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Based on interview and record review of Emergency Department (ED) logs, 72 Hour Return logs, medical records, Staffing and Physician On-Call Schedules, the facility failed to provide an appropriate medical screening examination within its capacity and capability for two patients (#1 and #22) of 23 patient's records reviewed. The hospital's failure delayed further examination and stabilizing treatment when staff discharged the patients to law enforcement who then transported patients # 1 and 22 to jail to await transfer to a hospital with psychiatric capabilities. The average ED monthly census was 3,371. The facility census was 98.

The hospital had the capacity and capability to provide an appropriate medical screening examination and further examination without delay.


Refer to A2406 for details.

Based on interview, record review and policy review, the facility failed to provide within its capabilities and capacity, an appropriate Medical Screening Exam (MSE) to two patients (# 1 and 22) selected for review from the emergency department (ED) log from March to September 2016. The hospital's failure inappropriately and significantly delayed further examination and treatment when ED staff discharged the two patients to law enforcement officers who took them to jail to await transfer to a hospital with psychiatric capabilities. The hospital's failure had the potential to increase the risk for a negative outcome for all individuals seeking treatment in the ED. The ED average monthly census was 3,371. The facility census was 98.

Findings included:

1. Review of the facility policy titled, "Psychiatric Evaluation of Patient in Emergency Services," showed that if inpatient treatment is indicated and no facility found, the patient should be admitted while awaiting for an available bed. When hospital personnel initiate the commitment process, staff should request an order to transport by county law enforcement if the patient is medically stable. If ambulance transportation is indicated, hospital staff should arrange for appropriate ambulance transport.

2. Review of Patient #22's ED medical record showed:

- She presented on 06/20/16 at 2:14 PM.
- The ED nurse assessment showed Patient #22 jumped off a deck into water and was trying to hurt herself, as she could not swim. She complained of back pain. She had a history of bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks) anxiety (fear and worry are constant and overwhelming), depression (a long period of feeling worried or empty with a loss of interest in activities once enjoyed), and thoughts of suicide. She had previously been to psychiatric facilities five times and she needed to get back on her medication.
- She received a non-narcotic medication for pain once.

-The ED Physician Documentation showed:
- She was with her brother and sister and jumped off a deck into a lake, which was approximately a 15 foot drop.
- She admitted she had been thinking about hurting herself.
- She was a poor historian and slow to answer any questions.
- She had no history of bipolar disorder.
- She had not taken her medication for a long time.
- She continued to want to hurt herself.
- She complained of back pain.
- Staff I, ED physician documented on 06/20/16 at 6:54 PM that the patient remained stable, x-rays of the lumbar spine (five vertebrae, bones of the spine, that correspond with the lower back) were negative, laboratory work was all normal. County law enforcement was taking care of psychiatric placement for the patient.

- Staff DD, RN, documented on 06/20/16 at 7:19 PM that Patient #22 was discharged into the custody of county law enforcement.

During an interview on 09/20/16 at 1:10 PM, ED physician I stated that:
- Patient #22 arrived to the facility by Emergency Medical Services (EMS), but the patient was already in custody of county law enforcement.
- If the patient was under arrest he could not have superseded the county law enforcement.
- It may not have been optimal to be incarcerated for her mental illness, but she would be safe from harming herself and would obtain psychiatric care in the near future.
- He thought county law enforcement had already started a 96 hour hold process (a person who presents a likelihood of serious harm to self or others as the result of a mental disorder or alcohol or drug abuse may be involuntarily detained for evaluation and treatment at a mental health or alcohol/drug abuse facility) with a judge and if the patient was medically cleared, county law enforcement could take the patient and find psychiatric facility placement.

ED physician I, was aware this patient still had thoughts to harm herself. The facility failed to follow their policy that if inpatient treatment is indicated and no facility is found to accept the patient, the patient should be admitted while awaiting for an available bed.

3. Review of the physician on call schedule for June 2016 showed the facility had no on call psychiatrists.

4. During a telephone interview on 09/21/16 at 10:59 AM, Patient #22 stated that:
- Staff told her she would be going to another hospital for psychiatric care.
- She did not know why, but county law enforcement came and took her to jail.
- She was transported the next day to a psychiatric facility.
- This process made her feel terrible and she did not get any medication.

5. Record review of Patient #1's ED medical record showed:

- She presented on 06/20/16 at 2:14 AM.
- Her chief complaint was that she had hallucinations (seeing or hearing things which were not there) and was in a psychotic state (a disorder characterized by false ideas about what was taking place or who one was).

- The ED psychosocial assessment showed the patient stated that she had a dream and was impregnated by aliens, woke up, and started to freak out. She had treatment for this in the past and according to her son her medication was changed approximately two weeks prior [to the ED visit]. She complained of being depressed and hallucinating.

- The Medication Administration record showed patient # 1 was chemically restrained while in the ED, receiving doses of anti-psychotic medication three times by injection.

- The ED Physician documentation showed that the patient had a mild urinary tract infection and received a dose of antibiotics.
Further documentation by the ED physician showed:
- The patient was brought to the ED by her son because of increasingly bizarre behavior, which has persisted over the last eight months with multiple hospitalizations.
- Over the last few days she had shown increased auditory hallucinations and increased withdrawal.
- She has been diagnosed with schizophrenia (mental disorder that leads to a withdraw from reality).
- Her usual pattern was to become gradually more agitated, and then to run off and be difficult to locate.
- During one of the episodes she sustained severe frostbite.
- The documentation showed on the morning of her arrival to the ED, the patient acknowledged a dream about being abducted by aliens. She was calm and lucid, but then became very disoriented, physically violent, and attempted to run out of the ED.
- Her psychological history showed depression and psychiatric disorders.
- Her appearance showed distress.

- Staff AA, ED Physician, documented on 06/20/16 at 7:00 AM that the patient was resting and the facility was waiting for an appropriate mental health facility with an available bed in order to transfer the patient.

- Staff W, Social Worker, documented on 06/20/16 at 5:09 PM that the patient was accepted by a facility (Hospital B) and would be transported by ambulance. Nursing staff were notified.

- A judge signed a 96 hour hold on 06/20/16.
- The ED staff discharged patient # 1 to county law enforcement on 06/20/21 at 9:56 PM.

- On 07/02/16 at 7:32 PM, an Addendum to the ED medical record showed Staff AA, ED Physician, documented that the patient was discharged to county law enforcement for protective custody prior to being taken as an involuntary commitment to a psychiatric facility (Hospital B).

During a telephone interview on 09/20/16 at 2:30 PM, Staff BB, Registered Nurse (RN) stated that:
- She received report from the day nurse that a bed at a psychiatric facility was available for Patient #1. Paper work was completed, and nursing staff were waiting for transportation for Patient #1.
- ED nurse BB stated that Staff Z, Charge Nurse, told her Patient #1 would be transported by county law enforcement to Hospital B in the morning because law enforcement had no staff to transport until the next morning. County law enforcement would take Patient #1 to jail to await transfer.
- Patient #1 had a 96 hour hold in place.
- She felt the patient was safe and that since the judge signed the paperwork he would have known the transfer would not occur until the next morning.
- Patient #1 should have stayed at the hospital.

During an interview on 09/15/16 at 4:07 PM, Charge Nurse Z, stated that when a patient was considered involuntary (had a 96 hour hold) county law enforcement transported the patient. County law enforcement took Patient #1 and told Charge Nurse Z that they were taking the patient back to the jail until they arranged transport. She stated that she received a call from Patient #1's son and he wanted to talk with his mother. The patient was leaving with county law enforcement and they did not allow the patient to talk with her son. The son was upset and Charge Nurse Z reported this to her ED Manager.

During an interview on 09/20/16 at 6:56 PM, Staff AA, ED Physician, stated that:
- He was aware Patient #1 had a 96 hour hold.
- When county law enforcement came to get Patient #1 and take her to jail, he questioned the nurses about this procedure. The nurses stated that was how county law enforcement wanted to proceed.
- He did not question the county law enforcement because he had questioned law enforcement on two occasions at a previous facility and he was threatened that he could be arrested.
- Patient #1 was medically stable and he knew if she had problems (psychological) that county law enforcement would bring her back.
- He did not think this was in the best interest for the patient, but did not think he had the authority or power over county law enforcement.
- He did not communicate his concerns to his supervisor.

ED physician AA, was aware, through the MSE, that this patient would be calm and suddenly become very agitated, disoriented, physically violent, and attempt to run off. ED physician AA failed to continue to assess and stabilize the psychiatric condition of this patient.

6. During an interview on 09/15/16 at 1:52 PM, Staff W, Medical Social Worker (SW), stated that:
- She set up the placement for Patient #1 and reported the information to the ED nurses.
- She felt that the patients going to a psychiatric facility should be transported by EMS for the patient's safety.
- She stated that Patient #1's son spoke with her and he did not understand why his Mom was not taken to the accepting facility. He reported the patient was taken to jail overnight, then to another facility, before arrival to Hospital B.
- She called county law enforcement and they reported that there was a misunderstanding, about which facility she was to go to, but the patient was at the correct facility and everything was ok.
- She notified her supervisor, the Director of the SW Department.
- She stated she was "mad" that the patient failed to go by ambulance and was not directly sent, since the bed was ready and available for the patient.

During an interview on 09/15/16 at 2:10 PM, Staff X, Director of SW Department, stated that:
- She was aware of a patient who had a placement and failed to show up timely to the accepting psychiatric facility.
- The medical record showed Patient #1 was picked up by county law enforcement and held at the jail due to county law enforcement not having staff to transport.
- After county law enforcement took a patient, decisions made for the patient were out of the facility's hands.
- Generally, county law enforcement took the patient if they had a 96 hour hold, to the accepting psychiatric facility.
- An ambulance would be used when in the best interest of the patient (ingestion injury, medical monitoring, or length of transfer).
- She encouraged her SW to check with county law enforcement to ensure the patient made it to Hospital B.
- She stated that she failed to report this to administration.

During an interview on 09/20/16 at 1:30 PM, Staff BB, ED Medical Director, stated that:
- County law enforcement took affidavits (written sworn statement) to a judge to sign to obtain 96 hour holds and returned the paper work to the hospital.
- County law enforcement took the patient once the patient was assessed, deemed medically stable and the facility had an accepting psychiatric facility in place.
- In the case of an ED patient being transported to a psychiatric facility, county law enforcement was to transport from Hospital A to Hospital B.
- He was unaware patients were taken to jail to await transport to a psychiatric facility. He expected when county law enforcement took the psychiatric patients they were transporting directly to the accepting psychiatric facility.
- It would not be beneficial for a psychiatric patient to go to jail.

During an interview on 09/20/16 at 12:20 PM, Staff D, Director of Nursing, stated that she was unaware any psychiatric patients waiting for placement in a psychiatric facility were taken to jail by county law enforcement. Staff D confirmed the process in which county law enforcement assisted with a 96 hour hold, but she thought when they took a patient, they took that patient directly to the accepting psychiatric facility. A patient needing psychiatric care would not benefit by being in jail.