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Based on interview and record review the facility failed to follow their own Emergency Medical Treatment and Labor Act (EMTALA) policy regarding stabilization and/or transfer of patients having an emergency medical condition. The facility discharged one of twenty patients reviewed (Patient #18) even though the patient remained agitated, had rambling thoughts, and thoughts of harming others. The facility census was 424.

Findings Included:

1. Review of the facility's policy entitled, "Treatment, Transfer and Referral of Patients......,"reviewed 08/08, showed the following:

- It is the policy of the hospital to ensure all individuals an appropriate medical screening exam (MSE) and stabilizing treatment prior to dismissal or transfer.
- The screening process determines the presence or absence of an emergency medical condition, and this screening exam is performed by the Emergency Department (ED) physician.
- The ED physician is to determine that the individual with a psychiatric condition is no longer considered to be a threat to him/herself or others.
- If it is determined the facility does not have the capability or capacity to treat the patient, the patient will be transferred.

Review of Patient #18's ED medical record revealed that a law enforcement officer brought patient #18 to the ED on 07/09/11 at 9:12 AM. The ED nurse documented patient #18 had been involved in an altercation earlier in the day, was agitated, anxious, restless, uncooperative and unable to be redirected. At 9:40 AM the ED nurse documented that patient #18 reported a prior attempt by non-lethal means. The law enforcement officer reported the patient, "stabbed his roommate this AM." The ED physician examined patient #18 and documented that he, "rambled tangentially with pressured speech," and diagnosed him with schizophrenia. At 10:48 AM mental health nurse B examined patient #18 and documented that law enforcement brought him to the emergency department after he stabbed someone living in his house. Further documentation revealed that patient #18 was fearful, irritable, labile, agitated, anxious, and that he had intermittent or fleeting thoughts of harming others and had a history of past attempts with high lethality. The patient was discharged in an "unchanged" condition, with a diagnosis of schizoaffective disorder (a condition with a combination of features of schizophrenia and a mood disorder. Symptoms included distorted thinking, seeing and hearing things not there, poor self care, rambling speech, depression, and mania), without any medications, with a referral to see a psychiatric physician for follow-up, on 07/09/11 at 12:19 PM.

During a phone interview on 07/19/11 at 1:20 PM, Mental health nurse B stated patient #18 could benefit from medications, however he refused.

Facility staff failed to follow their policy to ensure patient #18 received stabilizing medical treatment and/or a transfer to an appropriate facility prior to discharge.

Based on interview and record review the facility failed to arrange for an appropriate transfer to further stabilize one patient (Patient #18) with an emergency (psychiatric) medical condition, out of twenty patients reviewed. The facility also failed to consult a psychiatrist for further evauluation of the patient's emergency medical condition. The facility discharged Patient #18 from the Emergency Department (ED) in an unstable condition. The facility census was 424.

Findings Included:

1. Review of the facility's policy entitled, "Treatment, Transfer and Referral of Patients......,"reviewed 08/08, showed the following:

- It is the policy of the hospital to ensure all individuals an appropriate medical screening exam (MSE) and stabilizing treatment prior to dismissal or transfe;
- The screening process determines the presence or absence of an emergency medical condition, and this screening exam is performed by the ED physician;
- The ED physician is to determine that the individual with a psychiatric condition is no longer considered to be a threat to him/herself or others;
- If it is determined the facility does not have the capability or capacity to treat the patient, the patient will be transferred.

During an interview on 07/19/11 at 11:15 AM, Registered Nurse (RN) E stated the facility had psychiatrists/psychologists on-call.

Review of on-call documentation for the months of June/July 2011 showed a psychiatrist on-call for ED consults 24-hours a day, seven days a week.

During an interview on 07/19/11 at 1:55 PM, RN F, Quality and Risk, stated the adult psychiatric units were full at the time Patient #18 presented to the ED, and or would have needed an inpatient bed.

Review of Patient #18 ' s Emergency Department (ED) record, dated 07/19/11, revealed the following:

-The patient presented, in handcuffs, on the above date at 9:10 AM, accompanied by Greene County Sheriff staff.
-The patient was triaged at 9:12 AM, noting that the patient was extremely agitated. Involved in an altercation (stabbed a roommate) earlier in the day. Refused to answer questions. Patient was rambling. Patient was agitated, anxious, restless, and uncooperative. Patient had a past medical history of Schizophrenia, and no medications listed.
-Vital signs were somewhat out of normal limits, ie BP= 143/103, 151/95; pulse= 112, 120.
-The psych screening at 11:13 AM, noted the patient was easily agitated, angers easily, frustrated easily, impulsive, anxious, had intermittent flight of ideas with concerns regarding AIDS, homelessness, government, and homosexuality. The patient had not eaten all week and was not taking his medications. The patient had previous suicidal attempts
-The patient behaved eratically at 11:45 AM.
-The patient appeared restless at 11:56 AM.
-ED physician documentation showed the patient was rambling, refusing to answer questions. The patient was agitated and in the custody of the Greene Co. Sheriff. No medicines were listed.
-The patient was discharged at 12:19 PM in an "unchanged" condition, with a diagnosis of schizoaffective disorder (a condition with a combination of features of schizophrenia and a mood disorder. Symptoms included distorted thinking, seeing and hearing things not there, poor self care, rambling speech, depression, and mania), without any medications.

During a phone interview on 07/19/11 at 1:20 PM, RN mental health nurse B stated that Patient #18 could have benefited from medications.

Even though the patient exhibited eratic behavior, remained restless in the ED (nearing time of discharge), and was diagnosed with Schozoaffective Disorder but not on medications to control it, the facility failed to have the on-call psychiatrist evaluate the patient, and failed to transfer to another facility for psychiatric stabilization/treatment.