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Based on interview and record review, the facility failed to comply with provisions in 42CFR 489.20
and 489.24, when it failed to ensure a complete medical screening exam (MSE) was conducted on a suicidal patient in the emergency department (ED), for one patient (Patient 6). In addition, the facility failed to ensure Patient 6 was transferred appropriately.

These failures caused Patient 6 to be discharged from the facility without a psychiatric consult and was transported by the facility by a ride-share transport (a non-medical transportation service) to an address which is not the direct address of Facility B (a psychiatric [relating to mental illness or its treatment] facility which provides 24- hour mental health services). This failure resulted in Patient 6 being transferred to Facility C (an emergency psychiatric facility) instead of Facility B which was the intended destination. This failure had a potential to delay the treatment for Patient 6 and may cause harm to the patient.

Based on interview and record review, the facility failed to ensure a complete medical screening exam (MSE) was conducted on a suicidal patient in the emergency department (ED), for one of 20 sample patients (Patient 6).

This failure caused Patient 6 to be discharged from the facility without a psychiatric consult. This failure had a potential to delay the treatment for Patient 6 and may cause harm to the patient.

Findings:

On August 6, 2025, at 2:30 p.m., Patient 6's record was reviewed with Risk Coordinator (RC). facility document titled, "Rapid Initial Assessment," dated July 25, 2025, at 11:58 a.m., authored by Registered Nurse (RN) 1, was reviewed. The document indicated, "...PT [Patient 6] BIBA [brought in by ambulance] FOR SUICIDAL IDEATIONS [thoughts of death and committing suicide]. PT WAS RECENTLY RELEASED FROM JAIL, STATED TO STAFF HE WAS HAVING VISUAL HALLUCINATIONS [a sensory perception of something that isn't actually there]. CURRENTLY PT STATES "I DON'T WANT TO BE ON THIS EARTH ANYMORE". No active plan...HI [homicidal ideation, thoughts of harming others]..." The document indicated a "SUICIDE SCREENING [a systematic procedure which uses standardized instruments or protocols to identify individuals who may be at risk for suicide]" was completed by RN 3. The suicide screening indicated Patient 6's suicide risk level using the Columbia Suicide Severity Rating Scale [C-SSRS, a tool used for assessing an individual's risk of suicide] was high risk.

On August 6, 2025, at 2:45 p.m., a facility document titled, "Emergency Provider Report," dated July 25, 2025, at 12:08 a.m., authored by Physician (MD) 11, was reviewed with the Risk Coordinator (RC). The document indicated Patient 6 came into the ED with complaints of hallucinations and suicidal ideation (SI, suicidal ideation, thoughts of harming oneself). The document indicated Patient 6 was recently released from jail, homeless, had stated he heard auditory and visual hallucinations, and was having delusions that people were out to get him and he is scared for his life. The document indicated Patient 6 had a medical history of schizophrenia (a severe mental disorder which affects how a person thinks, feels, and behaves). the document indicated patient 6 had a past history of suicidal ideation and was placed on an involuntary legal hold (5150, a legal process where an individual is admitted to a mental health facility or receives supervised outpatient treatment against their will). The document indicated, "...no concern for SI [suicidal ideation, thoughts of harming self ], HI, command hallucinations [an auditory hallucination where a person hears voices instructing them to perform specific actions] at this time...Patient [Patient 6] is otherwise willing to present to a mental health CSU [crisis stabilization unit, a 24 hour urgent care for patients with psychiatric ([relating to mental illness or its treatment) needs] facility for further workup and treatment. I feel that this is appropriate as patient is a low risk...Overall risk level-suicide: no risk..." The document indicated, "...Discharged to Home...Yes...Time 0240 [2:40 a.m.]...Date...07/26/2025 [July 26, 2025]..." The document did not indicate a Suicide Detailed Risk Assessment (suicide DRA, a comprehensive evaluation process used by healthcare professionals to determine an individual's likelihood of engaging in suicidal behavior) was conducted by MD 11.

A facility document titled, "Disposition," dated July 26, 2025, at 3:56 a.m., authored by RN 12, was reviewed with the RC. The document indicated, "...Patient left via ...public transportation...Destination details: PATIENT STATED THAT HE WOULD GO TO CUS [sic, CSU, Facility B]..."

On August 7, 2025, at 7:45 a.m., an interview with RN 11 was conducted. RN 11 stated the patient (Patient 6) with high risk of suicidal ideations was endorsed to him by the nurse from the previous shift. RN 11 stated the ED physician did not ask him for explanation of the documented high risk of SI for the Patient 6 .

On August 7, 2025, at 11:30 a.m., an interview was conducted with the Informatics Nurse (IN, a registered nurse who uses their clinical expertise and knowledge of information technology to improve patient care). The IN stated the suicide-DRA was not completed for Patient 6. The IN stated if the suicide-DRA was completed, it would have been included on the ED Note authored by the provider. The IN stated she did not see the S-DRA assessment on the ED Note for Patient 6. The IN stated, when the physician answers yes to a high risk C-SSRS, the electronic medical record provides instructions to the provider which would indicate, " ...if the nursing calculated risk assessment shows pt [patient] at risk (low, moderate or high), the provider should then select Yes for the Pos [positive] Nur [nursing] Sui [suicide] Risk Screen [screening]...By doing so, 4 [four] additional queries will become required..."

On August 7, 2025, at 1:30 p.m., an interview was conducted with MD 11. MD 11 stated he was not aware nursing made Patient 6 a high risk for suicide on the C-SSRS. MD 11 stated he was not aware a subsequent assessment titled, "Suicide - DRA," was mandatory when the nurse deemed the patient a high risk on the C-SSRS in accordance with the facility's the Suicide Prevention Plan policy. MD 11 stated if Patient 6 met the criteria for an involuntary hold, he would get Tele Psych (a contracted service who evaluates a patient with SI, HI, or gravely disabled [not able to care for oneself]) via video call for a legal hold involved to evaluate the patient for a legal hold.

On August 7, 2025, at 2 p.m., an interview was conducted with the Director of Patient Safety (DPS). The DPS stated the subsequent assessment for the Suicide-DRA was not completed for Patient 6. The DPS stated the Suicide-DRA should have been completed by the physician once the registered nurse deems the patient a high risk for suicide.

A review of the facility policy and procedure (P&P) titled, "Suicide Prevention Plan," revised September 9, 2025, was conducted. The policy indicated, "...The C-SSRS [Columbia Suicide Severity Rating Scale] is the initial screening tool utilized by the nurse...Any patient with a positive, "at-risk" C-SSRS screening (i.e., low, moderate, or high risk) require a secondary level suicide DRA to identify activating events, protective factors, and contributing factors to risk of suicide. This should be completed by a licensed or credentialed physician/practitioner/Qualified Mental Health Practitioner...The Provider/Practitioner will use the information collected from the suicide DRA paired with clinical judgment to determine (estimate) the patient's ORL [overall risk level]..."

Based on interview and record review, for one of sample 20 patients (Patient 6), the facility failed to ensure Patient 6, a suicidal patient, was transferred appropriately.

This failure caused Patient 6 to be discharged from the facility without a psychiatric consult and was transported by the facility by a ride-share transport (a non-medical transportation service) to an address which is not the direct address of Facility B (a psychiatric [relating to mental illness or its treatment] facility which provides 24- hour mental health services). This failure resulted in Patient 6 being transferred to Facility C (an emergency psychiatric facility) instead of Facility B which was the intended destination.

Findings:

On August 6, 2025, at 2:30 p.m., Patient 6's record was reviewed with Risk Coordinator (RC). facility document titled, "Rapid Initial Assessment," dated July 25, 2025, at 11:58 a.m., authored by Registered Nurse (RN) 1, was reviewed. The document indicated, "...PT [Patient 6] BIBA [brought in by ambulance] FOR SUICIDAL IDEATIONS [thoughts of death and committing suicide]. PT WAS RECENTLY RELEASED FROM JAIL, STATED TO STAFF HE WAS HAVING VISUAL HALLUCINATIONS [a sensory perception of something that isn't actually there]. CURRENTLY PT STATES "I DON'T WANT TO BE ON THIS EARTH ANYMORE". No active plan...HI [homicidal ideation, thoughts of harming others]..." The document indicated a "SUICIDE SCREENING [a systematic procedure which uses standardized instruments or protocols to identify individuals who may be at risk for suicide]" was completed by RN 3. The suicide screening indicated Patient 6's suicide risk level using the Columbia Suicide Severity Rating Scale [C-SSRS, a tool used for assessing an individual's risk of suicide] was high risk.

On August 6, 2025, at 2:45 p.m., a facility document titled, "Emergency Provider Report," dated July 25, 2025, at 12:08 a.m., authored by Physician (MD) 11, was reviewed with the Risk Coordinator (RC). The document indicated Patient 6 came into the ED with complaints of hallucinations and suicidal ideation (SI, suicidal ideation, thoughts of harming oneself). The document indicated Patient 6 was recently released from jail, homeless, had stated he heard auditory and visual hallucinations, and was having delusions that people were out to get him and he is scared for his life. The document indicated Patient 6 had a medical history of schizophrenia (a severe mental disorder which affects how a person thinks, feels, and behaves). the document indicated patient 6 had a past history of suicidal ideation and was placed on an involuntary legal hold (5150, a legal process where an individual is admitted to a mental health facility or receives supervised outpatient treatment against their will). The document indicated, "...no concern for SI [suicidal ideation, thoughts of harming self ], HI, command hallucinations [an auditory hallucination where a person hears voices instructing them to perform specific actions] at this time...Patient [Patient 6] is otherwise willing to present to a mental health CSU [crisis stabilization unit, a 24 hour urgent care for patients with psychiatric ([relating to mental illness or its treatment) needs] facility for further workup and treatment. I feel that this is appropriate as patient is a low risk...Overall risk level-suicide: no risk..." The document indicated, "...Discharged to Home...Yes...Time 0240 [2:40 a.m.]...Date...07/26/2025 [July 26, 2025]..." The document did not indicate a Suicide Detailed Risk Assessment (suicide DRA, a comprehensive evaluation process used by healthcare professionals to determine an individual's likelihood of engaging in suicidal behavior) was conducted by MD 11.

A facility document titled, "Disposition," dated July 26, 2025, at 3:56 a.m., authored by RN 12, was reviewed with the RC. The document indicated, "...Patient left via ...public transportation...Destination details: PATIENT STATED THAT HE WOULD GO TO CUS [sic, CSU, Facility B]..."

A review of an undated facility document titled, "24/7 [24 hours seven days a week] MENTAL HEALTH URGENT CARE [CSU, Facility B]," was conducted with the RC and the Emergency room director (EDD). The document indicated the address of Facility B. During a concurrent interview, the EDD and the RC confirmed the address of Facilty B had a building number next to it.

A facility document titled, "[name of ride-share company] concierge," dated July 26, 2025, at 3:59 a.m., authored by RN 12, was reviewed with the RC and the EDD. The document indicated Patient 6 was given a ride from the facility to Facility B. The document did not include the building number for Facility B. During a concurrent interview, the EDD stated and confirmed there was no documentation of Facility B's building number on the listed address.

On August 7, 2025, at 8:30 a.m., an interview with RN 12 was conducted. RN 12 stated she arranged the ride-share transportation for Patient 6 upon the patient's discharge. RN 12 stated she entered the address of Facility B as the destination address on the ride-share application on the facility's computer. RN 12 stated the ride-share application did not give her the option of entering the building number as an additional location for Facility B. RN 12 stated she was not aware there were multiple buildings surrounding Facility B at the same address. RN 12 stated a report about Patient 6's transfer was not given to Facility C because Patient 6 was discharged to Facility B.

On August 7, 2025, at 1:30 p.m., an interview was conducted with Physician (MD) 11. MD 11 stated he was not aware Patient 6 was transported via a ride-share tranportation company to Facility B. MD 11 stated he was not aware Patient 6 ended up at another psychiatric facility (Facility C).

On August 7, 2025, at 1:45 p.m., an interview was conducted with the Director of Patient Safety DPS. The DPS stated the discharge nurse should have made sure the correct address was given to ride-share transportation company when arranging transportation for Patient 6 from the facility to Facility B.

A review of the facility policy and procedure titled, "Discharge Transportation Services Program," dated February 1, 2025, was conducted. The policy indicated, "...If the Discharged Patient is transported by ride share company Transport Vendor...a Transport Coordinator shall contact the ride share company and request the transportation...The Transport Coordinator shall include the...address to which the patient is to be transported (patient's residence or Alternate location) in the transport request..."