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Based on interview, record review of Emergency Department (ED) Logs, Policy review, Log of patients that return to ED within 72 hours of original visit, Medical Record review, Staffing, and Physician On-Call Schedules, the facility failed to appropriately complete a medical screening exam (MSE) within its capacity and capability for one Patient (#15) of 24 patient's records reviewed, when the facility staff failed to utilize documented information about the patient's activity while in the ED. This failure allowed the patient to be discharged without an appropriate comprehensive psychiatric examination. The emergency department average monthly census was 7500. The average number of Psychiatric patients per month was 620. The facility census was 506.


The facility had the capability and capacity to complete an appropriate MSE to determine whether the patient had an Emergency Medical Condition and was safe for discharge. The patient had several suicidal gestures while in the ED but that information was not reviewed by the psychiatric staff prior to the decision to discharge.

Please refer to A 2406 for details.

Based on record review, document review, and interviews, the hospital failed to provide a medical screening examination sufficient to determine the presence of a medical and or psychiatric emergency, within its capacity and capability, for one patient (#15) of 24 Emergency Department (ED) records reviewed. This failure occurred when psychiatric evaluation staff did not review critical information in the record and ED staff did not take appropriate actions to ensure the psychiatric staff was made aware of the patient's activity. This had the potential to affect the disposition and safety of all mental health patients who presented to the ED. The emergency department average monthly census was 7500 over the past six months. The average number of Psychiatric patients per month was 620 during the same period. The facility census was 506.

Findings included:

Record review of the facility's Policy #103, titled, "Medical Screening Examinations" (MSE) dated 06/2016, showed the following:
- Any patient who comes to the hospital requesting emergency services will receive an MSE to determine whether an Emergency Medical Condition (EMC) exists;
- A MSE is the process required to determine with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist;
- A MSE is not an isolated event. It is an ongoing process. The individual may be continuously monitored; and
- Documentation of this evaluation is done prior to discharge or transfer.

Record review of the facility's Policy #101, titled, "Definition of Emergency Medical Condition" (EMC), dated 06/2016, showed the following with respect to Behavioral Health conditions:
- Patient demonstrates symptoms of a mental disorder and is a danger to self, others or property;
- Patient's symptoms of a mental disorder prevent him/her to care for self; and
- Patient demonstrates symptoms of a mental disorder and is medically unstable.

Record review of Patient #15's ED visit showed the patient was a 56 year old female that arrived at the facility by Emergency Medical Services (EMS) on 09/10/16 at 11:47 PM for a psychiatric evaluation related to hallucinations (patient hears or sees things that are not there):
- ED Physician B began the evaluation at 11:51 PM and noted the chief complaint to be hallucinations;
- The physician noted the patient was positive for hallucinations, "going crazy, my mind is leaving me, I will die soon," and negative for suicidal ideas. The patient was alert, verbally/physically threatening, anxious, and impulsive;
- The physician ordered restraint in the form of seclusion (patient not able to leave) with every 15 minute observation;
- Past medical history included:
- Schizophrenia (chronic mental health disease the affects how person thinks, feels and behaves);
- Psychosis (loss of contact with reality);
- Hypothyroidism (low thyroid hormone production which can disrupt heart rate, body temperature, and cause fatigue, weight gain);
- Anxiety (feelings of panic, fear, hopelessness);
- Hypertension (high blood pressure);
- Methamphetamine abuse (street drug);
- Frostbite injury; and
- Knee replacement.
- ED Physician B ordered laboratory (blood, urine) tests;
- ED Physician B ordered medication- Zyprexa (antipsychotic) 10 milligrams (mg.-a unit of measure) and Ativan (for anxiety) 1 mg.
- The physician documented the patient was medically cleared and disposition decision was pending psychiatric evaluation; and
- There was no further documentation from this physician regarding any events after he filed this visit note at 3:47 AM.

Staff C, Patient Care Technician (PCT), recorded note on 09/11/16 at 4:30 AM which showed:
- Patient went to restroom and returned to room. Heard patient gagging and walked into room where patient had fingers in her mouth and attempted to gag herself. Told patient to stop and then I saw a glove in patient's mouth. Told patient to uncover her mouth and spit it out. I asked patient why she tried to swallow the glove and she stated she wanted to kill herself. Registered Nurse (RN) notified at this time.
- At 4:45 AM, PCT noted, found patient trying to gag self with blanket. Took blankets away.
- At 4:45 AM, PCT noted, found patient putting scrubs in mouth, and notified RN.
- At 5:25 AM, PCT noted that patient got up and out of bed and said, "I'm getting out of here" and was put back to bed by security.
- At 5:40 AM, PCT noted patient was up to bathroom with security assist. After patient used bathroom, patient attempted to leave area. Security had to put patient back in bed with force. RN was notified.

- Staff D, RN, nursing note recorded on 09/11/16 at 4:50 AM showed the following, "Tech notified this nurse that patient had been to bathroom and once back in her room patient tried to swallow glove and began gagging. Patient stated that she did this to try and kill herself. Patient was searched and moved to Room 26."
- At 5:46 AM to 5:47 AM Staff D administered Ativan 2 mg. Intramuscular (IM via needle directly into muscle) and Haldol (antipsychotic) 5 mg IM.

From 09/11/16 at 6:00 AM, until 09/12/16 at 12:30 AM the patient remained in restraint/seclusion with observation (every 15 minutes), vital signs, toileting, and meals, with no additional incidents.

At 12:30 AM on 09/12/16 Staff E, Psychiatric Evaluation Nurse (PEN) began the patient assessment and noted:
- Patient presented in frank psychotic state. Required medication to calm. Hearing voices. Unable to settle. Required almost constant redirection through the night last night. Was screaming and wailing some of the time. Seemed very unaware of her situation.
- Today patient seemed very alert and oriented, a totally different presentation. She denied suicidal/homicidal ideation. Stated she had never had suicidal ideation.
- Patient had been under care of Psychiatrist but stopped going and stopped medications.
- Patient rated herself as "2" on the 1-10 depression (feelings of hopelessness) scale, but admits to feelings of helplessness, hopelessness, worthlessness, guilt, increased irritability, and tolerance for frustration. She scored herself 10 on the same scale for anxiety.
- At 1:55 AM Staff F, Psychiatrist, was given report by Staff E, PEN, and recommended discharge with referrals.
- At 2:00 AM patient's husband was called and notified of discharge. Said he would be in at about 10:00 AM to pick up the patient
- At 2:58 AM ED Physician G documented that he spoke with the PEN (Staff E) and the patient had been cleared by the Psychiatrist (Staff F). The patient was okay for discharge. she did not have a ride home until 10:00 AM.
- At 2:59 AM, ED Physician G wrote orders to discharge patient.
- At 8:45 AM Staff H, RN, documented that the patient's son called and was very concerned that patient was going to be being discharged.
- At 11:20 AM patient was discharged to husband.

During a telephone interview on 09/22/16 at 10:30 AM, Staff F, Psychiatrist, stated that:
- She received report from the PEN about Patient #15;
- It sounded as if the patient presented in a psychotic state, received some medication to help her calm down and when the PEN evaluated the patient, she had cleared (was back to normal);
- It was possible for a patient to arrive in a psychotic state and have the issue resolve with medication;
- The decision to discharge was really a physician medical judgement call;
- Admission criteria was based on case by case scenario and the goal was to use the least restrictive intervention;
- It is rare that communication occurred directly with the ED physician, but if the ED physician had strong feelings about admission she would defer to the ED physician and admit the patient; and
- She was not aware that this patient had several suicidal gestures while in the ED and that if she had been made aware of that she would likely have admitted the patient.

During a telephone interview on 09/22/16 at 10:00 AM, Staff E, PEN, stated that:
- She became aware of Patient #15 on 09/11/16 around 12:30 AM and the patient was floridly (obviously and extensively) psychotic and not able to be assessed;
- She had heard the patient many times during the night as she called out, hallucinated and was very agitated;
- The PEN's are responsible for psychiatric evaluations in the ED and throughout the hospital;
- It took a while to get this patient assessed because of her psychotic state and the medications made her groggy for quite a while plus the hospital was busy with psychiatric evaluations;
- When she was able to assess this patient on 09/12/16 around 12:30 AM, (24 hours after arrival in the ED) the patient had calmed down a lot;
- She was not apprised of the suicidal gestures that the patient had attempted while in the ED the night before;
- Had she been aware of those gestures she would have "gone to the mat" (insisted) to get this patient admitted;
- She could not possibly review all of the nurse's notes for each patient she evaluated, there was not enough time;
- She did not report the suicidal events to the psychiatrist because she was not aware of them; and
- Affidavits for 96 hour hold (legal document that requested that someone be held against their will, this was not enforced on this patient) were routinely completed on patients that had a psychiatric evaluation.

During a telephone interview on 09/29/16 at 2:30 PM, Staff Q, Nursing Director Mental Health Services, stated that:
- She was surprised when she heard that some PEN's don't review the ED nurses notes prior to patient evaluation;
- She had confirmed with the PEN's direct supervisor that they should review that information prior to the assessment; and
- She believed that this patient would have been admitted if that information would have been included in the assessment and passed on to the psychiatrist.

During a telephone interview on 09/22/16 at 11:15 AM, Staff C, PCT, stated that:
- On arrival Patient #15 was psychotic, agitated, screaming, hallucinating, getting out of bed, tried to leave and was eating stuff (gloves, scrubs, blankets);
- She found the patient with a glove in her mouth and was trying to push it down her throat;
- The patient got the glove when she went to the bathroom;
- The patient also tried to push a blanket and her scrubs down her throat;
- The patient told the PCT that she was trying to kill herself;
- This information was reported to the nurses caring for the patient;
- The physician was advised of the situation; and
- The patient was given some medications and that calmed her down;

During a telephone interview on 09/22/16 at 2:00 PM Staff D, RN, stated that:
- Patient #15 seemed to be having a psychotic break and was in seclusion with observation;
- Patient hallucinated, talked to herself and heard God talk to her;
- Patient had tried to swallow a glove, was hitting herself in the head, tried to stuff a blanket down her throat, and tried to swallow scrubs;
- Patient said she did this in an attempt to kill herself;
- An ED Physician was made aware and he ordered some medications;
- She was surprised to hear that the PEN's don't always review the ED nurses notes and that
Staff E, PEN, stated that she was not aware of the patient's suicidal gestures;
- We don't always see the PEN's, they are in rooms, out in the hospital, or in their office. It's difficult to pass information directly to them. It seems it would be important for them to review the nurse's notes; and
- Based on this patient's presentation, she was surprised that this patient was not admitted to an inpatient psychiatric unit.

During an interview on 09/22/16 at 2:50 PM, Staff B, ED Physician, stated that:
- The patient's presentation was labile, psychotic, she admitted to previous methamphetamine use;
- She was agitated, hallucinated, and called out;
- The physical examination was unremarkable.
- He ordered some laboratory tests and medications;
- He thought she needed to be observed, so he ordered that;
- There was no family with her;
- He was informed of the glove issue, not the scrub or blanket issues;
- He will usually go back and update my note or make a progress note, not sure why he didn't include that information in this case;
- He thought all pertinent information should be reviewed. He can't make a blanket statement that everyone must read everything, he doesn't read everything, but there should be a mechanism to communicate significant information;
- We (ED Physicians) depend on the PEN and Psychiatrist to evaluate and decide on admission or discharge status. He doesn't usually get involved with that;
- Sometimes the medications are effective and the psychiatric patients stabilize; and
- He just tried to keep them safe while they were here.

During an interview on 09/22/16 at 11:45 AM, Staff K, ED RN, stated that:
- She was the first RN to care for this patient and performed the triage (vital signs, nursing history and assessment) in the ED treatment room because the patient arrived by ambulance;
- Patient was hallucinating, calling out, agitated;
- Initially patient refused Zyprexa but then decided to take it;
- Restraint/seclusion observation was initiated; and
- She drew the blood for lab tests and sent them off.

During a telephone interview on 09/22/16 at 3:35 PM, Staff L, ED RN, stated that:
- He took over care of Patient #15 shortly after her arrival along with Staff D, ED RN;
- Patient talked to things that were not there;
- Patient tried to swallow gloves, blanket and scrubs;
- This was passed on to ED Physician B and some medications were ordered;
- He was not aware if the PEN's read the RN's notes or not but he believed that they should; and
- He was surprised when he heard this patient was not admitted to the psychiatric unit based on her presentation.

During an interview on 09/21/16 at 9:30 AM, Staff M, RN, ED Clinical Director, stated that:
- Patients who present with a psychiatric complaint would receive a medical screening examination upon arrival;
- After the patient was cleared medically, the ED Physician would place order for a PEN evaluation; and
- The PEN would conduct a psychiatric assessment to determine, along with the Psychiatrist on call, and ED Physician, if the patient required inpatient psychiatric care or transfer (if patient was not appropriate for admission to this hospital) or was to be discharged.

During a telephone interview on 09/22/16 at 12:30 PM, ED Physician G, stated that:
- He did not have any memory of this patient;
- He did not believe he had any actual contact with this patient;
- He was told by the PEN that the psychiatrist had cleared the patient for discharge, so he wrote the order to discharge;
- Based on review of his progress note that was the extent of his involvement with this patient; and
- We see so many psychiatric patients, I can't remember all of them.

During a telephone interview on 09/22/16 at 12:55 PM, Staff H, ED RN, stated that:
- Her involvement with Patient #15 was on the morning of discharge;
- She had not seen the patient in the psychotic state;
- She spoke on the telephone with the patient's son who was concerned about the patient being discharged, he was agitated and irritated and finally said, "just forget it" and hung up;
- She verbally communicated that on to the PEN nurse; and
- The husband picked up the patient.

Record review of "Prehospital Care Report Summary" of Patient #15's transport to the hospital via EMS showed:
- EMS arrived at patient's mother house on 09/10/16 at 10:41 PM;
- At 10:52 PM transport began;
- Report given to hospital staff at 11:45 PM;
- Initial EMS dispatch was stated as: Psychiatric/Anxiety/Suicide Attempt;
- Patient stated she was hearing voices in her head that said patient would die in two days;
- Patient heard a voice that said she would die this night; and
- Patient asked medic to pray with her and then asked medic to pray for her family because the voices said she would die this night.

Record review of, "Affidavit in Support of Application for Involuntary Admission and Treatment" (96 hour hold) completed (but not enacted) by PEN Staff E at the time of evaluation on 09/12/16 showed the patient stated that she:
- Hears God's voice, he is always there, tells me to brush my teeth and stuff like that;
- Stated I'm going crazy, my mind is leaving me;
- Stated she has many symptoms of depression;
- Says her anxiety level is a "10";
- Stated the spells come and go;
- Stated she has hallucinations and delusions;
- Was non-compliant with psychiatric care and medication regimen; and
- Was observed in the ED in a psychotic state for many hours requiring medications to clear.

Record review of Patient #15's encounter at Hospital #2 on 09/12/16 at 6:30 PM showed that patient was evaluated in the ED for hallucinations and ultimately was admitted to an inpatient psychiatric unit for treatment. The patient told the initial provider in the ED that she was hallucinating and tried to kill herself yesterday (in another hospital).

The facility failed to ensure Patient #15 received an appropriate MSE to determine if an EMC existed when staff responsible for that determination did not review or receive information that was vital to that decision making process. This oversight caused the patient to be discharged from this ED and delayed psychiatric care she needed until she presented at another facility ED and was admitted as an inpatient. This facility had the capacity and capability to appropriately complete an MSE and admit or transfer a patient with an emergency psychiatric condition.