the Sheriff Department had been dumping patients in the ED.

During an interview on 4/13/21, at 10:15 a.m., Nurse Manager B stated in the interview she was coming to work when she saw Nurse A and the two officers talking. Nurse Manager B stated she asked to look at the 5150 paperwork and believed it was not completed appropriately. Nurse Manager B stated the deputy told them, "You have to take this lady." Nurse Manager A stated she told the two deputies that not taking medication was not an appropriate reason to initiate a 5150 involuntary hold. Nurse Manager B stated she told the deputy she would be happy to provide medical exam before to booking the patient to jail. Nurse Manager B stated the deputy would be required to stay with the patient until the MSE was done. Nurse Manager B stated they did not refuse to see the patient. Nurse Manager B stated she did not lay eyes on the patient, but assumed the patient was in the Sheriff's vehicle.

During an interview and review of surveillance videos on 4/13/21, at 10:34 a.m., Nurse Manager B, Administrator G, and Administrator H were present. The first video was recorded on a camera located outside the facility; outside the Ambulance door entrance to the ED. The first surveillance video dated 3/12/21 and time stamped at 7:25 a.m., showed one of the deputies walk toward the Ambulance door entrance, stop and write something on a paper, and then knock on the door. Facility staff opened the door. Nurse A was spoke to one of the deputies, then another deputy joined the conversation. Nurse Manager B walked toward the Ambulance bay and joined the conversation, too. At 7:28 a.m., the second deputy took the paper from Nurse Manager B, and both deputies walked away from the ED. There was no patient/individual seen with the two deputies.

The second surveillance video was recorded on a camera located inside the ED. The second surveillance video had audio, was dated 3/12/21, and started at 7:23 a.m. At 7:25 a.m., Admitting Clerk 1 opened the door leading outside to the Ambulance entrance. One officer who stood at outside the open door said to Admitting Clerk I, "We have one for you guys--um we have a female in the car for mental health." Nurse A walked toward the door and joined the conversation. Nurse A asked, "Is this person like assaulting people, with restraining orders? Because, we got a phone call from a family." One police officer responded, "We are trying to-she was at her ex's ... so she's different." Nurse A replied, "So assault-that goes to jail." Law enforcement denied the patient had assaulted anyone. Nurse A stated, "But assault ... is not a reason to be placed on 5150 in the [emergency room]. I am happy to provide jail clearance." The conversation continued, then a second officer and Nurse Manager B appeared at the doorway. After reviewing 5150 paperwork handed to her, Nurse Manager B stated: "This is not a reason to put her on hold, OK? She got in a fight with family members, and she acted a little nuts. This is not a reason to put someone on an involun-" The second officer said something unintelligible to Nurse Manager B, who responded, "I don't care." Hearing this, second officer reached toward and pulled the 5150 paperwork from Nurse Manager B's hand, and both officers left the ED at 7:28 a.m.

During an interview on 4/13/21, at 10:57 a.m., after watching the surveillance videos, Nurse Manager B clarified she said, "I don't care," after the deputy said the patient was not taking her medications.

During an interview on 4/13/21, at 11:30 a.m., Nurse C stated the ED staff take care of patients under 5150 holds and make sure they were medically clear.

During an interview on 4/14/21, at 9:13 a.m., the Humboldt County Sheriff's Office provided an e-mail address for the officer who was present during the 3/12/21 incident and who wrote the 5150 paperwork seen during the surveillance video. Two interview requests were sent to that officer by email. The officer did not respond to either request.

During an interview on 4/14/21, at 7:40 a.m., Nurse D stated the hospital cannot do anything about a patient presenting to the ED under a 5150 hold but accept a patient. Nurse D stated the ED cannot lift the 5150 hold, only the designated Psychiatric Facility. Nurse D stated when a patient who presented to the ED for jail clearance, that patient would be released back to the law enforcement if medically cleared. If not, that patient would remain an ED patient.

During an interview on 4/14/21, at 7:55 a.m., Physician E stated they see all the patients including patients brought in by the law enforcement. Regarding the incident on 3/12/21, Physician E stated law enforcement-the 5150 patient's legal custodian-left before he was given a chance to see the patient.

During an interview and record review on 4/15/21 at 10:06 a.m., Nurse Manager B, Administrator G, and Administrator H were present. Nurse Manager B stated the incident on 3/12/21 was not about refusing the patient, it was about safety. Nurse Manager B directed her comments to an e-mailed memorandum, of which Nurse Manager B stated all ED staff and the local Sheriff and police had been notified. The memo, dated 2/24/21, indicated: " ... [A]ny patient who presents to the Emergency Department in the custody of Law Enforcement (LE), must remain in the LE vehicle until such time as the patient can be placed directly into a bed in the department. Patients who present via LE to the Emergency Department will not be registered or receive a triage evaluation until such time as they can be placed in a bed in the department. It is not safe to allow a patient in the custody of the LE to be in the Triage room or sitting outside of the department for triage. [The facility] is not a designated facility under [California's] Welfare and Institutions Code for patients who are on a LE-placed involuntary hold. Therefore, in the best interest of safety of the patient and staff; patients who present via LE must remain in the LE transport in the custody of LE until such time as a bed is available in the department."

During a concurrent interview and record review on 4/15/21, at 10:06 a.m., Nurse Manager B reviewed the ED log from 3/12/21, the date of the incident. Nurse Manager B stated at the time of the incident only two of the ED's seven available beds were occupied. Nurse Manager B also stated the ED had staff two registered nurses to care for ED-admitted patients.

During an interview on 4/15/21, at 11:00 a.m., Physician F stated a patient who was brought to the ED under 5150 hold needed to be evaluated and medically cleared by a physician until he or she could be transferred to a behavioral or psychiatric facility.

During an interview on 4/15/21, at 11:20 a.m., Nurse A stated the facility instituted a process where nursing staff reviewed 5150 paperwork, checking if the form was filled out correctly and the reason for applying the 5150 involuntary hold was appropriate: person gravely disabled, or a danger to self or others.

During a review of the clinical record for Patient 1's visit to an alternative hospital facility, the "Emergency Department Report," dated 3/12/21, at 9:39 a.m., indicated a physician at an alternative hospital had eventually examined Patient 1, at 8:15 a.m. At the alternative hospital, Patient 1's chief complaint was indicated as: "Medical Clearance [for a] 29 year old female with history of anxiety, schizophrenia, and type 1 bipolar disorder brought in on [a] hold pending clearance to [a psychiatric facility]." The record indicated Patient 1 had "cellulitis on her brow line," which also required treatment. The record indicated an uncomplicated stay at the hospital, and contained no indication that Patient 1 exhibited violence or assaultive behavior. The record indicated Patient 1 was discharged from the alternative hospital on 3/13/21, at 11:20 a.m., after the 5150 hold was rescinded.

A review of Patient 1's 5150 involuntary hold form ("Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment"), completed 3/12/21, at 7:19 a.m., indicated the form had been completed by law enforcement, and law enforcement sought emergency services for Patient 1 because the patient was "a danger to ... herself" due to walking outdoors in cold weather without appropriate clothing, not answering simple questions appropriately, not taking her medication, and because the patient was experiencing a manic episode. The form neither indicated Patient 1 was assaultive nor gravely disabled. The form indicated the facility was "designated" to assess Patient 1 for psychiatric intervention or placement.

A review of e-mail correspondence authored by Nurse Manager B, and provided by complainant, dated 3/12/21, at 8:14 a.m., indicated Nurse Manager B informed the local law enforcement leaders about the facility's incident with Patient 1. The correspondence indicated: "This morning [the facility] refused a 5150 from (2) of your deputies. I cannot stress, strongly enough, that your deputies need some comprehensive training in the use and misuse of the involuntary hold. Involuntary holds nullify an individual's civil rights and subject them to unnecessary, at times frightening examinations and treatment. The individual in question this morning was involved in a domestic dispute, and had violated a restraining order. Both of the items are matters to be handled by law enforcement. Taking away their rights and dropping them in the ER bed is NOT the appropriate method to handle it nor is it in the best interest of the individual. The deputy made a statement that ' ... she hasn't been taking her meds.' Individuals has a have the right to refuse medication and it is NOT the purview of this medical facility to enforce that either. This individual has a history of violence, according to her family and I cannot stress enough that the ER is not the place for violent individuals. ... ALL involuntary holds will be evaluated by either the Charge Nurse or myself and a hold which is not for a primary psychiatric/behavioral health reason will be questioned and may be refused. Domestic disputes, violation of restraining orders, people having difficulty coping and refusing their medication are not adequate reasons to put someone on an involuntary hold and ameliorate their civil rights and this facility will NOT be party to it. It is grossly inappropriate as well as dangerous to drop people with a history of violence in this emergency room. I will not further endanger the well-being of my staff or the providers by subjecting them to physical and verbal abuse from individuals who are dodging jail or under the influence."

The facility policy and procedure titled "Psychiatric Crisis - 5150," effective 6/2010, last reviewed 2/2019, indicated: "5150 authorizes Emergency Department physicians and persons designated by the County (including peace officers and designated licensed psychiatrist) to take, or cause to be taken, a person into custody and placed in a designated facility. The Hospital Emergency Department physicians are credentialed by the Hospital Medical Staff to perform patient assessments and place 5150 holds and have completed all requirements established by the County for designation to perform this function. ... If by assessment ... the ED physician deems that the patient is a danger to him/herself or others, and/or is gravely disabled, a 5150 hold may be placed on the patient. ... B. Patients presented by law enforcement to the Emergency Department for a Medical Screening Exam (MSE) after external placement of a 5150 hold: 1. The ER physician provides a medical screening examination if requested by the patient or would seem reasonably indicated or someone familiar with the patient condition."

The facility policy and procedure titled "Medical Screening Examination (EMTALA)," effective 10/2011, last reviewed 10/2018, indicated the "essential requirements" of the facility's "EMTALA obligation for appropriate medical screening ...." The policy indicated an "appropriate Medical Screening Examination (MSE) within the capability and capacity of the hospital is provided to any individual with a medical condition that presents to the Hospital emergency ... to determine whether or not an [emergency medical condition] exists. ... Psychiatric Emergency[.] In the case of psychiatric emergencies, an individual ... determined dangerous to self ... is considered to have an [emergency medical condition]. ... Law Enforcement[.] ... Hospitals are not relieved of their EMTALA obligation to screen ... because of prearranged community or State plans that have designated specific hospitals to care for selected individuals (psychiatric patients, pregnant women). ...."

The facility policy and procedure titled "EMTALA Compliance," effective 9/2011, last reviewed 10/2018, indicated the "Hospital's EMTALA obligation is triggered when an individual comes by him or herself, with another person, or by ambulance to the Emergency Department[,] and a request is made by the individual, or on the individual's behalf ... for examination or treatment of an emergency medical condition (EMC) ... The [medical screening examination] determines whether or not an EMC exists. ... If an individual ... comes elsewhere on hospital property (but not the ED), an EMTALA obligation on the part of the hospital is triggered if the individual requests examination or treatment for an EMC ...."