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Based on review of medical records, policy and procedures and staff interviews it was determined that the facility failed to ensure that one patient (P) (P#2) of 22 sampled patients received stabilizing treatment. Specifically, P#2 presented to the facility's emergency department (ED) accompanied by law enforcement for a psychiatric evaluation on 4/19/21 at 8:25 a.m. P#2 was discharged home via Lyft on 4/23/21 at 8:07 p.m. After discharge, P#2 assaulted a Lyft driver and carjacked the vehicle. P#2 subsequently wrecked the vehicle and was arrested.

Cross Refer to A-2407.

Based on review of medical records, policy and procedures and staff interviews it was determined that the facility failed to ensure that one (P#2) of 22 sampled patients received stabilizing treatment.

Findings included:

A review of the facility's Central Log revealed that Patient (P) #2 presented to the Emergency Department (ED) and was registered as a patient on 4/19/21 at 8:25 a.m.

A review of P#2 medical record revealed that he presented on 4/19/21 at 8:25 a.m. accompanied by law enforcement for a psychiatric evaluation. A medical screening examination (MSE) by ED Physician (MD) CC dated 4/19/21 at 8:43 a.m. revealed that P#2 had been seen in the ED by ED MD CC 'a few shifts ago' and P#2 was transferred to a behavioral health facility on an involuntary hold. P#2 was discharged from the behavioral health facility this morning. P#2 was riding in a vehicle with a family member, became combative and got out of the vehicle while it was still moving. P#2 exhibits inappropriate laughter and reports that he wants his brother dead. P#2 stated that he does not want to return to live with his family.

A review of a medical decision making (MDM) note by MD CC, signed 4/19/21 at 11:36 a.m. revealed that P#2 tested positive for COVID. Continued review of the note revealed that the facility could not admit P#2 as an inpatient due to his COVID test. P#2 will be transferred to a behavioral health facility.

Review Social Worker note dated 4/19/21 at 3:08 p.m. revealed call to GCAL (Georgia Crisis and Access Line) for assistance. A state facility was not available for a covid positive patient at that time.

A review of a physician note dated 4/20/21 at 11:58 p.m. revealed that P#2 became extremely combative with staff swinging and punching at the security staff as well as nursing staff. Law enforcement was called, and P#2 was given Geodon. Review Social Worker note dated 4/20/21 at 1:26 p.m. revealed call to GCAL, pt still cannot be placed on state board until covid screening is negative.

Review nurse note dated 4/21/21 at 12:06 a.m. revealed P#2 came out of room and refused to go back in. States that he was leaving. Law enforcement was called to help with situation. Pt#2 was transferred to room 6.

Review Social Worker note dated 4/21/21 at 2:22 p.m. revealed call to GCAL, pt will still need to be covid negative to be placed on region one board.

A review of nurses note dated 4/21/21 at 5:40 p.m. revealed that P#2 was pacing and urinated on sheets and dumped out his urinal in room. P#2 made verbal threats to the sitter. Security and the physician were notified.

A review of a physician note dated 4/21/21 at 5:50 p.m. revealed that P#2 became agitated and urinated all over the patient room. Law enforcement was called, and four officers responded and stood by to enable the staff to safely clean the patient room. On 4/21/21 at 6:33 p.m., Geodon was administered.

A review of a physician note 4/23/21 at 7:32 a.m. revealed that P#2 refused his home medications. P#2 became aggressive toward staff.

Review of Social Worker note dated 4/23/21 at 10:36 a.m. revealed per physician, request was made with mobile crisis to have pt re-evaluated. Review of Social Worker note dated 4/23/21 at 12:58 p.m. revealed mobile crisis staff were in to evaluate pt face to face.

A review of a Psychiatric Assessment dated 4/23/21 at 12:07 p.m. completed by LPC (licensed professional counselor) revealed that evaluation was of patient that presented with psychosis and depressive symptoms. P#2 was admitted to ED on 4/19/21 due to active psychosis and aggression towards others. P#2 was placed on 1013 due to active psychosis and thoughts of harm to brother. P#2 was unable to be transferred due to COVID positive results. P#2 remained in ED and has since returned to baseline after being treated with prescribed psychiatric medications. P#2 appeared to respond to internal stimuli without distress. There were no command hallucinations observed and patient remained engaged in conversation after redirection. P#2 stated, "Yeah, I want to blow my brains out", after being asked about SI (suicidal ideations). The patient seemed to make the statement jokingly. P#2 stated moments later that he did not want to harm himself. ED staff reported that P#2 had not endorsed SI since admission to the ED. Observed P#2 to be oriented, calm with blunted affect, fair eye contact. P#2 consumed his own urine while assessor was present. P#2 explained that he drank his urine because he had an urge. Continued review of the psychiatric assessment revealed that P#2 was not presently in imminent danger to self or others and was able to return to the community and referred for outpatient counseling. Family was being contacted by the ED staff and will be included in the safety plan. P#2 will be referred to outpatient counseling. The ED Attending physician will rescind the 1013 as P#2 was not in crisis.

Review of physician note dated 4/23/21 at 2:24 p.m. revealed P#2 was reevaluated by mobile crisis of Georgia and found to be at baseline mental status. Continued review of the note revealed that P#2 no longer met inpatient criteria and was on baseline medication. Plan for outpatient follow-up and will be discharged to a family member's house. Family members were aware and expecting him.

A review of nurse's notes dated 4/23/21 at 7:45 p.m. revealed that transportation company had a ride en route to pick up P#2. Continued review revealed that a nurse's note at 8:07 p.m., a Lyft came and picked up P#2 to take him home. P#2 refused to sign discharge paperwork and refused to have his vital signs taken. P#2 left discharge paperwork at the nurse's station. P#2 was calm as he walked out of the ED and got in the backseat of the vehicle.

Review of a nurse note dated 4/23/21 at 8:07 p.m. revealed that the nurse received a call from the Lyft (ride share app) driver who had picked P#2 up from the ED. The Lyft driver stated that P#2 started hitting him and the driver exited the car. P#2 stole the vehicle while the driver was out of the car. The nurse notified the nurse manager as well as the transportation company.

Review of P#2's Form 1013 revealed form signed by MD CC on 4/19/21 and rescinded (withdrawn) by MD PP on 4/23/21.

A review of a police report dated 4/23/21 at 9:18 p.m. revealed that on 4/23/21 at approximately 9:18 p.m. the officer responded to a report of a carjacking. The victim reported that he was a driver for Lyft and picked up the suspect (P#2) from the ED. Driver observed hospital security escort P#2 from the ED and into the victim's car. Victim reported that P#2 had been agitated and was talking nonsense during the entire ride. P#2 began to strike the victim about the shoulder and neck and demanded that the vehicle be stopped. The victim stopped the vehicle and exited the vehicle. P#2 crawled into the driver's seat and stole the vehicle.
While taking the report, a call was received that the victim's vehicle had been involved in a wreck. P#2 was found at the scene of the wreck hiding under a bridge. P#2 was transported back to the facility for evaluation. Continued review of the report revealed that prior to the carjacking, P#2 had been held on a 1013 at the facility. The facility could not find a facility to accept P#2 and rescinded the 1013. The report revealed that facility staff had paid for the Lyft in order to remove P#2 from the facility. P#2 was arrested and transported to jail after medical clearance.

An interview was conducted with House Administrator (HA) AA on 10/24/23 at 9:00 a.m. in the administration conference room. HA AA stated that he has worked at the facility for five years and as the HA in the emergency department (ED) for two years. He stated that he was familiar with P#2's case and did have a chance to review his chart. He continued to explain that although he did not provide care to P#2 during his time in the ED from 4/19/23 - 4/23/23 he did recall P#2 being brought back to the ED after being discharged early in the day due to a car accident. HA AA stated that the ED process for behavioral health patients is to follow the EMTALA guidelines and triage the patient, get a medical screening, and stabilize the patient then determine the next course of action to ensure the patient's safety. He continued to explain that behavior health patients are re-evaluated before discharge.

An interview was conducted with Social Worker (SW) BB on 10/24/23 at 12:35 p.m. in the administration conference room. SW BB stated that she does recall P#2 and the incident, after he was discharged, he was involved in a car accident. She continued to explain that she did have an opportunity to review P#2's chart and recalled making an attempt to have P#2 placed at two inpatient psychiatric facilities, however due to his COVID-19 (Coronavirus Disease 2019) (an infectious disease caused by the SARS-CoV-2 virus) positive status, the facilities would not accept him. She continued to explain that patients could not be placed in state facilities until all other options were exhausted. P#2 had traditional Medicaid and it was more difficult to place patients. SW BB explained that although the patient needed to be transferred to a psychiatric facility, the behavioral health assessors made the recommendation to either discharge or admit. The physician had the final decision. She went on to explain that the behavioral health assessment was conducted by a company regulated by GCAL (Georgia Crisis and Access Line). SW BB stated that if a patient had been in the ED for several days, the assessors recommended discharge.

A telephone interview was conducted with Emergency Department (ED) Physician (MD) PP on 10/25/23 at 12:30 p.m. MD PP stated that he recalled P#2 and his visit to the ED. He continued to explain that P#2's visit was for a psychiatric (psych) evaluation and that after discharge he was involved in a car accident. He continued to explain that although it was few years ago, he did recall that while in the ED, P#2 was drinking his own urine and that he remained in the ED for few days. MD PP continued to explain that P#2 was being evaluated daily from telepsychiatry (telepsych) (allows psychiatrists to treat more patients in distant locations) while in the ED. He continued to explain that what he could recall is that after telepsych completed their evaluation they recommended discharge and did not recommend an inpatient placement at the time. MD PP confirmed rescinding the 1013 (physician requesting mental evaluation for a person) after telepsych recommended discharge, although P#2 had been noted to consume his urine and make comments of self-harm with a gun. He continued to say that in general when a psych patient presents to the ED, he/she is assessed and given a medical screening exam and the necessary stabilizing treatment. He continued to explain that once the patient is stabilized, a call was made to telepsych for an evaluation for further treatment etc. MD PP stated that once telepsych provides their recommendations then there is a conversation between the telepsych counselor and the ED physician. He states that in most cases he will side with the telepsych counselor, however, there have been instances where he did not agree and did not follow their recommendation. MD PP stated that in the case involving P#2 he did defer to the psychiatric counselor's judgment as far as the psychiatric or mental health component and rescinded the 1013 based on their psychiatric evaluation. He continued to explain that the ED physician and the psychiatric personnel work together in a dual role to complete an evaluation as it pertains to psych patients. However, ultimately the ED physician is responsible for both.

A telephone interview was conducted with Risk Manager (RM) KK on 10/25/23 at 1:30 p.m.
RM KK recalled that she had been made aware of the incident with P#2 a few days afterward by HA DD. RM KK explained that an investigation was not conducted, and an incident report was not warranted. She further explained that the incident did not warrant an EMTALA violation because P#2's actions took place after discharge and off hospital property. RM KK acknowledged that an investigation was initiated after this onsite survey was started.
She had an opportunity to review P#2's medical record and stated that prior to P#2's discharge he was assessed by a psychiatric counselor, who mentally cleared him for discharge. P#2 was assessed by MD PP, who medically cleared him for discharge. She continued to explain that MD PP rescinded the 1013 on the recommendation for discharge by the psychiatric counselor. RM KK stated that once the 1013 request was rescinded and P#2 wanted to leave, the hospital was obligated to release him. She added that the facility could not hold the patient and if he was able to ambulate on his own, get into the car on his own then there was no reason to hold P#2. RM KK stated that once P#2 left the hospital and committed a crime there was no hospital liability therefore there was no investigation or incident report to be completed as a result of his actions or his discharge.

A review of the facility's policy entitled, "EMTALA Guidelines-Treatment & Transfer of Individuals in need of Emergency Medical Services," Policy #PC-07179, last reviewed 5/2021 revealed the Hospital will provide to any individual, including any infant who is "Born Alive" at any stage of development, who "comes to the Emergency Department" an appropriate Medical Screening Examination ("MSE") within the capability of the Hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an EMC exists, regardless of the individual's ability to pay. The MSE will be conducted by an individual(s) determined to be qualified by Hospital bylaws or rules and regulations. The Hospital's EMTALA obligations are triggered when there has been: (1). A request for examination and/or treatment of a medical condition by an individual (or someone on that individual's behalf) made within a dedicated emergency department ("DED") as further defined below; or (2). When an individual (or someone on that individual's behalf) requests examination and/or treatment for an Emergency Medical Condition ("EMC") while on hospital property other than in a DED; or (3). When a prudent layperson would recognize that an individual on hospital property, other than in a DED, requires examination and/or treatment for an EMC although no request for treatment is made. EMTALA obligations do apply to an individual who comes to the DED and is retained under observation status. B. Medical Screening Examination. 4. The MSE is an ongoing process. The medical record will reflect an ongoing assessment of the individual's condition. Monitoring of the individual will continue until the individual is stabilized, admitted to the hospital, appropriately transferred if an EMC exists and the individual requires care and treatment that exceeds the Hospital's capabilities, is discharged, or expires. The MSE process must be documented in the medical record. DD. "To Stabilize" means: 3. The emergency medical condition has been resolved. EE. "Stable for Discharge" means: 2. With respect to an individual with a psychiatric condition, the physician has determined that the patient is no longer conserved to be a threat to himself/herself or others.

A review of the facility's policy entitled, "Emergency Involuntary Detentions, Admissions & Transports," Policy #RI-03248, last revised 5/2021 revealed the purpose is that this part outlines the processes for pre-screening patients located in Georgia for mental health or substance abuse emergencies and the criteria under which such patients may be temporarily involuntarily detained for examination and transport to another facility for further evaluation. CHI cannot involuntarily admit patients. CHI can only temporarily detain patients without a court order for completion of an examination to determine whether a certificate (DBHDD Form 1013 or 2013) should be issued to direct their transport to an ERT (emergency receiving or treatment) facility for further evaluation. Once transported to an ERT facility, the patient will be further evaluated by personnel at that facility for possible involuntary admission to that or another ERT facility.