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Based on interview, central log, polices, and record review the facility failed to provide care in a safe setting when it failed to provide an appropriate emergency medical screening examination for 1 out of 10 patients who presented to the emergency department with an emergency medical condition. ( Patient #2)

Findings include:

Refer to A2406

Based on interview, central log, polices, and record review the facility failed to provide care in a safe setting when it failed to provide an appropriate emergency medical screening examination for 1 out of 10 patients who presented to the emergency department with an emergency medical condition. ( Patient #2)

Findings include:

Review of the Facilities Emergency department central log reads, "[Patient #2's name], arrival date/time 11/03/2022 1527 (3:27 PM) Discharge date /time: 11/03/2022 2123 (9:23 PM) Dispo (disposition): LWBS (left without being seen) after triage Acuity: 2, CC (chief complain): depression suicidal."

Review of the Emergency department demographics sheet for Patient #2 dated 11/3/2022 reads, "Visit information: Admission information: Arrival date/Time: 11/03/2022 1527 (3:27 PM), admission type: Emergency, Means of arrival: Walk in, Primary Service: Emergency Medicine. Reason for visit: Depression (history of anxiety and depression, reports has been battling these for many years, currently on meds. Reports over the last two days she has felt she wanted to "end" things and "take a bunch of pills to go to sleep and not wake up". Suicidal (states she is "scared to go home, because she does not know what she will do to herself")

Review of the ED (emergency department) triage notes dated 11/3/2022 at 1617 (4:17 PM) authored by Staff A Registered Nurse (RN) reads, "Chief complaint: Patient presents with depression history of anxiety and depression, reports has been battling these for many years, currently on meds. Reports over the last two days she has felt that she wanted to "end things" and "take a bunch of pills to go to sleep and not wake up". Suicidal states she is "scared to go home because she does not know what she will do to herself."

Review of the ED Notes dated 11/3/2022 at 1632 (4:32 PM) authored by Staff A, RN reads, "made charge nurse aware of pt (patient) complaint and status. No current open beds available in ED. Husband is accompanied with pt. Charge nurse is aware of pt in lobby with husband. Verbalized to husband to let us know if he leaves so that we can accommodate one-on-one supervision. Husband verbalized understanding and said "he was not going to leave her"

Review of physician orders dated 11/3/2022 at 1633 (4:33 PM) reads, "Notify provider for evaluation of need for security watch/ MA/BA. frequency STAT."
Review of physician orders dated 11/3/2022 at 1633 (4:33 PM) reads, "Place patient in a treatment space under direct observation of RN. To notify charge nurse. Frequency STAT."

Review of the electronic medical record document there was no physician notification that Patient #2 was in the emergency room.
Review of the medical record document that Patient #2 was not placed in a treatment space under the direct observation of RN.
Review of the progress note dated 11/3/2022 at 2123 (9:23 PM) reads" LWBS (left without being seen)."

During an interview on 11/9/2022 at 11:50 AM Staff A, Registered Nurse (RN) stated, "I remember that she (Patient #2) came in with her husband saying she was depressed and said she was on medications that weren't working and that she had thoughts of depression and sadness. She had thought to take a bunch of pills and not wake up. She did state she was afraid to go home because she didn't know what she would do. I don't remember if I told the doctor about her, I just can't tell you if I did or not, but I should have. It was crazy busy people were signing in one after the other. I was on until 1000 PM that day, but at 7 PM I went to fast track and was not in triage any longer. This patient did not tell me she was leaving, and I have no idea what time she did leave. I should have let the doctor know; I should have given the patient a sitter. She did not have a medical screening exam after I placed the standing order. I did discuss it with the charge nurse, and I did document that I let her know. I did not tell the doctor; I really can't remember if I told him. I did not place her with a sitter. I was not aware that I could place a patient on suicide precautions. Normally we will place the patient in a separate area and let the providers know. That day we did not have any beds available. We have had Baker Acts stay in the lobby, but they have always had a sitter. She was not a Baker act. She was suicidal she did tell me she was afraid. I did complete the suicide screen and she was positive for being a risk for suicide. It was really busy, and I just forgot to let the doctor know. This was the first time I used this order set, it's new to us and I forgot. She was not seen by a doctor or a nurse practitioner. I did not get a sitter for her. I did not tell the nursing supervisor that we had a suicidal patient in the waiting room. I did not get her seen. Stat means to do it right away, I did not notify the physician or have a sitter stat."

During an interview on 11/9/2022 at 11:50 AM Staff B, RN stated," I was on that evening that {Patient #2's name] came in and went off at 7 PM. It was very busy that afternoon there was no movement no beds, we were beyond rations. When it is like that we contact the Nursing Supervisor, and they send help, and they decide if and when we can go on divert. If [Staff A's name} documented that I was notified I must have been. I don't really remember. I don't know if she told me that she didn't have anyone to watch the patient. She wasn't a Baker Act so there would not be a need. Well, she was not evaluated by a physician, so I don't have any idea whether she needed to be Baker acted or not. I was not aware that she left. No one told me. I did not review her chart to see what was stated. I did not see the suicide screening. I really can't tell you if she was safe while in the waiting room, but we had nowhere else to put her. I guess she was not in a safe environment. She did leave without being seen. Yes, she should have been evaluated by a physician. We did not follow our policy related to suicide precautions. She was not evaluated, and she was not assessed for having a sitter until she could be seen. There was a set of standing orders, they were not followed. She did not get a medical screening exam to determine if she needed to be a Baker Act."

During an interview on 11/9/2022 at 12:28 PM Medical Doctor #1 stated, "I was the practitioner on 11/3/2022, I cannot remember what time I went off shift. But yes I was on at 3:30 PM and would have been on at 4:30 and 5:30 PM. I was not notified that there was a depressed or suicidal patient in the waiting room. I will expect that if staff have someone who screens positive as a suicidal risk or presents stating they want to "take pills, go to sleep, and end it all" that the staff would get us, and they would be evaluated by a practitioner for the need for a baker act. I would expect staff to place the patient on suicide precautions until they could be evaluated if there was any reason for a delayed examination. I don't know anything about this case specifically. But anyone who is suicidal does require an evaluation to determine if they meet require a baker Act and further treatment. We do have standing orders that indicate staff should notify a practitioner and provide one to one and making sure they are within sight of the RN. If the nurses entered those standing orders, I would expect that they carry them out. I believe they should have been evaluated for the need for a Baker Act and for a psychiatric evaluation. I was not notified that this patient was here or that they left. I did not provide the patient a medical screening examination."

During an interview on 11/9/2022 at 12:55 PM the Emergency Department Medical Director stated," I was not aware of this case. So, I will not speak to any specifics. Patients can stay in the waiting room with suicidal ideation if they are continually visualized. I would not say and did not say she [Patient #2] was in a safe situation. She [Patient #2] needed to be evaluated if what the medical record states is she [Patient #2] was suicidal. She [Patient #2] did need to be seen by a practitioner if there was an order to do that. I would expect that the nurses followed the standing orders. I would expect that if the patient stated she [Patient #2] wanted to take pills and go to sleep that they were placed on one-to-one observation, not just left with her husband but with a staff member until they could be evaluated by a physician. There should have been physician notification and a verbal discussion of what the patient presented with so the physician could make a proper determination of her [Patient #2] needs. Apparently she was not provided a medical screening examination."

During an interview on 11/9/2022 at 1:26 PM the ED Nurse Manger stated, "I was not aware that this happened. I had no idea that a depressed suicidal patient left the emergency room. I wasn't aware that they left without being seen. They should have had staff supervision and not been able to leave without being seen. We did not follow up with this patient to make sure she was alright. We could have called or had the police do a well check, but we did not. We are not reviewing patients who leave without being seen. We are beginning something related to baker Acts, but no patients who are leaving without being seen. I don't know why beyond high volumes at times. We do get additional help when the census begins to climb. I do not think she was in a safe setting when we didn't follow the orders and notify the physician or give her a sitter until she could be evaluated. She should have been screened by a physician to determine if she needed to be Baker Acted. I can't tell you why this was not done. There is no incident report filled out related to this patient. Yes they should have done one. That would have been completed, it would have raised a red flag and been investigated. No, this patient did not get a medical screening examination and she should have."

During a telephone interview conducted on 11/14/2022 at 5:25 PM Patient #2 and Patient #2's husband stated, "We were so upset with the care that this hospital provided or should I say did not provide. She has had very serious depression for many years and every few years she feels suicidal. She told them that she was afraid to be at home alone, she was afraid of what she would do to herself. She wanted to take pills and go to sleep. We told the nurse at triage that, they didn't do anything to get her help. We asked them how much longer it would be, and they said it would be hours before she could be seen. The nurse said that she wasn't a priority, there were sicker people there and they would get to her after the other sicker people. They didn't let the doctor know she was there, and they didn't seem upset that she was threatening to commit suicide. We told the person at the desk that we were leaving that was about 7:00 PM, she told us that was our prerogative, that it was fine if we wanted to go we could. I know that there are other people, but they just didn't care. They did not call and do any follow up and they did not send any police to do a well check. We do not live out of state we live in the area. It was so distressing, I spent all night awake making sure she didn't do anything to herself. We finally got her to a doctor. They did more harm than good to my wife."

Review of the policy and procedure titled, "Triage, Five Level", policy # 3376, last revision date of 2/21/2022 reads, "Standard/Purpose: Establish guidelines for assigning a triage category to each patient presenting to the Emergency Department. Policy: The nurse will evaluate every non ambulance patient who presents to the Emergency Department to determine priority of treatment required. Ambulance patient priority will be determined by the primary care nurse.
Procedure: Utilizing the emergency severity index, each patient will be evaluated, categorized and treatment initiated based on the severity of their condition. The completion of the evaluation documentation on the triage note by the triage nurse will vary depending on the severity of the patient and necessity for intervention to be started immediately. The primary nurse will assure completion of the necessary information when appropriate. Level 2-MAGENTA-Emergent: These patients are in risk of deterioration and should not wait to be seen; they are considered high risk for deterioration if treatment does not occur in a timely fashion."

Review of the policy and procedure titled, "Medical Screening Policy", Policy number 4666 effective date 8/23/2022 reads, "Purpose: To Require that a hospital with an emergency department provide an appropriate medical screening examination (MSE) as required by the emergency medical treatment and active labor act (EMTALA), 42 U.S.C., section 1395dd and all federal regulations and interpretive guidelines promulgated thereunder. Policy: The hospital with an emergency department must provide an individual that is not a patient who "comes to the emergency department" an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition ("EMC") exists, regardless of the individual's ability to pay. The EMTALA Obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED) or when an individual requests emergency medical care on hospital property, other than in a DED. If an EMC is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer. EMTALA obligations do not apply to individuals who have begun to receive outpatient services as part of an encounter, other than an encounter that the hospital is obligated by EMTALA to provide. EMTALA is also not applicable to inpatients. Existing Medicare hospital conditions of participation and relevant state laws protect individuals who are already patients of a hospital and who experience EMC's. Procedure: Definitions: Capabilities of a medical facility or main hospital provider means the physical space, equipment, supplies and services (e.g., trauma care, surgery, intensive care, pediatrics, obstetrics, burn unit, neonatal unit, or psychiatry) including ancillary services available at the hospital. The capabilities of the hospital staff mean the level of care that the hospitals personnel can provide within the training and scope of their professional licenses. The hospital is responsible for treating the individual within the capabilities of the hospital as a whole, not necessarily in terms of the particular department at which the individual presented. The hospital is not required to locate additional personnel or staff to off campus departments to be on call for possible emergencies. Emergency Medical Condition "EMC" means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy. 3. with respect to an individual with psychiatric symptoms: a. that acute psychiatric or acute substance abuse symptoms are manifested; or b. That individuals are expressing suicidal or homicidal thoughts or gestures and are determined to be a danger to self or others. Medical Screening Examination ("MSE") is the process required to reach within reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists, or a woman is in labor. Such screening must be done within the facilities capability and available personnel, including on call physicians, and be applied in a nondiscriminatory manner (i.e., A different level of care must not exist based on payment status, race, national origin, etc.) Screening is to be conducted to the extent necessary, by physicians and or other qualified medical personnel to determine whether an EMCC exists. With respect to an individual with psychiatric symptoms, and MSE consists of both a medical and psychiatric screening. The MSE is an ongoing process, and the medical records must reflect continued monitoring based on the individual's needs and must continue until the individual is either stabilized or appropriately transferred. Qualified Medical Personnel means an individual in addition to a licensed physician who is licensed or certified and who has demonstrated current compliance in the performance of MSE, for example: Registered Nurse in perinatal services. psychiatric social worker, registered nurse in psychiatric services, psychologist, physician assistant, advanced registered nurse practitioner, certified registered nurse midwife. Hospital Policies: each hospital that participates in the Medicare program and provides emergency medical services must develop policies and procedures to ensure compliance with EMTALA requirements related to the medical screening process or adopt this policy as outlined. Such policies should contain the following provisions. General Requirements: 1. in order for EMTALA to be triggered, hospital personnel must be aware of the individual's presence and observe the appearance or behavior, or both with that person. This also applies to presentments for off campus DED. The hospital must be on notice of the individual's existence and condition for any EMTALA violation to take place. When a Medical Screening Examination is Required: An individual MUST receive a medical screening examination within the capabilities of the hospitals DED, to determine whether or not an EMC exists, or with respect to a pregnant woman having contractions, whether the woman is in labor and whether or not treatment requested is explicitly for an emergency condition if: 1. If individual comes to a dedicated emergency department of a hospital and a request is made on his or her behalf for examination or treatment for a medical condition, including where: c. If an individual comes to the emergency department and has a complaint of suicidal ideation, a report of suicidal ideation, behavior consistent with suicidal ideation, or impairment from drugs or alcohol, to prevent to the delay of the MSE, the person will be under constant surveillance until the MSE can be accomplished. When the individual leaves against Medical advice: 2. Leaving DED after triage but before an MSE. If an individual presents to the DED and request services for a medical condition, is triaged and then indicates a desire to leave prior to the MSE ("LPMSE"), the facility should use its best efforts to c. the individual further medical examination and treatment as may be required to identify and stabilize an EMC; every effort will be made to have the patient seen by a medical provider prior to leaving. g. Document the individuals refusal of MSE, or the attempts to locate the individual if he or she left without notifying someone. How to provide the Medical Screening Examination: 1. Hospitals are obligated to perform the MSE to determine if an EMCC exists. It is not appropriate to merely "log in" an individual and not provide an MSE. 3. For individuals who come to a DED seeking care for a medical condition, the hospital must provide an MSE beyond initial triage. Triage is not equivalent to an MSE. Triage merely determines the "order" in which individuals will be seen, not the presence or absence of an EMC. 5. The extent of the necessary examination to determine whether an EMC exists is generally within the judgment and discretion of the physician or other qualified medical personnel performing the examination functioning according to algorithms or protocols established and approved by the medical staff and governing board. 9. For individuals with psychiatric symptoms, the medical record should indicate both a medical and psychiatric MSE. The medical MSE is to determine that from a physical perspective, there is no EMC (e.g., electrolyte imbalance, alcohol or substance abuse, etc.) The psychiatric MSE includes an assessment of suicide or homicide attempt or risk, orientation and assaultive behavior that indicates danger to self or others."

Review of the policy and procedure titled "Suicide Risk Screening (C-SSRS) Suicide Risk Assessment (SAFE-T) "policy # 7380 last revision date of 1/11/2022 reads: "Standard/Purpose: TO provide a consistent approach to identify patients who are at risk for suicide and for implementing safeguards that will minimize the potential for harm. Policy: A Suicide risk screening (C-SSRS) shall be completed on all patients 12 years old and over who present to a UF Health Central Florida Hospital Emergency Department or UF Health Central Florida inpatient units. A suicide risk assessment (SAFE-T) shall be completed on all patients 12 years old and over who are screened positive for suicide risk. Patients determined to be at risk for suicide will be placed on suicide per cautions to minimize the potential for self-harm. Core procedure: I. Initial suicide risk screening and assessment process: A. UF Health Central Florida Emergency departments: At UF health Central Florida hospitals, the initial screening is completed in the emergency departments. Once a patient screens positive for suicide risk, and order is placed by the emergency department requesting a psychiatric consult to perform an assessment on the patient using the Columbia Suicide Risk Assessment SAFE-T tool. II. Process for meeting the patients immediate safety needs: A. if patient is assessed to be a suicide risk, the nurse is required to: 1. place patient on suicide precautions (refer to UF health Central Florida policy). 2. notify MD/ provider that patient has screened positive for suicide. 3. Request an order for a psychiatric console and for suicide precautions within one hour. 4. Suicide precautions may only be discontinued by a physician. 5. Request staff(sitter) for continuous 1:1 monitoring."

Policy and procedure titled, "Suicide Precautions" policy # 3912 last revision date 1/11/2022 reads, "Standards/Purpose: To provide guidelines for safeguards to employ on non-psychiatric nursing unit/clinical area at UF Health Central Florida hospitals using the least restrictive manner when a patient's condition could lead to suicidal behavior. Policy: The UF Health central Florida hospitals are committed to ensuring a safe healing environment for our patients. Screening for suicide risk and implementing individualized care are important steps we take to protect our patients from harm. The use of suicide precautions shall be justified and used to protect patients from intentionally harming themselves. Suicide precautions procedures are implemented when a patient is screened high risk for suicide based on the C-SSRS screen.
Procedure: I. Initiating Suicide Precautions: A. Any RN on any nursing units/clinical areas (emergency departments) may initiate suicide precautions when patient is screened positive for suicide risk. B. The RN can enter the order for suicide precautions "Per Policy". C. To ensure patient safety, a patient observer is assigned to provide 1:1 continuous monitoring. III. Monitoring: A. The patient must be continuously visualized by a staff member until suicide precautions are discontinued by a physician. The patient is visualized by any staff member who has completed the education specific to suicide prevention. IX. Discontinuing Suicide precautions: A. Suicide precautions may be discontinued when the physician assess the patient and determines that the patient no longer is experiencing suicidal ideation. B. The discontinuance of suicide precautions require a physician's order. "