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Based on interviews and record reviews, the hospital failed to abide by the provider's agreement that required a hospital to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements in that 1 of 1 patient (Patient #1) who presented to the center on 06/29/2023 with a chief complaint of suicide ideation, was discharged on the same day. Less than 6.5 hours later, Patient #1 committed suicide.

Cross refer to Tag:
Tag A2406 - 42 CFR §489.24 (a) (1) (i) Appropriate Screening Examination

Based on interview and record review, the hospital failed in providing an appropriate Medical Screening Exam. The assessment/evaluation was incomplete in that it lacked available information for 1 of 1 patient (Patient #1). This failure resulted in an inappropriate Medical Screening Exam for Patient #1. Patient #1 was subsequently discharged on the same day she presented to the hospital. Less than 6.5 hours later the 20-year-old patient committed suicide.

Findings included:

Patient #1's Medical Record

During a review of Patient #1's medical record the following was reviewed:

Triage form. Date: 06/29/2023. Patient #1 listed suicidal ideation (SI) for the reason for her visit. She said she had presented to an emergency department for a suicide attempt 10 days prior.

Behavioral Health Intake Assessment Summary. Date of Service: 06/29/23. Author: Personnel #4.
Patient #1's Chief Complaint: "I keep having the thoughts that I shouldn't be here."
Patient #1 was a 20-year-old female. The patient reported that she had attempted suicide by cutting her wrists 10 days ago. She was admitted to a local behavioral health unit at a local hospital on an APOWW (Apprehension by Pease Officer Without a Warrant). She was discharged 2 days later. Since her in-patient discharge 1 week ago, she had continued to have passive thoughts of wanting to be dead, wishing she were not here, "but has not had any active SI with plan or intent since that time." She denied HI (homicidal ideation), hallucinations, and substance abuse. She reported a primary trigger was she was sexually assaulted by a younger brother one year ago. Living in the same house as him was a major trigger. "At this time pt is appropriate for PHP program [partial hospitalization program] and is agreeable to this recommendation."

Her suicide risk level was moderate. She had no suicidal ideation present "today."
Her risk level was reviewed with Personnel #3.
The patient completed a Columbia Suicide Severity Rating Scale. The score was 10 (Moderate Suicide Risk)
The patient had a safety plan that was created with Personnel #4.

Disposition:
"Collateral Contacted: Yes - mother participated in discussion after assessment, with pt verbal consent."
Recommendation: PHP-Psych
Treatment Disposition: PHP-Psych
Status: Voluntary

Primary Diagnosis: Depressive Disorder
Depressive Disorder: Major Depressive Disorder Recurrent Episode
Major Depressive Disorder: With anxious distress
Current Severity: Severe
Secondary Diagnosis: Trauma and Stressor Related Disorders
Trauma and Stressor Related Disorders: Posttraumatic Stress Disorder

Patient Demographics
Patient Expiration. Date of Death: 06/29/2023.

Interviews

During an interview on 08/29/2023 at 11:05 AM with Personnel #4 she told the surveyor she could receive information from a family member without consent from a patient. After her assessment of Patient #1, she had spoken with Family Member #2 regarding their concerns, and they matched the information she had received from Patient #1 during her assessment. Family Member #2 "said nothing different from what the patient had told me. It was the same X, Y, and Z." Personnel #4 said Family Member #2 said Patient #1 was manipulative and had continued to have suicidal ideation.

Personnel #4 said Patient #1 wrote an email that included an attachment of suicidal notes. The email was written before the patient's most recent in-patient hospitalization and treatment (approximately 10 days ago). The email was on a scheduled delivery for a later date. The email was to be delivered to the patient's family and her boyfriend. After Patient #1's inpatient discharge (approximately 1 week ago), the email was delivered.

Patient #1 said the razor blades were ordered online before the Patient #1's recent inpatient hospitalization and treatment. The razors were delivered after the patient's recent inpatient discharge.

The surveyor asked Personnel #4, "If the patient had written the emails before her last hospitalization, then why didn't the patient cancel the emails if she was no longer planning her suicide?" Personnel #4 said she asked Patient #1 that question, and the patient said she was busy and forgot to cancel them.

Patient #1 asked if she could leave the PHP early on Tuesday, so she could go to work. The patient said she was planning on moving out of her parents house.

In regard to Patient 1's assessment and treatment plan, the surveyor asked Personnel #4, "Looking back would you have done anything differently?" She responded, "I wouldn't have done anything differently. She [Patient #1] had plans looking forward and I thought it was a solid decision."

The surveyor asked Personnel #4 why so much of the information she shared with the surveyor was not documented in the medical record. Personnel #4 said, "I could have been more thorough in my notes."

During a telephone interview on 08/30/23 at 10:10 AM with Family Member #2 she said Patient #1 purchased razor blades from Target, and wrote a suicidal email on the late afternoon/evening of 06/28/2023. She said the patient had not written suicidal notes prior to 06/28/2023.

Family Member #2 said Patient #1 had poor coping skills and recently had a breakup with her boyfriend. She was devastated. Patient #1 had cut her wrists (approximately 10 days ago). She was taken to the hospital by paramedics, then was taken to a local behavioral health hospital by police on an APOWW (apprehension by Peace Officer Without Warrant). During her admission at the local behavioral health hospital, she felt traumatized. She was very small and was around big men who were off of their meds, and she was around homeless people. She was constantly afraid. She stayed there for 48 hours. She was discharged with a prescription of Zoloft. She continued to have thoughts of suicide after her discharge. Family Member #2 said they were trying to find a suitable place where Patient #1 could receive treatment in a safe place.

On the late afternoon of 06/28/2023 Patient #1 wanted to go for a drive and visit her best friend. Family Member #2 said Patient #1 did this often, and she thought nothing of it. Patient #1's ex-boyfriend came by the parent's home and looked frantic. He gave the parents his cell phone number and left without explanation. Patient #1 came home later and seemed okay. She said she was going to bed.

Later that evening, Family Member #2 received a phone call from the ex-boyfriend. He said he had received an email earlier that afternoon from Patient #1 with attached suicide notes. He was instructed to distribute the suicide notes to family members after Patient #1 committed suicide. Patient #1 had written the email that afternoon (06/28/23). The ex-boyfriend told Family Member #2 he looked at Patient #1's location and went to find her. When he found her, he discovered she had bought some razor blades at Target. He talked her out of harming herself, and she gave him the razor blades. Patient #1 told the ex-boyfriend she thought she had scheduled the email to be delivered to him on a future date, but it did not work. Instead, the email was sent immediately to him. The ex-boyfriend forwarded the email to Family Member #2 that night. Family Member #2 said the suicide notes reflected how serious Patient #1 was about her plans to commit suicide. At that time, no family members, including herself, had received any suicidal emails from Patient #1.

Family Member #2 and her husband did not sleep the night of 06/28/2023. They stayed up all night checking on Patient #1, afraid she would commit suicide. The next morning (06/29/2023), Family Member #2 called the Suicide Hotline. She was told the patient needed to be taken to a hospital and have a "face to face" evaluation

When Family Member #2 told Patient #1 she needed to go to the Behavioral Health Center (BHC), the patient became very upset and fearful. She was afraid it would be like her last hospitalization. She finally consented to go. When they arrived at BHC on the morning of 06/29/23, Family Member #2 went inside to check it out and see if it looked like a safe place. Family Member #2 told the receptionist that she was afraid Patient #1 would lie about her suicidal thoughts, and would not be truthful about her plans to commit suicide the evening before. The receptionist told Family Member #2 that the counselors were trained to recognize lying and not to worry. Patient #1 was a psychology major and knew how to answer questions.

Family member #2 insisted that Personnel #4 refused to listen to her when she attempted to provide her with collateral information. Family member #2 was not included in Patient #1's assessment and evaluation until the evaluation was over. Personnel #4 invited her to join the patient while Personnel #4 informed Family member #2 of Patient #1's planned treatment plan. Personnel #4 said she was recommending partial hospitalization, and it would begin the next day. Family member #2 said she felt frantic. She asked if the patient could stay overnight, or could at least stay for the day. She told Personnel #4 she did not know how she was going to keep her safe. Personnel #4 said in a very "clipped and cool" voice that she had gone over the Safety Plan with Patient #1. Family Member #2 said, "She was very clear, she was not interested in hearing what I had to say."

Family Member #2 said after Patient #1 was discharged on the afternoon of 06/29/2023, she went home with Family Member #1 and Family Member #2. Patient #1 said she was tired and was going to take a nap. Family Member #2 said she herself had not had any sleep the night before, and she went and took a nap. After her nap and a shower, she went to Patient #1's room and knocked on the door. There was no answer. She knocked louder. Still no answer. She opened the door and Patient #1 appeared to be sleeping. She walked over to her, and she appeared to be dead. The paramedics were called, and they tried to resuscitate her. They took Patient #1 to the hospital where she was pronounced dead. Her autopsy report said she died of an overdose of Zoloft and allergy medication.

Family Member #2 said she went to see her daughter's body (Patient #1) a few days later. When she got home, she found out that her older daughter had received an email from Patient #1. The mom had also received an email from Patient #1. Other family members had also received emails from Patient #1. The emails were written as Patient #1 was dying. She explained how tired she was, and just could not take it any longer. She had scheduled the emails to arrive a few days after her death.

Family Member #2 told the surveyor that if Personnel #4 had only listened to what she had to say, she believed her daughter would still be alive. Family #1 and Family #2 filed a complaint with the Behavioral Health Center (BHC). After filing the complaint, Family Member #2 said she and Family Member #1 received a letter from the hospital. In the letter, it said she (Family Member #2) was included in part of the assessment. She said that was a lie. She was never part of any of the assessment. "I was not heard. I tried to tell her [Personnel #4] but she refused to listen."

Hospital's Response Letter to Family Member #1.
Date of Letter: 08/01/2023.
On 07/07/2023 the hospital learned of the concerns of Family Member #1 and Family Member #2. The following concerns were identified:

Concern #1. Family Member #2 advised the Behavioral Health (BH) clinician that although the clinician could not talk to her, she could listen to Family #2. The clinician responded that "we don't really do that for adults."

The BHC Administrator "spoke with the BH intake clinician [Personnel #4], who was unable to recall her specific statement to you [Family Member #2]. However, the statement you described is accurate, as we strive to provide adult patients with the opportunity to privately share their current behavioral health concerns in their own words. However, family members and friends are allowed during some parts of the assessment when desired by the patient for emotional support or (if approved by the patient) to provide information. We apologize if the intake clinician did not fully explain our process to you. Since [Patient #1] was an adult, she was the primary source of information, though we do appreciate and understand the value of family input which is why the clinician included you in the assessment and listened to your input."

Concern #2. "After the Partial Hospitalization Program (PHP) was recommended, [Family Member #2] felt dismissed as she attempted to communicate her concerns for [Patient #1's] safety, stating, 'I cannot keep her safe, what are we going to do to keep her safe.' The BH clinician responded, 'we are trained to evaluate for that.' The clinician was not empathetic or supportive. [Family Member #2] felt she was not heard or even considered at all. [Family Member #2] felt the subsequent death of [Patient #1] was not 'human error' but rather 'human arrogance' on behalf of the clinician as she did not allow [Family Member #2] to provide any additional information.
The Partial Hospitalization Program (PHP) is generally intended for patients who are not voicing active suicidal intent or plan."

The BHC Administrator "spoke with the BH intake clinician regarding your [Family Member #1's] concerns. The clinician recalls including [Family Member #2] during the appropriate portion of the assessment and noted that the information that [Family Member #2] provided was not different from what [Patient #1] herself shared with the clinician. Because of this, the BH intake clinician did not further discuss criteria or the reasons for recommending PHP."

Hospital Policy
Medical Screening Examinations and Patient Transfers policy. Last reviewed 10/07/2022.
5.10 Medical Screening Examination - Means the process to determine, with reasonable clinical confidence, whether the patient is suffering from an Emergency Medical Condition.
5.11 Qualified Medical Personnel or Qualified Medical Person
5.11.3 Behavioral Health. In the Behavioral Health environment, "Qualified Medical Personnel" means either a member of the medical staff of Hospital or other licensed members of the behavioral health team to include Psychologists (Ph.D., PsyD), Registered Nurses, Master's prepared Social Workers (LCSW, LMSW), Licensed Professional Counselor (LPC, LPC Intern), and Licensed Marriage and Family Therapist (LMFT, LMFTA). Each Psychologist, Registered Nurse, Social Worker, Licensed Professional Counselor, or Licensed Marriage and Family Therapist who serves as Qualified Medical Personnel shall have received training on what constitutes an appropriate Medical Screening Exam.