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Based on review of facility documents, review of medical records (MR), observation, and interview with staff, it was determined the facility failed to ensure compliance with §489.24 as evidenced by failure to provide an appropriate medical screening examination (MSE) in 1 out of twenty (20) patients sampled (Patient 1).

Cross Reference:
489.24(a) & 489.24(c): Medical Screening Exam

Based on document review, medical record review, observation and staff interviews, it was determined the facility failed to ensure the patient had a appropriate medical screening examination in one (1) out of twenty (20) patients, Patient #1. This failure has the potential to negatively impact all patients receiving care in the facility's Emergency Department (ED).

Findings include:

A review was conducted of the "Medical Staff Bylaws, Policies and Rules and Regulations," adopted 11/28/17. Section "Rules and Regulations" states in part, "...Article X Emergency Services ...10.1 General: (a) Emergency services and care will be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facilities and qualified personnel available to provide such services or care ...10.2 Medical Screening Examinations: (a) Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified medical personnel who can perform medical screening examinations within applicable Hospital policies and procedures are defined as: (1) Emergency Department physicians; (2) Emergency Department physician assistants; (3) Emergency Department nurse practitioners; and (4) Obstetrical Registered Nurses (only in the case of women in labor.) (b) The results of the medical screening examination must be dictated within 48 (forty-eight) hours of the condition of an Emergency Department visit."

A policy was reviewed titled "Suicide Risk Assessment in the Emergency Department", effective 7/19/22. The policy has a section titled "Procedure" which states, in part, "Patient presents to the Emergency Department with a chief complaint of Suicidal or Homicidal Ideation. These patients are roomed and changed into paper scrubs by emergency department staff. The patient ' s personal belongings are inventoried by security and stored in locked cabinet for safety and security ...Ask Suicide-Screening Questions (ASQ) positive screening has two (2) pathways. If the patient answers YES to question one (1) - four (4) and no to question five (5) they should remain in a room that is video monitored or if answering YES to any of the questions one (1) - four (4) and answering Yes to question five (5) the patient is determined to be at high or imminent risk requiring a one (1) : one (1) patient sitter."

A medical record review was conducted for patient #1. The patient presented to the facility's Emergency Department (ED) on 06/09/24 via Emergency Medical Services (EMS) at 11:03 a.m. The patient signed their consent for treatment. The triage was initiated at 11:09 a.m. by Emp #5 and states, "Pt (Patient) arrives to ED via EMS on RA (room air) from [Patient #1's crisis center]. Per EMS pt was found with t-shirt around neck and states [Patient #1] was 'going to jump off a cliff.' EMS reports withdrawing from '75 (seventy-five) ml (milliliters) of Methadone a day.' Pt reports left arm spasms which EMS reports has caused [Patient #1] to 'flail around everywhere.' Pt denies SI/HI (suicidal ideations/homicidal ideations) upon arrival."

The Suicide Monitoring/Prevention was completed at 11:13 a.m. by Emp #5 and is titled, "Ask Suiside-Screening Questions" or ASQ. The patient answered the first four (4) questions yes, and the last one No. Per facility policy, this places the patient initially at moderate risk for attempting suicide, and requires video monitoring, which was already in place. The question the patient answered "No" to states, "Are you having thoughts of killing yourself right now?"

The "Emergency Department Provider Note" was started at 11:13 a.m. by Emp #1 and states in part, "HPI (History of Presenting Illness)... It is expressed by EMS that their initial call was for SI (suicidal ideations). Upon [Patient #1]'s arrival the patient denies SI/HI. RN (Registered Nurse) will attempt to contact [Patient #1's crisis center] in order to verify the exact situation ... there are no other complaints at this time ...Physical Exam:...Musculoskeletal: Patient has intermittent sporadic movement of the BUE and BLE... Psychiatric:Patient appears anxious but cooperative with examination ...Work up: CBC (complete blood count), comprehensive metabolic panel- non-fasting, ethanol- serum, drug screen with confirmation urine, thyroid stimulating hormone with free T4 reflex, urinalysis- macroscopic, Covid-19 screening, urinalysis- microscopic, Suboxone confirmatory\definitive urine, methadone confirmatory/definitive urine, fentanyl confirmatory/definitive urine, ECG (electrocardiogram) 12 (twelve) lead, benztropine (cogentin) 1 mg/ml (one milligram per milliliter) injection."

Additional orders included " Consult to Psych (psychiatry) Clinical Assessment Coordinator." May it be noted, the only ordered test that had resulted at the time of elopement was the ECG.

At 11:17 a.m. a note by Emp #5 states, "Pt placed in paper scrubs, belongings bagged up and given to security. Security at the bedside. Constant monitoring in place. Safety measures maintained."

At 12:05 p.m. a note by Emp #8 states, "Patient reports [Patient #1] is unable to stay in the room. Patient reports I just want to leave. Patient ambulated out of ED without difficulty, patient deniesSI/HI. Provider-aware."

At 12:07 p.m. a note by Emp #8 states, "Patient denies SI and HI. patient reports withdrawing, States I just need help."

At 12:38 p.m. a note by Emp #8 states, "attempted to call [Patient #1's crisis center] multiple times to notify patient eloping, no answer. unable to notify [Patient #1's crisis center]. provider aware."

A 12:54 p.m. a note by Emp #11 states, "alerted for substance use. patient came to Ed from [Patient #1's crisis center] .Patient left ED AMA."

At 3:09 p.m. a note by Emp #3 states, "Pt walked out of BHU (Behavioral Health Unit) with security guard stating [Patient #1] wanted to go outside and get some air. Patient escorted back to [Patient #1]'s room."

Emp #1 documented "ED Course" at 11:58 a.m. and it states, "Patient eloped from the emergency department shortly after blood collection. [Patient #1] denies suicidal and homicidal ideation during interview. Attempts were made to contact [Patient #1's crisis center] to confirm whether patient reported homicidal or suicide ideation to them." The patient was listed as eloped at 12:15 p.m.

A video review of the facility's Emergency Department (ED) was conducted on 6/12/24 at 11:00 a.m. with Employee (Emp) #2. Emp #2 states camera is two (2) minutes fast. 11:59:55 a.m. Patient into the waiting room, then outside ED main entrance 12:00 p.m. Patient sitting on bench outside ED entrance, security with the patient 12:01:24 p.m. Patient ambulates back into waiting room followed by security, sits in chair 12:01:52 p.m. Emp #8 arrives with patient, removes IV access 12:02:38 p.m. Patient walks out main ED entrance 12:04:16 p.m. Patient ambulating out of ED, uses crosswalk to cross main road, into parking lot across the street from ED entrance 12:05:37 p.m. Patient out of camera sight

An interview was conducted with Emp #4 on 6/12/24 at 2:14 p.m. Emp #4 was asked about their involvement with the events surrounding Patient #1. Emp #4 was asked about the process for taking a patient ' s belongings if they are found to be suicidal. Emp #4 stated "Well, Patient #1 denied SI, but our process would be to take the patient's clothes and give them paper scrubs to put on. Their belongings are inventoried and put in a locker for safety. The patient is searched for weapons. If the patient is suicidal, we will do one (1) to one (1) monitoring." Emp #4 was asked why Patient #1 ' s belongings were not taken. Emp #4 stated, "At that point, [Patient #1 ' s] blanket and shoes should have been taken and put in the locker."

An interview was conducted with Emp #5 on 6/12/24 at 3:02 p.m. Emp #5 was asked about their interaction with Patient #1 on 6/9/24. Emp #5 stated in part, "I was in charge of triage, and I took report from the EMS personnel. EMS reported that [Patient #1] was at the detox facility and was found with a t-shirt around [Patient #1 ' s] neck.."

A telephone interview was conducted with Emp #1 on 6/12/24 at 3:40 p.m. Emp #1 was asked about their interaction with Patient #1 on 6/9/24. Emp #1 stated in part, "I came to the room to see the patient. [Patient #1] was having a lot of spontaneous movements of [Patient #1]'s extremities, especially the arms. [Patient #1] was complaining about arm pain since receiving Suboxone earlier that morning. [Patient #1] was having trouble sitting still but was not complaining of pain anywhere other than in the arms. The behavioral health unit (BHU) protocol was started, and blood work was started for medical clearance. [Patient #1] let them get blood and started intravenous access (IV). Sometime later, the nurse told me that [Patient #1] wanted some fresh air and had eloped." Emp #1 was asked what interventions had been prescribed for Patient #1. Emp #1 stated, "[Patient #1] could not remember the name of their blood pressure medication, but I had written an order for a medication to help with the involuntary movements." Emp #1 was asked about Patient #1's demeanor. Emp #1 stated, "[Patient #1] was nice, I did get report regarding SI, but I did not get any impression that [Patient #1] was suicidal."

An interview was conducted with Emp #8 on 6/12/24 at 4:58p.m. Emp # 8 was asked about their interaction with Patient #1 on 6/9/24. Emp #8 stated in part, "...[Emp #5] did not say that the patient mentioned anything about events that happened at the detox facility." Emp #8 was asked about their assessment of Patient #1. Emp #8 stated, "I asked [Patient #8] if they were suicidal or trying to harm themselves and [Patient #1] said 'no, they were not.' I did get the patient's labs and start an IV. I did not give any medication. The patient did express that they wanted to leave the ED." Emp #8 was asked about the provider that saw the patient. Emp #8 stated, "I was not in the room when the physician came to assess the patient." Emp #8 was asked about how Patient #1 left the facility. Emp #8 stated, "One of the security guards told me that [Patient #1] wanted to leave, so I went and told [Emp #1] that [Patient #1] wanted to leave. [Emp #1] said that if [Patient #1] 'wanted to leave and is not suicidal, then [Patient #1] can leave.' I then went and removed [Patient #1's} IV. [Patient #1] wanted to leave and [Emp #1] was not able to talk to the patient about leaving against medical advice (AMA)."

A telephone interview was conducted with Emp #9 on 06/13/24 at 11:13 a.m. Regarding Patient #1, Emp #9 states in part, "We responded to the call of the patient trying to commit suicide with a t-shirt ..."

A telephone interview was conducted with Emp #12 on 06/13/24 at 11:38 a.m. Regarding Patient #1, Emp #12 states in part, "... I would have given the same report I gave to medcom (medical command) to the employee at the hospital. I gave a report verbally to [Emp #5]. Yes I did tell [Emp #5] the patient tried to open the door of the ambulance. I worded it exactly [Patient #1] tried to open up the ambulance door while we were going down Route Fifty (50). The [Patient #1] said they weren't trying to jump out, just trying to get air. I did ask the patient directly if they were suicidal with a plan as required by medcom and [Patient #1] told me no."

A telephone interview was conducted with Emp #3 on 06/13/24 at 2:42 p.m. Regarding Patient #1, Emp #3 states, "The patient walked out of the behavioral health unit (BHU) with security. I looked at [Patient #1] and spoke with [Patient #1] and [Patient #1] said [Patient #1] just wanted to get some air. At that time [Patient #1] agreed to go back into [Patient #1]'s room. I did not talk to [Patient #1] when [Patient #1] came back out and left. After [Patient #1] left, [Emp #8] told me [Patient #1] left and [Emp #8] took [Patient #1]'s IV out. [Patient #1] was not currently endorsing suicide or homicidal ideations. We aren't allowed to keep them unless they're actively endorsing it. The only time we can hold someone is with a hold order and they have to be actively suicidal."

An interview was conducted with Emp #13 on 06/13/24 at 2:07 p.m. Regarding Patient #1, Emp #13 states, "We went by the EMS report that the patient was suicidal. Anytime we get a patient from a detox unit they are placed in the behavioral health unit pod. They are not specific to suicidal or homicidal patients. Even detox patients will get the video monitoring. The patient was placed in paper gowns. When the patient said they wanted to leave, their belongings were given back to [Patient #1] and [Patient #1] declined changing back into [Patient #1]'s clothes before [Patient #1] left. If a patient elopes, we only call the police if the patient is having active suicidal ideations, had an alcohol level greater than 100 (one hundred) or had an IV in place. I can't answer as to why the provider didn't have time to go talk to the patient. We had tried to talk to [Patient #1's crisis center] but the patient had already walked out."

An additional telephone interview was conducted with Emp #8 on 06/13/24 at 2:30 p.m. Regarding Patient #1, Emp #8 states, "I don't know exactly what the patient said for the reason [Patient #1] was leaving. [Patient #1] just told me [Patient #1] was leaving. The charge nurse [Emp #3] had already talked to [Patient #1] and I'm not sure what [Patient #1] told [Emp #3]. The provider said as long as [Patient #1] wasn't actively suicidal [Patient #1] could leave. I asked [Patient #1] again [Patient #1] said no. I took [Patient #1]'s IV out and [Patient #1] left."