HospitalInspections.org

Based on medical record review, hospital policy review, and staff interviews, the Hospital's administrative staff failed to ensure the Emergency Department (ED) staff provided 3 of 20 sampled patients (Patient #1, Patient #5, and Patient #9) with an appropriate medical screening exam (MSE) and the appropriate stabilizing treatment after presenting to the ED seeking medical care between 7/24/23 and 10/11/2023.

Failure to provide an appropriate MSE and provide the appropriate stabilizing treatment, placed patients at risk that have an undiagnosed emergency medical condition resulting in a deterioration in health and at a potential risk for death.

Findings include:

1. Review of policy, "Emergency Examination and Transfer-EMTALA", effective 6/2020, revealed in part, " ...an individual who presented at an ...dedicated emergency department and requests examination or treatment for a medical condition ...manifesting itself by acute symptoms of sufficient severity (including ...psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in ...serious impairment of bodily functions ...Medical Screening Examination (MSE) ...The screening process required to determine within reasonable clinical confidence whether an emergency medical condition exists or does not exist. MSE is an ongoing process that requires the physician or QMP to reach within reasonable confidence whether an individual has an EMC or not. To stabilize with respect to an Emergency Medical Condition, to provide such medical treatment of the condition necessary to assure within reasonable medical probability that no material deterioration of the condition is likely to result from, or occur ..."
" ...Stable for discharge: a patient is stable for discharge when, within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or later as an inpatient ..."

2. Review of policy, "Emergency Medical Services- Medical Staff," effective 12/2022 revealed in part, "...Patients presenting to the Emergency Department will receive a medical screening examination by a practitioner to determine if an emergency medical condition exists ..."

3. Review of policy, "Suicidal/Homicidal Patient- Emergency Department," effective 5/2022 revealed in part, " ...Individuals are screened for risk of suicide guide by an evidence-based tool. The Columbia Suicide Severity Rating Scale (C-SSRS) Screening and Risk Assessment tool will be utilized. The nurse completing the C-SSRS Screening is responsible for communicating a positive screening to the ED charge nurse, Behavioral Health Team and the ED practitioner ...C-SSRS Risk Assessment is conducted by a Behavioral Health Consultant or Tele psychiatry practitioner. For all positive initial screenings, a behavioral health professional will complete the suicide risk assessment to validate the level of suicide risk and interventions ...The behavior health professional will communicate their findings and recommendation to the ED practitioner who will determine whether the patient meets the low, moderate, or high-risk suicide level and risk interventions."

4. Review of policy, "Disruptive/Violent Patient - Emergency Department," effective 5/2022 revealed in part, " ...To ensure the safe and appropriate care of the disruptive or violent patient in the Emergency Department ...after examination and treatment by the ED practitioner, the ED practitioner may decide to discharge a stable patient. A patient discharged to Law Enforcement custody must be medically stable. A patient under the influence of alcohol or drugs may be discharged with a responsible adult after appropriate instructions have been given to the responsible adult."

5. Review of the policy, "Telehealth Psychiatry Services", effective 4/2020, revealed the hospital utilized telehealth psychiatry services 24/7 for psychiatic consultations including in the ED.

6. Review of the medical record for Patient #1 revealed the following:

a. On 10/11/2023 at 11:53 AM, Patient #1 arrived at the ED by ambulance with complaints of suicidal ideation with a plan. The patient called the Mental Health Walk-in Clinic multiple times that morning reporting they felt suicidal with a plan to overdose on medication. During that phone call the patient verbalized they had been cutting their hand and wrist in an attempt to self-harm. The Mental Health walk-in Clinic staff called for a welfare check on Patient #1. The Police and Emergency Medical Services (EMS) picked the patient up and brought the patient to the Hospital for a mental health evaluation and assessment.

b. On 10/11/2023 at 12:06 PM, ED nursing triage revealed the patient's temperature, pulse, respirations, and blood oxygen saturation levels were within normal limits. The nurse measured the patient's blood pressure (BP) to be high with a reading of 165/118 (normal 121/83 millimeters per Mercury- mmHg-147/91 mmHg).

c. On 10/11/2023 at 12:11 PM, ED Physician B documented an initial evaluation of the patient. ED Physician B documented the patient had discharged from the hospital's inpatient mental health unit on 10/10/2023. ED Physician B documented EMS stated that when they responded to the patient's call, they found the patient sitting in the living
room with pills in front of the patient with the intention of taking the pills. ED Physician B documented EMS reported the patient had superficial cuts on the left wrist, was tearful and upset and the patient reported feeling suicidal for last couple of months. The patient was sitting in the ED room not answering questions directed from ED Physician B. The patient only mumbled that they were "shutting down." ED Physician B's note documented an inability to perform the patient's review of systems due to Patient #1 having been uncooperative; however, the ED Physician B did document the patient's vital signs and a review of bodily systems including a physical exam minus an assessment of the patient's cardiovascular system, a psychiatric assessment of the patient's behavior and a neurological assessment which described the patient as alert with no focal deficits. ED Physician B documented the patient displaying attention seeking behaviors. The patient was not suicidal with no indication for admission to the Mental Health Unit (MHU). The Physician's clinical impression was Patient #1 was malingering (profound exaggeration of illness to gain external benefits).

The medical record lacked documentation that the ED provider performed a medical screening examination or provided Patient #1 with any stabilizing treatment for the patient's high blood pressure, examination or treatment of any self-inflicted wrist/hand wounds and presenting psychiatric concerns including any assessment to determine if the patient had overdosed on medications.

d. On 10/11/2023 at 12:26 PM, review of the nursing assessment revealed, ED RN A documented Patient # 's psychosocial assessment was as follows:
-Is patient at risk for suicide? Yes
-Psychosocial: Depressed, Anxious, Labile, and Agitated
-Affect: Bizarre
-Patient Behaviors: Non-compliant; Uncooperative
-Judgment- Impaired

e. On 10/11/2023 at 12:27 PM, review of departure information revealed, ED RN A did not give or review the After Visit Summary (AVS) with Patient #1 because the patient refused discharge teaching related to patient education in the AVS.


7. During an interview on 1/29/2024 at 12:00 PM with ED Physician B revealed, Patient #1 was uncooperative and did not allow a completion of a medical screening exam (MSE) to occur. ED Physician B reported Patient #1 did not need a psychiatric evaluation because they were attention seeking.

When this surveyor asked as to why ED Physician B did not get a 48-hour hold for this patient. The Physician reported that patients who frequent the ED often and have not actually overdosed, cut themselves to a point there was a medical need for sutures or surgery there was not a concern because they were not at a risk of harming themselves. Some patients were attention seeking like Patient #1.

8. During an interview on 1/31/2024 at 9:30 AM with ED Nurse A revealed, after attempting to triage Patient #1 ED Physician B went right in to see the patient then quickly walked out of Patient #1's room and informed ED Nurse A that ED Physician B was discharging the patient.

The evidence in the medical record revealed the Hospital failed to provide Patient #1 with an appropriate medical screening examination and the appropriate stabilization treatment per hospital policy. The patient presented to the ED on 10/11/2023 with concerns of suicidal ideation. The medical record lacked evidence of an appropriate MSE and stabilizing treatment to treat the patient's emergency medical condition of suicidal ideation and high blood pressure (hypertension).

9. Review of the medical record for Patient #5 revealed the following:

a. On 7/28/2023 at 3:13 PM Patient #5 arrived at the Emergency Department (ED) by ambulance for acute alcohol intoxication with complaints of severe abdominal pain and vomiting. The patient had a history of pancreatitis (inflammation of the pancreas associated with symptoms of abdominal pain, nausea and vomiting). The patient requested to be detoxed and have their abdominal pain addressed.

b. On 7/28/2023 at 3:22 PM the nursing triage assessment revealed Patient #5's vital signs were normal, except a pain level of 10 (scale of 0 to 10 with 10 reported as the most severe pain) in the patient's abdominal area. The nurse completed a Fall risk assessment for mobility and documented that the patient had dizziness with generalized weakness. The patient had memory loss with confusion and required reorientation.

c. On 7/28/2023 at 3:21 PM ED Physician P was at Patient #5's bedside. ED Physician P documented Patient #5 reported they were intoxicated with alcohol and had a last drink 1 hour ago. The patient reported having abdominal pain and vomiting for about a day and a half. Patient #5 reported a new diagnosis of recent seizures. ED Physician P documented the patient had been uncooperative with ED care and had been verbally and physically assaultive to ED staff. The patient had pulled out their intravenous line (IV) that the ambulance crew had placed earlier. The patient could not communicate properly, was demanding medications, hallucinating, hitting and grabbing at ED staff. ED staff called the local police department. Police officers escorted the patient out of the ED.


10. During an interview on 1/31/2024 at 2:30 PM with ED Physician P revealed Patient #5 wanted medication for abdominal pain. The ED physician did not feel this patient had an emergency medical condition (EMC). ED Physician P did feel Patient #5 was under the influence of something and did not want them to walk out onto the streets because they were unsafe. The ED Physician reported they did not call the Police Department. They were called by the ED staff but were unsure who had called.

When this surveyor asked how this physician determined the patient had not had an EMC. Physician P explained they reviewed the previous day's ED visit. Then when asked why the ED physician did not follow the hospital policy on "Disruptive/Violent Patient - Emergency Department." ED Physician P did not respond.

The evidence in the medical record revealed the Hospital failed to provide Patient #5 with an appropriate medical screening examination and the appropriate stabilization treatment to stabilize the patient's EMC of acute intoxication and severe abdominal pain. The medical record lacked evidence the ED physician ordered any diagnostic laboratory tests or imaging tests such as an ultrasound of the abdomen to evaluate the patient's medical condition. The medical record lacked evidence the ED physician attempted protective safety interventions, such as medication, sufficient staffing resources, and restraints to assist in the diagnosis and treatment of Patient #5.

11. Review of the medical record for Patient #9 revealed the following 2 separate ED visits, one on 7/24/23 and a second visit on 7/25/23:

a. (initial ED visit) On 07/24/2023 at 4:36 AM, Patient #9 arrived at the ED by ambulance with complaints of a red spot on their middle lower bottom lip, feeling a little worn out and sad. The patient reported hearing voices and had "a hit of weed and meth about an hour ago."

1) On 7/24/2023 at 4:50 AM the nursing triage assessment revealed Patient #9's vital signs were normal. The nursing triage psychosocial assessment revealed the patient was anxious and hallucinating with bizarre behavior.

2) On 7/24/2023 at 4:53 AM ED Physician R ordered labs, urinalysis, a drug screen, electrocardiogram (EKG a test to identify abnormal rhythms of the heart) and a psychiatric evaluation.

3) Abnormal lab and test results were as follows:

A low potassium level of 2.9 (normal levels 3.5- 5.0 millimoles per liter mmol/L; indicated a risk for abnormal heart rhythms, impaired kidney function and muscle weakness); urine drug screen was positive for Cannabinoids and Amphetamines; urinalysis with reflex microscopic testing was abnormal indicating urinary tract infection.

4) On 7/24/2023 at 6:20 AM ED Physician R placed a one-time order for Patient #9 of Potassium Chloride Extended Release (ER) tablet 40 milliequivalents (meq). ED staff administered the Potassium to the patient shortly afterwards.

5) On 7/24/2023 at 8:12 AM Tele psychiatric evaluation revealed Psychiatrist OO suggested the following:

a) 1 tablet of 0.5 mg Clonazepam (anxiety medication) to be given once, no prescription; and,

b) send patient to the Crisis Center (Adult Crisis Stabilization Center (ACSC) serves those in need of a temporary place to stay while addressing their mental health needs) for follow up.

The medical record lacked evidence that ED Physician J ordered the one-time dose of oral medication of Clonazepam per the suggestion of Psychiatrist OO prior discharging Patient #9. The medical record also lacked evidence ED Physician J addressed the patient's urinary tract infection.

6) During an interview on 1/30/2024 at 8:00 AM with ED Physician J revealed that the ED providers gave medications to the patients when recommended by the tele psychiatrist. ED Physician J was unsure as to why they did not give the medication recommended by the psychiatrist to Patient #9. ED Physician J reported patients with a UTI without symptoms were not treated.

The evidence in the medical record revealed the Hospital failed to provide Patient #9 with the appropriate stabilizing treatment per hospital policy. The medical record lacked evidence the provider reviewed the tele psychiatrist medication suggestions. There was a lack of documentation from the ED provider as to why they did not order the medication suggested by the tele psychiatrist. The medical record lacked evidence the provider followed up with treatment of the patient's UTI.

b. (In a separate ED visit) On 07/25/2023 at 2:36 AM, Patient #9 arrived at the Emergency Department (ED) with complaints of suicidal ideation. The patient reported the need for an ultrasound to see what was in their stomach and the patient reported that they had something "pokey" in their head. Patient #9 also reported having auditory hallucinations of hearing "Lucifer."

1) On 7/25/2023 at 2:40 AM the nursing triage assessment revealed Patient #9's vital signs were normal. The nursing triage psychosocial assessment revealed the patient was anxious, hallucinating with bizarre behavior. The assessment noted Patient #9 reported to be suicidal with a plan to kill themselves with pills. ED RN G did place Patient #9 on a 1:1 observation.

2) On 7/25/2023 at 2:55 AM ED Provider LL ordered labs, urinalysis, drug screen, and psychiatric evaluation.

3) On 7/25/2023 at 3:50 AM review of laboratory testing revealed the following results:

A low potassium level of 3.1 (normal levels 3.5- 5.0 millimoles per liter mmol/L; indicated a risk for abnormal heart rhythms, impaired kidney function and muscle weakness); urine drug screen was positive for Cannabinoids and Amphetamines; urinalysis with reflex microscopic testing was abnormal indicating urinary tract infection.

4) On 7/25/2023 at 6:47 AM ED Provider MM ordered one tablet of Potassium Chloride ER 40 milliequivalent (meq).

5) On 7/25/2023 at approximately 7:00 AM ED RN F administered Patient #9 a Potassium Chloride ER tablet and the Psychiatrist PP ' s evaluation recommended giving the patient one 5 milligram (mg) Haldol (antipsychotic medication) tablet now for substance-induced psychosis. Psychiatrist PP then ordered one 50 mg tablet of Vistaril (anxiety medication) now, a script for Haldol 5 mg tablet twice daily for substance-induced psychosis, and to follow up with their outpatient psychiatrist as scheduled.

The medical record lacked evidence that the ED Provider ordered the medications suggested by the psychiatrist, including the one-time dose of Haldol and Vistaril and a prescription for Haldol, prior to Patient #9's discharge. The medical record also lacked documentation that the ED provider addressed the patient's UTI.

6) On 7/25/2023 at unknown time the hospital's Behavior Health Consultant (BHC) C documented review of a safety plan with Patient #9 prior to the patient's discharge to an apartment address.

7) On 7/25/2023 at 9:33 AM ED staff discharged Patient #9.

8) During an interview on 2/1/2024 at 8:00 AM with ED Provider MM revealed when a tele psychiatrist completed a psychiatric evaluation, the ED provider typically accepted the suggestions made by the tele psychiatrist. In this case, ED Provider M explained they overlooked the psychiatrist's suggestions by mistake, as well as the patient's abnormal lab results of a UTI. ED Provider MM reported they typically have not treated a patient with a mild UTI unless they were symptomatic. Patient #9's psychosis made it difficult to tell if the patient was symptomatic or not. ED Provider MM explained, with the patient's psychosis, there may have been a need for further evaluation to determine if the patient had a medical condition related to the patient's head or stomach and this may have been missed.

The evidence in the medical record revealed the Hospital failed to provide Patient #9 with an appropriate medical screening examination and the appropriate stabilization treatment per hospital policy. The patient presented to the ED on 7/25/2023 with complaints of suicidal ideation. The patient reported the need for an ultrasound to see what was in their stomach and they had something "pokey" in their head. Patient #9 also reported having auditory hallucinations of hearing "Lucifer." The medical record lacked evidence the ED provider reviewed, or ordered the medications suggested by the tele psychiatrist. The medical record lacked further evidence that the ED provider addressed and treated the patient's UTI, abdominal and head complaints prior to the patient's discharge.


Please refer to A-2406 and A-2407 for additional information.

Based on medical record and staff interviews, the Hospital's emergency department (ED) staff failed to ensure 3 of 20 patients (Patient #1, Patient #5, and Patient #9) selected for review, who presented to the hospital's emergency department (ED) for medical care between 7/24/2023 and 10/11/2023, received an appropriate medical screening examination (MSE) prior to discharge. Failure to provide an appropriate MSE places patients at risk for an undiagnosed emergency medical condition which may worsen up to and including death.

Findings include:

1. Review of the medical record for Patient #1 revealed the following:

a. On 10/11/2023 at 11:53 AM, Patient #1 arrived at the ED by ambulance with complaints of suicidal ideation with a plan. The patient called the Mental Health Walk-in Clinic multiple times that morning reporting they felt suicidal with a plan to overdose on medication. During that phone call the patient verbalized they had been cutting their hand and wrist in an attempt to self-harm. The Mental Health walk-in Clinic staff called for a welfare check on Patient #1. The Police and Emergency Medical Services (EMS) picked the patient up and brought the patient to the Hospital for a mental health evaluation and assessment.

b. On 10/11/2023 at 12:06 PM, ED nursing triage revealed the patient's temperature, pulse, respirations, and blood oxygen saturation levels were within normal limits. The nurse measured the patient's blood pressure (BP) to be high with a reading of 165/118 (normal 121/83 millimeters per Mercury- mmHg-147/91 mmHg).

c. On 10/11/2023 at 12:11 PM, ED Physician B documented an initial evaluation of the patient. ED Physician B documented the patient had discharged from the hospital's inpatient mental health unit on 10/10/2023. ED Physician B documented EMS stated that when they responded to the patient's call, they found the patient sitting in the living room with pills in front of the patient with the intention of taking the pills. ED Physician B documented EMS reported the patient had superficial cuts on the left wrist, was tearful and upset and the patient reported feeling suicidal for last couple of months. The patient was sitting in the ED room not answering questions directed from ED Physician B. The patient only mumbled that they were "shutting down." ED Physician B's note documented an inability to perform the patient's review of systems due to Patient #1 having been uncooperative; however, the ED Physician B did document the patient's vital signs and a review of bodily systems including a physical exam minus an assessment of the patient's cardiovascular system, a psychiatric assessment of the patient's behavior and a neurological assessment which described the patient as alert with no focal deficits. ED Physician B documented the patient displaying attention seeking behaviors. The patient was not suicidal with no indication for admission to the Mental Health Unit (MHU). The Physician's clinical impression was Patient #1 was malingering (profound exaggeration of illness to gain external benefits).

The medical record lacked documentation that the ED provider performed a medical screening examination for the patient's high blood pressure, examination of any self-inflicted wrist/hand wounds and presenting psychiatric concerns including any assessment to determine if the patient had overdosed on medications.

d. On 10/11/2023 at 12:26 PM, review of the nursing assessment revealed, ED RN A documented Patient #1's psychosocial assessment was as follows:
-Is patient at risk for suicide? Yes
-Psychosocial: Depressed, Anxious, Labile, and Agitated
-Affect: Bizarre
-Patient Behaviors: Non-compliant; Uncooperative
-Judgment- Impaired

e. On 10/11/2023 at 12:27 PM, review of departure information revealed, ED RN A did not give or review the After Visit Summary (AVS) with Patient #1 due to the patient refusing discharge teaching related to patient education in the AVS.

2. During an interview on 1/29/2024 at 12:00 PM with ED Physician B revealed, the patient was uncooperative and did not allow a completion of a medical screening exam (MSE) to occur. ED Physician B reported Patient #1 did not need a psychiatric evaluation because they were attention seeking.

When this surveyor asked as to why ED Physician B did not get a 48-hour hold for this patient. The Physician reported that patients who frequent the ED often and have not actually overdosed, cut themselves to a point there is a medical need for sutures or surgery there is not a concern because they are not at a risk of harming themselves. Some patients are attention seeking like Patient #1.

3. During an interview on 1/31/2024 at 9:30 AM with ED Nurse A revealed, after attempting to triage Patient #1, ED Physician B went right in to see the patient. ED Physician B then quickly walked out of Patient #1's room and informed ED Nurse A that ED Physician B was discharging the patient.

Patient #1's medical record lacked evidence of an appropriate medical screening examination to treat the patient's suicidal ideation and high blood pressure.

4. Review of the medical record for Patient #5 revealed the following:

a. On 7/28/2023 at 3:13 PM Patient #5 arrived at the Emergency Department (ED) by ambulance for acute alcohol intoxication with complaints of severe abdominal pain and vomiting. The patient had a history of pancreatitis (inflammation of the pancreas associated with symptoms of abdominal pain, nausea and vomiting). The patient requested to be detoxed and have their abdominal pain addressed.

b. On 7/28/2023 at 3:22 PM the nursing triage assessment revealed Patient #5's vital signs were normal, except a pain level of 10 (scale of 0 to 10 with 10 reported as the most severe pain) in the patient's abdominal area. The nurse completed a Fall risk assessment for mobility and documented that the patient had dizziness with generalized weakness. The patient had memory loss with confusion and required reorientation.

c. On 7/28/2023 at 3:21 PM ED Physician P was at Patient #5's bedside. ED Physician P documented Patient #5 reported they were intoxicated with alcohol and had a last drink 1 hour ago. The patient reported having abdominal pain and vomiting for about a day and a half. Patient #5 reported a new diagnosis of recent seizures. ED Physician P documented the patient had been uncooperative with ED care and had been verbally and physically assaultive to ED staff. The patient had pulled out their intravenous line (IV) that the ambulance crew had placed earlier. The patient could not communicate properly, was demanding medications, hallucinating, hitting and grabbing at ED staff. ED staff called the local police department. Police officers escorted the patient out of the ED.

5. During an interview on 1/31/2024 at 2:30 PM with ED Physician P revealed Patient #5 wanted medication for abdominal pain. The ED physician was aware of the patient's recent seizures but did not feel this patient had an emergency medical condition (EMC). The ED Physician P did feel Patient #5 was under the influence of something and did not want them to walk out onto the streets. ED Physician P reported the patient was unsafe, unsteady on their feet and acting out aggressively to staff by trying to hit them.

6. During an interview on 1/30/2024 at 3:15 PM with Security Officer NN revealed Patient #5 was so strong of alcohol you could smell it outside the room. The Police Department had been called prior to Security Officer NN's arrival to the ED.

The evidence in the medical record revealed the Hospital failed to provide Patient #5 with an appropriate medical screening examination of the patient's EMC, acute intoxication and severe abdominal pain. The medical record lacked evidence the ED physician ordered any diagnostic laboratory tests or imaging tests such as an ultrasound of the abdomen to evaluate the patient's medical condition. The medical record lacked evidence the ED physician attempted protective safety interventions, such as medication, sufficient staffing resources, and restraints to assist in the diagnosis of the patient.

7. Review of the medical record for Patient #9 revealed the following:

a. On 07/25/2023 at 2:36 AM, Patient #9 arrived at the Emergency Department (ED) with complaints of suicidal ideation. The patient reported the need for an ultrasound to see what was in their stomach and the patient reported that they had something "pokey" in their head. Patient #9 also reported having auditory hallucinations of hearing "Lucifer."

b. On 7/25/2023 at 2:40 AM the nursing triage assessment revealed Patient #9's vital signs were normal. The nursing triage psychosocial assessment revealed the patient was anxious, hallucinating with bizarre behavior. The assessment noted Patient #9 reported to be suicidal with a plan to kill themselves with pills. ED RN G did place Patient #9 on a 1:1 observation.

c. On 7/25/2023 at 2:55 AM ED Provider LL ordered labs, urinalysis, drug screen, and psychiatric evaluation.

d. On 7/25/2023 at 3:50 AM review of laboratory testing revealed the following results:

A low potassium level of 3.1 (normal levels 3.5- 5.0 millimoles per liter mmol/L; indicated a risk for abnormal heart rhythms, impaired kidney function and muscle weakness); urine drug screen was positive for Cannabinoids and Amphetamines; urinalysis with reflex microscopic testing was abnormal indicating urinary tract infection.

e. On 7/25/2023 at 6:47 AM ED Provider MM ordered one tablet of Potassium Chloride ER 40 milliequivalent (meq).

f. On 7/25/2023 at approximately 7:00 AM ED RN F administered Patient #9 a Potassium Chloride ER tablet and the Psychiatrist PP's evaluation recommended giving the patient one 5 milligram (mg) Haldol (antipsychotic medication) tablet now for substance-induced psychosis. Psychiatrist PP then ordered one 50 mg tablet of Vistaril (anxiety medication) now, a script for Haldol 5 mg tablet twice daily for substance-induced psychosis, and to follow up with their outpatient psychiatrist as scheduled.

7) On 7/25/2023 at 9:33 AM ED staff discharged Patient #9.

8) During an interview on 2/1/2024 at 8:00 AM with ED Provider MM revealed Patient #9's explained, with the patient's psychosis, there may have been a need for further evaluation to determine if the patient had a medical condition related to the patient's head or stomach and this may have been missed.

The evidence in the medical record revealed the Hospital failed to provide Patient #9 with an appropriate medical screening examination. The patient presented to the ED on 7/25/2023 with complaints head and abdominal pain. The patient's medical record lacked evidence the ED provider assessed the patient's head and abdominal complaints.

Based on medical record review and staff interviews, the Hospital's administrative staff failed to ensure 3 of 20 patients (Patient #1, Patient #5, and Patient #9) selected for review, who presented to the hospital's emergency department (ED) for medical care between 7/24/2023 and 10/11/2023, received all appropriate stabilizing treatment.

Failure to provide all patients appropriate stabilizing treatment, placed the patients at risk for a worsening emergency medical condition up to and including death.

Findings include:

1. Review of the medical record for Patient #1 revealed the following:

a. On 10/11/2023 at 11:53 AM, Patient #1 arrived at the ED by ambulance with complaints of suicidal ideation with a plan. The patient called the Mental Health Walk-in Clinic multiple times that morning reporting they felt suicidal with a plan to overdose on medication. During that phone call the patient verbalized they had been cutting their hand and wrist in an attempt to self-harm. The Mental Health walk-in Clinic staff called for a welfare check on Patient #1. The Police and Emergency Medical Services (EMS) picked the patient up and brought the patient to the Hospital for a mental health evaluation and assessment.

b. On 10/11/2023 at 12:06 PM, ED nursing triage revealed the patient's temperature, pulse, respirations, and blood oxygen saturation levels were within normal limits. The nurse measured the patient's blood pressure (BP) to be high with a reading of 165/118 (normal 121/83 millimeters per Mercury- mmHg-147/91 mmHg).

c. On 10/11/2023 at 12:11 PM, ED Physician B documented an initial evaluation of the patient. ED Physician B documented the patient had discharged from the hospital's inpatient mental health unit on 10/10/2023. ED Physician B documented EMS stated that when they responded to the patient's call, they found the patient sitting in the living room with pills in front of the patient with the intention of taking the pills. ED Physician B documented EMS reported the patient had superficial cuts on the left wrist, was tearful and upset and the patient reported feeling suicidal for last couple of months. The patient was sitting in the ED room not answering questions directed from ED Physician B. The patient only mumbled that they were "shutting down." ED Physician B's note documented an inability to perform the patient's review of systems due to Patient #1 having been uncooperative; however, the ED Physician B did document the patient's vital signs and a review of bodily systems including a physical exam minus an assessment of the patient's cardiovascular system, a psychiatric assessment of the patient's behavior and a neurological assessment which described the patient as alert with no focal deficits. ED Physician B documented the patient displaying attention seeking behaviors. The patient was not suicidal with no indication for admission to the Mental Health Unit (MHU). The Physician's clinical impression was Patient #1 was malingering (profound exaggeration of illness to gain external benefits).

The medical record lacked documentation that the ED provider provided Patient #1 with any stabilizing treatment for the patient's high blood pressure, treatment of any self-inflicted wrist/hand wounds and treatment of the presenting psychiatric concerns.

d. On 10/11/2023 at 12:26 PM, review of the nursing assessment revealed, ED RN A documented Patient #1 ' s psychosocial assessment was as follows:
-Is patient at risk for suicide? Yes
-Psychosocial: Depressed, Anxious, Labile, and Agitated
-Affect: Bizarre
-Patient Behaviors: Non-compliant; Uncooperative
-Judgment- Impaired

e. On 10/11/2023 at 12:27 PM, review of departure information revealed, ED RN A did not give or review the After Visit Summary (AVS) with Patient #1 because the patient refused discharge teaching related to patient education in the AVS.

2. During an interview on 1/29/2024 at 12:00 PM with ED Physician B revealed, the patient was uncooperative and did not allow a completion of a medical screening exam (MSE) to occur. ED Physician B reported Patient #1 did not need a psychiatric evaluation because they were attention seeking.

When this surveyor asked as to why ED Physician B did not get a 48-hour hold for this patient. The Physician reported that patients who frequent the ED often and have not actually overdosed, cut themselves to a point there was a medical need for sutures or surgery there was not a concern because they were not at a risk of harming themselves. Some patients were attention seeking like Patient #1.

3. During an interview on 1/31/2024 at 9:30 AM with ED Nurse A revealed, after attempting to triage Patient #1, ED Physician B went right in to see the patient. ED Physician B then quickly walked out of Patient #1's room and informed ED Nurse A that ED Physician B was discharging the patient.

The evidence in the medical record revealed the Hospital failed to provide Patient #1 with the appropriate stabilizing treatment to treat the patient's emergency medical condition of suicidal ideation and high blood pressure (hypertension).

4. Review of the medical record for Patient #5 revealed the following:

a. On 7/28/2023 at 3:13 PM Patient #5 arrived at the Emergency Department (ED) by ambulance for acute alcohol intoxication with complaints of severe abdominal pain and vomiting. The patient had a history of pancreatitis (inflammation of the pancreas associated with symptoms of abdominal pain, nausea and vomiting). The patient requested to be detoxed and have their abdominal pain addressed.

b. On 7/28/2023 at 3:22 PM the nursing triage assessment revealed Patient #5's vital signs were normal, except a pain level of 10 (scale of 0 to 10 with 10 reported as the most severe pain) in the patient's abdominal area. The nurse completed a Fall risk assessment for mobility and documented that the patient had dizziness with generalized weakness. The patient had memory loss with confusion and required reorientation.

c. On 7/28/2023 at 3:21 PM ED Physician P was at Patient #5's bedside. ED Physician P documented Patient #5 reported they were intoxicated with alcohol and had a last drink 1 hour ago. The patient reported having abdominal pain and vomiting for about a day and a half. Patient #5 reported a new diagnosis of recent seizures. ED Physician P documented the patient had been uncooperative with ED care and had been verbally and physically assaultive to ED staff. The patient had pulled out their intravenous line (IV) that the ambulance crew had placed earlier. The patient could not communicate properly, was demanding medications, hallucinating, hitting and grabbing at ED staff. ED staff called the local police department. Police officers escorted the patient out of the ED.

5. During an interview on 1/31/2024 at 2:30 PM with ED Physician P revealed Patient #5 wanted medication for abdominal pain. The ED physician was aware of the patient's recent seizures but did not feel this patient had an emergency medical condition (EMC). The ED Physician P did feel Patient #5 was under the influence of something and did not want them to walk out onto the streets. ED Physician P reported the patient was unsafe, unsteady on their feet and acting out aggressively to staff by trying to hit them.

When this surveyor asked how this physician determined the patient had not had an EMC. Physician P explained they reviewed the previous day's ED visit. Then when asked why the ED physician did not follow the hospital policy on "Disruptive/Violent Patient - Emergency Department." ED Physician P did not respond.

6. During an interview on 1/30/2024 at 3:15 PM with Security Officer NN revealed Patient #5 was so strong of alcohol you could smell it outside the room. The Police Department had been called prior to Security Officer NN's arrival to the ED.

The evidence in the medical record revealed the Hospital failed to provide Patient #5 with the appropriate stabilizing treatment of the patient's EMC, acute intoxication and severe abdominal pain. The medical record lacked evidence the ED physician attempted protective safety interventions, such as medication, sufficient staffing resources, and restraints to assist in the diagnosis and treatment of Patient #5.

7. Review of the medical record for Patient #9 revealed the following 2 separate ED visits, one on 7/24/23 and a second visit on 7/25/23:

a. (initial ED visit) On 07/24/2023 at 4:36 AM, Patient #9 arrived at the ED by ambulance with complaints of a red spot on their middle lower bottom lip, feeling a little worn out and sad. The patient reported hearing voices and had "a hit of weed and meth about an hour ago."

1) On 7/24/2023 at 4:50 AM the nursing triage assessment revealed Patient #9's vital signs were normal. The nursing triage psychosocial assessment revealed the patient was anxious and hallucinating with bizarre behavior.

2) On 7/24/2023 at 4:53 AM ED Physician R ordered labs, urinalysis, a drug screen, electrocardiogram (EKG a test to identify abnormal rhythms of the heart) and a psychiatric evaluation.

3) Abnormal lab and test results were as follows:

A low potassium level of 2.9 (normal levels 3.5- 5.0 millimoles per liter mmol/L; indicated a risk for abnormal heart rhythms, impaired kidney function and muscle weakness); urine drug screen was positive for Cannabinoids and Amphetamines; urinalysis with reflex microscopic testing was abnormal indicating urinary tract infection.

4) On 7/24/2023 at 6:20 AM ED Physician R placed a one-time order for Patient #9 of Potassium Chloride Extended Release (ER) tablet 40 milliequivalents (meq). The medication was administered to the patient shortly afterwards.

5) On 7/24/2023 at 8:12 AM Tele psychiatric evaluation revealed Psychiatrist OO suggested the following:

a)1 tablet of 0.5 mg Clonazepam (anxiety medication) to be given once, no prescription; and,

b) send the patient to Crisis Center (Adult Crisis Stabilization Center (ACSC) serves those in need of a temporary place to stay while addressing their mental health needs) for follow up.

The medical record lacked evidence that ED Physician J ordered the one-time dose of oral medication of Clonazepam per the suggestion of Psychiatrist OO prior discharging Patient #9. The medical record also lacked evidence ED Physician J addressed the patient's urinary tract infection.

6) During an interview on 1/30/2024 at 8:00 AM with ED Physician J revealed that the ED providers gave medications to the patients when recommended by the tele psychiatrist. ED Physician J was unsure as to why they did not give the medication recommended by the psychiatrist to Patient #9. ED Physician J reported patients with a UTI without symptoms were not treated.

The evidence in the medical record revealed the Hospital failed to provide Patient #9 with the appropriate stabilizing treatment per hospital policy. The medical record lacked evidence the provider reviewed the tele psychiatrist medication suggestions. There was a lack of documentation from the ED provider as to why they did not order the medication suggested by the tele psychiatrist. The medical record lacked evidence the provider followed up with treatment of the patient's UTI.

b. (In a separate ED visit) On 07/25/2023 at 2:36 AM, Patient #9 arrived at the Emergency Department (ED) with complaints of suicidal ideation. The patient reported the need for an ultrasound to see what was in their stomach and the patient reported that they had something "pokey" in their head. Patient #9 also reported having auditory hallucinations of hearing "Lucifer."

1) On 7/25/2023 at 2:40 AM the nursing triage assessment revealed Patient #9's vital signs were normal. The nursing triage psychosocial assessment revealed the patient was anxious, hallucinating with bizarre behavior. The assessment noted Patient #9 reported to be suicidal with a plan to kill themselves with pills. ED RN G did place Patient #9 on a 1:1 observation.

2) On 7/25/2023 at 2:55 AM ED Provider LL ordered labs, urinalysis, drug screen, and psychiatric evaluation.

3) On 7/25/2023 at 3:50 AM review of laboratory testing revealed the following results:

A low potassium level of 3.1 (normal levels 3.5- 5.0 millimoles per liter mmol/L; indicated a risk for abnormal heart rhythms, impaired kidney function and muscle weakness); urine drug screen was positive for Cannabinoids and Amphetamines; urinalysis with reflex microscopic testing was abnormal indicating urinary tract infection.

4) On 7/25/2023 at 6:47 AM ED Provider MM ordered one tablet of Potassium Chloride ER 40 milliequivalent (meq).

5) On 7/25/2023 at approximately 7:00 AM ED RN F administered Patient #9 a Potassium Chloride ER tablet and the Psychiatrist PP's evaluation recommended giving the patient one 5 milligram (mg) Haldol (antipsychotic medication) tablet now for substance-induced psychosis. Psychiatrist PP then ordered one 50 mg tablet of Vistaril (anxiety medication) now, a script for Haldol 5 mg tablet twice daily for substance-induced psychosis, and to follow up with their outpatient psychiatrist as scheduled.

The medical record lacked evidence that the ED Provider ordered the medications suggested by the psychiatrist, including the one-time dose of Haldol and Vistaril and a prescription for Haldol, prior to Patient #9's discharge. The medical record also lacked documentation that the ED provider addressed the patient's UTI.

6) On 7/25/2023 at unknown time the hospital's Behavior Health Consultant (BHC) C documented review of a safety plan with Patient #9 prior to the patient's discharge to an apartment address.

7) On 7/25/2023 at 9:33 AM ED staff discharged Patient #9.

8) During an interview on 2/1/2024 at 8:00 AM with ED Provider MM revealed when a tele psychiatrist completed a psychiatric evaluation, the ED provider typically accepted the suggestions made by the tele psychiatrist. In this case, ED Provider M explained they overlooked the psychiatrist's suggestions by mistake, as well as the patient's abnormal lab results of a UTI. ED Provider MM reported they typically have not treated a patient with a mild UTI unless they were symptomatic. Patient #9's psychosis made it difficult to tell if the patient was symptomatic or not. ED Provider MM explained, with the patient's psychosis, there may have been a need for further evaluation to determine if the patient had a medical condition related to the patient's head or stomach and this may have been missed.

The evidence in the medical record revealed the Hospital failed to provide Patient #9 with the appropriate stabilizing treatment. The patient presented to the ED on 7/25/2023 with complaints of suicidal ideation. The patient reported the need for an ultrasound to see what was in their stomach and they had something "pokey" in their head. Patient #9 also reported having auditory hallucinations of hearing "Lucifer." The medical record lacked evidence the ED provider reviewed, or ordered the medications suggested by the tele psychiatrist. The medical record lacked further evidence that the ED provider addressed and treated the patient's UTI, abdominal and head complaints prior to the patient's discharge.