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Based on interview and record review, the facility failed to complete a full medical screening exam to one of 21 sampled patients (Patient 100) when Patient 100 presented to the emergency department (ED) at Hospital 1 with a psychiatric complaint and did not get a psychiatric evaluation to determine if she was stable. This failure resulted in a delay in care for Patient 100 who was later diagnosed with grave disability (a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic needs for food, clothing, or shelter) at another ED (Hospital 2).

Finding:

Review of Patient 100's medical records from Hospital 2 revealed an untimed note documenting a call Patient 100's adult children made to the nurse advice line on 3/31/23 (the day before she presented to Hospital 1 for care). Patient 100's children reported Patient 100 had been locked in the bathroom for hours at the time of the call. They reported Patient 100 had begun acting paranoid and hallucinating since the beginning of the year and that the behavior had been escalating since 3/15/23. Patient 100 had abruptly quit her job and moved in with them a week ago, was no longer lucid and communicating as before, and was no longer taking care of herself. They reported Patient 100 would go two to three days without eating, going weeks without bathing, not speaking, lies wrapped head-to-toe in a blanket all day and does not appear to recognize them. Patient 100's son stated that at night he heard her make statements such as, "God, why don't you just take me?" Patient 100's children stated Patient 100 had been forcibly taken to the hospital in 2019, and given psychiatric medication which improved her symptoms, but she had not taken her medication in years. The note further indicated that the plan was to send a police officer to the house to attempt to take Patient 100 to the nearest ED.

During a record review and concurrent interview with Nursing Director at Hospital 1 on 4/19/23 at 2 p.m., Patient 100's Hospital 1 triage note dated 4/1/23 at 11:36 a.m. indicated, "Husband states she has stopped taking meds (medications) recently and has been reported to hear voices and see things. . . . PT (patient) declined to answer questions." Patient 100's History of Present Illness note, dated 4/1/23 at 11:47 a.m., indicated, ". . . past medical history of psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality) who presents to the emergency department with a chief complaint of not eating and not following directions according to the family. She also become [sic] more withdrawn and is not answering questions. . . . she is not suicidal homicidal and has no difficulty with caring for herself. She is subsequently medically cleared and sent to [nearby acute care hospital, Hospital 2] directly." Patient 100's 4/1/23 ED record revealed no documentation that Patient 100 was under the care of a psychiatrist nor if any medications had been prescribed. Patient 100's "Care Timeline" indicated Patient 100 left the ED on 4/1/23 at 12 p.m. (approximately 24 minutes after triage). Nursing Director verified Patient 100 was discharged.

Review of Patient 100's "After Visit Summary," dated 4/1/23 at 11:53 a.m., indicated, "Please go straight to [Hospital 2] and go to the emergency department so that you can be appropriately treated . . . she is clearly stable to be taken there immediately."

During a telephone interview on 4/20/23 at 12:05 p.m., Psychiatric Liaison B (Liaison B) stated her job duties included assessing psychiatric patients, placing them on 5150 holds (if necessary), and finding them placement (at a psychiatric facility for further treatment). She stated, "99%" of psychiatric evaluations at this hospital were performed by tele psych (psychiatric services, remotely performed by a psychiatrist or other qualified healthcare professional) and the psychiatric liaison then assisted with placement. Liaison B stated if there were psychiatric concerns with a patient, the (ED) physician would notify her to perform an assessment. She stated an assessment included determination if a patient was a danger to self, danger to others, or had grave disability. When queried, Liaison B stated either tele psych or a psychiatric liaison (not an ED physician) performed psychiatric evaluations.

During an interview on 4/20/23 at 3 p.m., Physician A stated he remembered Patient 100 and her husband. Physician A stated the medical screening exam process determined if a patient had an emergency medical condition. Physician A stated in the case of Patient 100, he determined her psychosis was a chronic condition, she had recently been started on medications, and she was not at high risk of deteriorating. Physician A stated a 5150 hold (5150 is the number of the section of the Welfare and Institutions Code, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization) criteria included suicidal ideation, homicidal ideation, and grave disability. Physician A verified Patient 100's medical record indicated that she did not speak during her visit to the ED on 4/1/23. When queried, Physician A stated when a patient did not speak during his evaluation, he determined whether the patient met 5150 criteria "just by looking." Physician A stated Patient 100 did not have any cuts or outward signs of self-harm. Physician A stated it was his clinical judgement who performed the psychiatric part of the patient's evaluation. Physician A stated he would get a qualified health professional for a psychiatric evaluation if in his clinical judgement the patient was at risk for deteriorating. Physician A stated Patient 100 was well-appearing, well-groomed, and her husband stated she had just been seen by her psychiatrist.

During a record review and concurrent interview with Chief Medical Officer (CMO), Quality Director, and Nursing Director on 4/20/23 at 3:42 p.m., when queried, CMO stated that as a physician, if he was unable to evaluate a patient (because they would not speak) he would reach out for more help. CMO and Quality Director reviewed Patient 100's 4/1/23 ED visit documentation and the hospital policy "Management of Behavioral Problems - Patients and Visitors," last revised 6/2020. CMO and Quality Director verified the policy indicated the list of qualified health professionals authorized to perform psychiatric evaluations did not include the ED physician. Nursing Director verified ED physicians were not qualified to perform psychiatric evaluations in the ED. CMO and Quality Director verified the "Management of Behavioral Problems" policy also indicated the ED physician determined medical clearance and then the qualified health professional determined the need to place the patient on a 5150 hold. When queried about an initial suicide screening, Nursing Director stated Patient 100 did not have a suicide screening because the primary nurse typically completed the screening and Patient 100 was discharged before she had a primary nurse assigned.

During the same interview on 4/20/23 at 3:42 p.m., the Quality Director stated Resident 100's medical screening exam was not complete (as it did not include a psychiatric evaluation by a qualified practitioner) and was not performed per hospital policy and procedure. Quality Director stated that from a Quality standpoint, it was her expectation that policy be followed, for patient safety and quality of care.

Review of Patient 100's ED visit notes at Hospital 2 indicated she arrived at the ED on 4/1/23 at 12:58 p.m. Review of Patient 100's psychiatric evaluation at Hospital 2, dated 4/1/23 at 2:24 p.m. (approximately 2.5 hours after Physician A discharged Patient 100 from ED), indicated Patient 100's husband was called as part of the evaluation. Patient 100's husband stated Patient 100 had been prescribed an antipsychotic medication in 2019, but she stopped taking it after 2.5 months and has slowly been becoming more paranoid. He stated a few days after Patient 100 had moved in with her children, they called him and told him Patient 100 had not been eating or sleeping and had been crying all day and night. He said Patient 100's best friend finally convinced her to let him take her to the hospital. Patient 100's husband stated Patient 100 would not take any medications. Further review of Patient 100's psychiatric evaluation revealed she was placed on a 5150 hold for grave disability. Patient 100's document "Physician Assessment and Certification - Patient Transfer Under EMTALA/COBRA," dated 4/3/23, indicated Patient 100 was transferred to an acute psychiatric hospital for specialized care.

Review of Hospital 1 policy and procedure "Screening, Stabilization and Transfer of Individuals with Emergency Medical Conditions (EMTALA-CA), last revised 3/2022, indicated under "Definitions" section, "'Emergency Medical Condition' ('EMC') means: . . . 3. With respect to individuals with psychiatric symptoms: a. That psychiatric disturbances and/or symptoms of substance abuse are being expressed. . . . "'Medical Screening Exam' ('MSE') means the screening process performed by a physician or another QMP (qualified medical person) required to determine with reasonable clinical confidence whether an EMC does or does not exist. . . . Individuals with psychiatric or behavioral symptoms: The medical records should indicate both medical and psychiatric components of MSE. . . . The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicates danger to self or others." Review of "Procedures" section revealed, "MSE Process: a. Within the Capability of the DED (dedicated emergency department), the MSE should be performed to the extent sufficient to determine within reasonable medical probability whether an Emergency Medical Condition exists."

Review of Hospital 1 policy and procedure "Management of Behavioral Problems - Patients and Visitors," last revised 6/2020, indicated under "Definitions" section, "Suicide Screening: The tool used by the primary nurse to screen for risk of suicide or self-harm. . . . Qualified Health Professional: A person authorized to perform a mental health assessment by virtue of their education, training, and/or experience. At [Hospital 1 named] 'qualified health professionals' are the following: Psychiatrists, Psychiatric Nurses, Psychiatric Liaisons; Other Qualified Licensed Practitioners of Allied Health Professionals (i.e. Behavioral Health RN and psychiatric liaisons and social workers)." Review of "Policy" section revealed, "Patients who have significant psychiatric or behavioral needs . . . are assessed by staff trained in behavioral health . . . . A qualified professional shall determine whether he or she can be properly served without being detained. . . ." Review of "Procedure" section revealed, "A. Emergency Department: 1. Initial Screening of Patients: Patients will be screened for the risk of suicide/danger to self/others utilizing the . . . Suicide Risk screening tool. . . . 2. Suicide Risk Assessment/Validation: The Emergency Physician will evaluate and determine medical clearance. Once medical clearance has been obtained, a qualified health professional will assess and evaluate for the need to place the patient on a 72 hour hold (5150) . . . ."