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Based on policy review, medical record review, and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings included:

The hospital's Dedicated Emergency Department (DED) failed to provide timely stabilizing treatment for 2 of 33 patients (Patient #7, Patient #6) who arrived to the DED seeking emergency medical care.

~ Cross refer to Stabilizing Treatment - Tag A2407

Based on policy review, medical record reviews and staff interviews, the hospital failed to stabilize patients with an emergency medical condition for 2 of 33 patients who arrived to the Dedicated Emergency Department (DED) seeking emergency medical care. (Patient #7, Patient #6)

The findings included:

Review of the Emergency Medical Treatment and Labor Act (EMTALA) Compliance policy, effective date 08/11/2022 revealed "...PROCEDURE ...3. The QMP [Qualified Medical Personnel] will determine if an emergent medical condition exists. After the initial examination, the treating provider may contact an on-call provider to request further evaluation and/or treatment necessary to stabilize an individual with an emergent medical condition 9. Continued monitoring shall occur according to the patient's individual needs and shall continue until the individual is stabilized..."

1. DED medical record review, on 08/16/2023, revealed Patient #7 arrived to the Campus A DED on 11/18/2022 at 1231 by private vehicle with a chief complaint of "Extremity Laceration." Review of the "ED Care Timeline" revealed vital signs at 1351 [1 hour 20 minutes after arrival] were Blood Pressure [BP] 131/95, temperature 97.6, pulse 80, respirations 18, SpO2 100% on room air. A pain score of 5 [on a scale of 0-10, with 0 (zero) being no pain and 10 being worst pain] was recorded at 1353 and at 1354 Patient #7 was assigned an acuity of 4 [on a scale of 1-5 with 5 being least severe]. Review of a "Emergency Medicine Provider Triage Evaluation Note" by a Physician Assistant [PA], dated 11/18/2022 at 1356, revealed "...[Patient #7], a 36 y.o. [year old] male was evaluated in triage. Pt. complains of injury to left foot. At noon patient had a 200 pound piece of equipment landed on his left foot. Patient has laceration to left fourth toe. Patient complains of pain and numbness to left foot. Patient's last tetanus shot was 2 years prior Physical Exam....MSK: [musculoskeletal] Moves extremities without difficulty Other: Patient has laceration circumferentially around 4 digit of left foot. Decree (sic) sensation to fourth and fifth digits of left foot. +2 left DP pulse. Diffuse tenderness throughout midfoot. Medically screening exam initiated at 1:55 PM. Appropriate orders placed. [Patient #7) was informed that the remainder of the evaluation will be completed by another provider, this initial triage assessment does not replace that evaluation....Concern for open fracture. ..." At 1604 a Provider Note indicated "Spoke to orthopedic PA [Name] who advised that patient will need to be started on Ancef [antibiotic]. Patient will need to be evaluated by Dr. [Name] when he is moved back to a room." ED Care Timeline review revealed at 1604 [~ 3 1/2 hrs after arrival] an order was placed for Ancef IV piggyback. Patient #7 was in the waiting room. Labs were drawn at 1630. At 1721 the CBC (Complete Blood Count) resulted as abnormal with a White Blood Count of 11.3 [Reference Range {RR} 4.0-10.5], Neutro Abs of 8.5 [RR 1.7-7.7]. At 1806 Patient #7 was assigned a new patient acuity of 3. At 2208 [9 hours, 37 minutes after arrival] Patient #7 was moved into an ED room and at 2226 was assigned new providers. At 2233 orders were acknowledged, including for the Ancef IV piggyback which was ordered at 1604. An IV was placed at 2248 and Ancef was started at 2258 [6 hours, 54 minutes after the 1604 order and over 10 hours after arrival]. At 2252, per Timeline review, an inpatient consult was placed to Orthopedic Surgery. Orthopedic Surgery was paged, per the Timeline, at 2303/ 2304 and at 2358. At midnight a note on skin condition was recorded as "...Exceptions to WDL (redness, swelling, bleeding (controlled), partial toe degloving to left 4th digit from the injury pta [prior to arrival])." Review of an "...Emergency Department Provider Note", date/time of service 11/18/2022 at 2226, revealed "...HPI [space] 36-year-old male with no significant PMH [past medical history] who presents to the ED with complaints of left foot injury. Patient reports that at 11:30 AM today, he was at work when a piece of work equipment fell onto his left foot that he describes as a metal bar with spikes. He had immediate bleeding and pain of his left fourth and fifth digits. He denies any other injuries....He was unable to ambulate after the injury. He came to the ED immediately after... Review of
Systems.... Neurological: Positive for numbness. Negative for syncope and weakness Physical Exam ....Musculoskeletal: Left foot: Decreased range of motion. Feet: Left foot: Protective Sensation: 5 sites tested. 3 sites sensed Comments: Numbness of the left distal third, fourth, and fifth digits. Circumferential laceration of the left fourth DIP (distal interphalangeal joint) joint with TTP, hemostatic Labs: Leukocytosis with left shift, hemoglobin stable Imaging: Left foot x-ray notable for comminuted distal phalanx of the left fourth toe History, examination, and objective data most consistent with comminuted open fracture of the toe. ...Orthopedic Surgery consulted. Wound copiously irrigated at the bedside and wound base examined Postop shoe given and nonstick dressing applied. Re-evaluated prior to discharge, Hemodynamically stable and in no acute distress. Patient states pain is minimal. Discharged home in stable condition. Rx [prescription] cefadroxil [antibiotic] x7 days. Outpatient PCP follow-up advised, and patient will follow-up with orthopedic surgery on Monday. Patient understands and agrees with the plan. The plan for this patient was discussed with my attending physician, who voiced agreement and who oversaw evaluation and treatment of this patient." Further review of the "ED Provider Note" revealed an Attestation, signed by a MD on 11/19/2022 at 2306, which stated "This patient was seen in conjunction with the resident physician. The documentation accurately reflects the patient's evaluation in the Emergency Department, with the following additions / clarifications. On my evaluation, he was awake, alert, presenting after smash injury to his toe. There was substantial delay in care, but eventually the patient received IV antibiotics, irrigation, wound care as above, well-tolerated."

Review of Patient #7's DED medical record revealed a delay in treatment and did not reveal Orthopedics saw or evaluated Patient #7 in the ED.

Interview on 09/01/2023 at 1100 with MD #42, the orthopedic surgeon on-call during Patient #7's DED visit, revealed Patient #7 arrived to the ED before 1400. Interview revealed MD #42 did not see Patient #7 in the ED but saw him in the office. Interview revealed when Patient #7 came to the office, the orthopedic surgeon was "somewhat appalled" by his course in the ED, how long it was before he got to a room, received antibiotics and the surgeon was contacted. Interview revealed Patient #7 did not receive antibiotics until about 11 o'clock that night. MD #42 stated the Orthopedic PA spoke with someone in the ED earlier in the day but was not formally consulted and MD #42 was not aware of the patient at that time. The PA thought the patient needed to get into a room and get antibiotics and then would be seen by orthopedics. MD #42 stated it was very late when the physician was called and stated the wound was a crush wound without any nail bed involvement. At that point after washing out the wound carefully, closing loosely and receiving antibiotics, it was okay for Patient #7 to be seen in the office for follow-up. There was nothing else that needed to be urgently done. Interview revealed afterwards, MD #42 tried to figure out what happened. Interview revealed the goal for treatment would be 60 minutes. The patient needed prompt antibiotics, the wound washed out well and loosely sutured/wrapped. Interview revealed the MD did not write an occurrence report but did reach out to another physician and both had the same difficulty pinning down what needed to be fixed.

Telephone interview with MD #44, on 09/01/2023 at 1230, the provider who wrote the attestation stating there was a delay, revealed there was no delay in screening, there was a delay in completion of care. Interview revealed there were so many patients boarding in the ED awaiting beds that the patient did not get back into the ED timely. Interview revealed the wound needed to be cleaned out. MD #44 stated it was most important to start the process and provide prophylactic therapy. Interview revealed that regardless of what was done problems could show up later. Further interview revealed MD #44 did not believe any adverse outcomes came from the delay. Interview revealed there was a phone consult with orthopedics but MD #44 was not sure what was discussed. Interview revealed there was generally no problem with orthopedics; if they were asked to come a see a patient, they came.

2. Medical record review on 08/15/2023 for Patient #6 revealed a 26-year-old male arrived to Campus B's Emergency Department (ED) on 07/08/2023 at 0304 for "Aggressive Behavior". ED Triage Note at 0309 revealed "BIB (brought in by) ... EMS ([county initials] emergency medical services) & (and) PD (Police Department) with c/o (complaint of) aggressive behavior. Initially taken to Campus C, given Geodon (medication used to treat mental health conditions) and Ativan (sedative medication), told too aggressive for them and sent here. Hx (history) of autism." Patient #6 was assigned an acuity level of 2 (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute). Review of the ED Provider Note at 0515 revealed "attempted to call patient's Father but call went to voicemail. Will continue to observe in the ED, sedation as needed with CSW (clinical social work) assistance in the AM (morning) ... Clinical Course 0513 Patient becoming increasingly loud and agitated in the hallway. Had Geodon at Campus C just a few hours ago. Will give additional Ativan IM (intramuscular) for now. 0529 Patient becoming more physically aggressive with staff as Ativan given. Will attempt to de-escalate but if he continues to be dangerous, will need restraints. 0638 Spoke with the patient's Step-mother ... who reports he has attacked her and his father He was previously in and out of hospitals and group homes. They have only had him for the last month. They are no longer able to take care of him ... Final diagnoses: Aggressive behavior ... ED Discharge Orders: None." Review of the Nurse Note dated 07/08/2023 at 0805 revealed "This nurse called patients father at 0804, no answer. Called step mother (Name of step mother) at 0805 ... explained ... that patient is medically and psych cleared and patient must be picked up from ER (emergency room). (Name of step mother) states she is afraid of patient because patient is screaming. This nurse gave (Name of step mother) names of 3 (three) psychiatric hospitals in NC (North Carolina) per (Name of step mother) request. (Name of step mother) stated she will file IVC (involuntary commitment) on member. Writer educated (Name of step mother) is welcome to file IVC, however, patient is already psych cleared by providers. Educated member must be picked up from ED or parents could be held liable for abandonment. (Name of step mother) stated ED needs to let patient sign himself out. Writer advised patient will not be allowed to leave ED on his own due to ID/cognitive impairment and presence of legal guardianship. (Name of step mother) stated she is not picking patient up and hung up the phone." A Nurse Note dated 07/08/2023 at 1325 revealed "Pt refusing to cooperated (sic), screaming and leaving room, pinch (sic) grabbing staff, placed in soft restraints for safety. Pt has been medicated and will be removed after med effect." A Nurse Note dated 07/08/2023 at 1936 revealed "Patient is hitting himself in the head and biting the police. Patient walked up on sitter and security staff had to physically move patient back to his room." Nurse Note dated 07/08/2023 at 2000 revealed "Patient just smacked the police officer in the head."

Nurse Note dated 07/09/2023 at 2036 revealed "Patient open handed hit me in the chest. Then charged at me. (County initial) PD (police department) and security took patient down. We restrained the patient. MD (Medical Doctor) notified."

Nurse Note dated 07/10/2023 at 0055 revealed "Patient wake (sic) up and start to get agitated. Patient yelling and screaming in the bed 'I want to go home'. Restraints ordered and applied. ..." Review of the ED Provider Note on 07/10/2023 at 0719 revealed "... Currently, the patient is currently restraint (sic) after aggressive behavior overnight ... Plan: Current plan is for placement ... is not under involuntary commitment." Nurse Note dated 07/10/2023 at 1350 revealed "Pt shouting out in his room ...Pt difficult to redirect ... After exiting the room pt charged towards me and made it approximately 15' (feet) before being accosted (approached/addressed) by (County initial) PD police officers and carried to bed. De-escalation techniques unsuccessful ... patient attacking (County initial) PD officers. Pt made two attempts at charging (County initial) PD officers and forcibly grabbed one's arm trying to scratch and claw at his skin. (MD #36) called to bedside and pt placed in soft restraints."

The ED Provider Note dated 07/11/2023 at 0900 revealed "... Recent changes in the last 24 (twenty-four) hours include outburst of aggressive behavior, scratched staff members overnight and required to be restrained ... Plan: Current plan is for placement ... is under involuntary commitment." ED Provider Note dated 07/11/2023 at 1814 revealed "... evaluated the patient multiple times this afternoon, he continues to be aggressive, violent and requiring multiple people and physical restraint to keep him in bed. He has been medicated today with additional medicines ... without relief ... will give additional medication at this time ... anticipate he will require additional restraint and close observation. He is being followed closely by the TTS/psychiatry (Therapeutic Triage Specialist). Hopefully they will continue to monitor and offer medication and behavioral guidance. There is been (sic) a concern the patient has been self injuring himself by pounding his head. He does not show any signs of acute head injury at this time ... do not think it would be beneficial to get a head CT (computerized tomography - combination of x-ray images from different angles to form detailed images of a body part) at this time."

A Nurse Note dated 07/12/2023 at 0831 revealed "While giving medication, pt became extremely agitated and began screeching. Pt kicked this RN (Registered Nurse) in abdomen. Pt then took medication." ED Provider Note dated 07/12/2023 at 0906 revealed "... Currently, the patient is violent and aggressive requiring chemical and physical restraint ... Plan: Current plan is for psychiatric placement ... is under involuntary commitment." Nurse Note dated 07/12/2023 at 1203 revealed "Pt verbally and physically aggressive with staff. Pt charging sitting (sic) and making hand motions as if to hit her. Pt placed in violent restraints ..." Nurse Note dated 07/12/2023 at 1700 revealed "Pt screaming, comtinues (sic) to hit his head, and hit security officer." Nurse Note dated 07/12/2023 at 2207 revealed Pt aggressive. Pt attempted to grab staff by arm, but was unsuccessful. Pt ran out of room, trying to fight with security. Pt redirected to room. Pt attempted to hit and kick staff while redirecting to room ... Restraints administered. Pt attempted to hit and kick staff while putting on restraints."

Nurse Note dated 07/13/2023 at 0525 revealed "Patient pushed (NT #11 Name) aggressively to the door. Screaming, uncooperative. (MD #37) notified for medication and violent restraints order." ED Provider Note dated 07/13/2023 at 0810 revealed "...Currently, the patient is restraint (sic) in the bed. Sleeping ... have reviewed the labs performed to date as well as medications administered while in observation. Recent changes in the last 24 hours include patient continues (sic) with severe aggression and agitation. He has required multiple. (sic) Some restraint as well as psychotropic medications. Plan: Current plan is for placement to (initials of hospital) hospital when bed becomes available... is under involuntary commitment." Nurse Note dated 07/13/2023 at 2234 revealed "Message sent to (MD #38) regarding pt's behavior and restrain order to expire at 2245, feel unsafe for pt and medical staff for pt to be removed from restraints at this time as pt still have (sic) outburst of behavior and has not shown extensive periods of calm and cooperative behavior. ..."

ED Provider Note dated 07/14/2023 at 0517 revealed "Patient intermittently agitated, yelling and physically aggressive with staff. Had several hours of good control after Haldol (medication used to treat certain types of mental disorders) earlier in the shift. Has not had good control with other antipsychotics (medication used to treat mental disorders) and anxiolytics (medication to treat anxiety). Will give additional dose now. In soft restraints for patient and staff safety." Nurse Note dated 07/14/2023 at 0831 revealed "Pt remains in four point restraints. He is non-redirectable. Shouting constantly at staff. ..." Nurse Note dated 07/14/2023 at 1422 revealed "Patient running out to desk trying to hit security guard then proceeds to fall on floor. Patient escorted back to bed and restrained."

Nurse Note dated 07/15/2023 at 0951 revealed "Pt screeching, coming out of room charging at staff. Pt escorted back to room by security and (County initial) PD. Restraints placed on pt for staff and patient safety ..." Nurse Note on 07/15/2023 at 1335 revealed "MD notified of pressure injuries to bilateral wrists." Nurse Note dated 07/15/2023 at 1720 revealed "Pt talked on phone to dad, then became very upset, screeching, charging at security and (County initial) PD out of room. Pt swinging fists and grabbing this RN and NT sitter. Pt carried back to bed and physical hold performed to place patient in restraints. Pt continued to be aggressive and uncooperative while placing restraints. MD notified."

Review of the ED Provider Note dated 07/16/2023 at 1019 revealed "... Recent changes in the last 24 hours include (sic) continues with periods of outburst requiring intermittent chemical as well as physical restraint. Patient has explosive behavior. Will benefit from not being in the unit where he is at. Plan: Current plan is for placement ... is under involuntary commitment." Nurse Note dated 07/16/2023 at 1300 revealed "Pt continues to charge out of room at staff despite redirection and security assist back to bed. Pt resisting and on floor. Kicking (County initial) PD. Placed in 4 point restraints, provider aware and order obtained. Pt aware of criteria for release." Nurse Note dated 07/16/2023 at 1854 revealed "Pt is increasingly agitated and rushed out of his room towards his sitter; put his hands on safety sitter's shoulders. Sitter and security staff were able to get pt to return to his room but he is highly agitated and difficult to redirect at this time. RN and sitter explained behavioral rules and told pt he would be placed back into restraints if he puts his hands on staff or continues acting aggressively."

ED Provider Note dated 07/17/2023 at 0900 revealed "... Plan: Current plan is for placement. Family unable to care for patient at home ... is under involuntary commitment."

Nurse Note dated 07/19/2023 at 0622 revealed "Patient attempting to push past sitter to exit room. Patient unable to be redirected. MHT (mental health technician) and (County initial) PD had to physically place patient back in bed." ED Provider Note dated 07/19/2023 at 0636 revealed "Patient became agitated and threatening to staff, required physical restraints for staff safety. I have ordered a dose of ziprasidone (medication used to treat mental health conditions) for staff safety."

ED Provider Note dated 07/21/2023 at 0908 revealed "... Pt (patient) with hx (history of) autism and chronic behavioral issues, periods of agitated behavior. He was abandoned in ED by family who have refused to pick him up. Pt desires to return home. On exam, pt with mild swelling and erythema (redness) to left shoulder (?due to prior IM injections). No crepitus or abscess noted. ?mild cellulitis (bacterial skin infection). Staff to avoid using left shoulder for IM injections (and avoid any IM injections as much as possible). Warm compresses to area. Keflex (antibiotic) po (by mouth) ... Recent changes in the last 24 hours include ED obs (observation), reassessment, and TOC (transition of care) placement. Plan: TOC team working on placement ..." Nurse Note dated 07/21/2023 at 1333 revealed "Pt increasingly agitated, charged staff member and grabbed them. Pt given IM sedation, and then tried to get out of bed. Pt screaming, and placed into violent restraints. MD notified."

Nurse Note dated 07/24/2023 at 2127 revealed Patient charged out of room screaming multiple times even after PRN (as needed) zyprexa (medication to treat mental disorders) (sic) and PRN ativan (sic). Notified (MD #38). New order for one-time dose IM Geodon ordered and given ..." Nurse Note dated 07/24/2023 at 2209 revealed "Patient not calming down after medications and constant calm de-escalation speaking with patient and holding his hand. He is screaming, yelling and charging at staff. He grabbed the security officer and almost broke the skin with his nails. New order for violent restraints and placed on patient ..."

ED Provider Note dated 07/25/2023 at 1056 revealed "... Psych NP (Nurse Practitioner) saw the patient and they still recommend that patient be placed. Plan: Current plan is for inpatient psychiatry placement. Patient will be managed in the ED until placement ... is under involuntary commitment."

Nurse Note dated 07/26/2023 at 1230 revealed "Pt attempted to push nurse tech through door. Pt redirected to sit in his bed and PRN meds were given." Nurse Note dated 07/26/2023 at 1514 revealed Pt came out of room, began hitting the windows on the door and screaming." Nurse Note dated 07/26/2023 at 1950 revealed "Pt. Became aggressive, grabbing staff and scratching back of neck. Pt. Became aggressive when informed he will go home when his daddy feels better. Pt. Jumped up and grabbed staff around neck, digging finger nails in back of staff's neck." Nurse Note dated 07/26/2023 at 2117 revealed "Patient very agitated and charging out of room multiple times. He scratched MHT (NT #11's name), on the back of the neck and broke the skin ... Violent restraints ordered and IM medication. Violent restraints applied with staff and security present. IM medication given ..."

Nurse Note dated 07/27/2023 at 2007 revealed "Pt attempted to come at this writer d/t (due to) 'feeling anxious' about his father. Security redirected pt back to bed."

Nurse Note dated 07/28/2023 at 0828 revealed "Patient continues to be agitated. Yelling, coming out of room, trying to attack security, grabbing, scratching staff, uncooperative with redirection. Provider notified." ED Provider Note dated 07/28/2023 at 0927 revealed "... patient got agitated and started trying to attack staff and running out of his room. Patient was placed in restraints and was given his daily medicines ... Recent changes in the last 24 hours include agitation and violence towards staff requiring restraint and getting his medications. Plan: Current plan is for inpatient placement ... is under involuntary commitment."

Nurse Note dated 07/30/2023 at 0302 revealed "Pt very focused on discharge home and phone call to family members, pt came out of room attempting to grab staff and assault them. Verbal redirection ineffective, pt ran out of room and attempted to to (sic) grab staff after working himself into a rage. Several attempts to verbally de-escalate and well as bargain with pt with privileges." Nurse Note dated 07/30/2023 at 0415 revealed "Patient agitated walk (sic) from room to nursing statin (sic) grabbed the this (sic) tech wrist and hand hard." Review of the ED Provider Note dated 07/30/2023 at 1521 revealed "... Plan: Current plan is for social work helping to seek placement ... is under involuntary commitment."

Review of the ED Provider Note dated 07/31/2023 at 1120 revealed "Recent changes in the last 24 hours include he continues to have behavioral problems requiring constant redirection. Plan: Current plan is for placement when bed is available ... redid his involuntary commitment paperwork today ... is under involuntary commitment." Nurse Note dated 07/30/2023 at 1625 revealed "Pt becoming agitated, came from room and grabbed tech by wrist and shirt. Pt assisted back to room by security ..." Nurse Note dated 07/30/2023 at 1812 revealed PT to door asking this RN to 'come here.' When RN states that she will not come now, he charges at desk, pt assisted back to room and bed by security. As soon as staff leaves the room, pt comes out of room again and charges at staff. Pt placed in 4 point restraints at this time." Nurse Note dated 07/31/2023 at 0225 revealed "Becoming aggressive and violent attempting grab at staff when he is met at the door." Nurse Note dated 07/31/2023 at 0442 revealed "Is able to bite his wrist restraints off." Nurse Note dated 07/31/2023 at 0450 revealed "Throughout the night security called to the bedside due to patients outbursts, aggressive posture and attempts to physically grab at staff and to assist in restraining patient." Review of the ED Provider Note dated 07/31/2023 at 2100 revealed " ... Patient acutely agitated, threatening staff, not redirectable. Patient presented danger to himself and other hospital staff. Will apply chemical restraints and physical restraints. Patient with improvement to his mental status and compliance following chemical restraints ..." Nurse Note dated 07/31/2023 at 2205 revealed "This is the worst I have ever seen this patient behave. He has tried to scratch, bite, squeeze the hands of security, and rip the clothing of security office. (sic) He has got out of his restraints three times and laid across the floor. He is constantly screaming the names of staff members repeatedly. The MD has been made aware of the volatile behavior."

Nurse Note dated 08/01/2023 at 0249 revealed "Patient came running out of his room for the phone. Staff had to physically put the patient back in his room. Back in restraint for patient and staff safety."

Nurse Note dated 08/02/2023 at 2210 revealed "Patient is banging fist against door and walls. Grabbing on staff and attempting to wrap his arm around staff member neck."

Review of the Psychiatry Provider Note dated 08/03/2023 at 1214 revealed "Patient is not suicidal, homicidal, or psychotic and does not need inpatient psychiatric care. Crisis and safety planning done by NP prior to recommending discharge ..." Review of the Provider Note dated 08/03/2023 at 1245 revealed "Patient needs to have a repeat kidney function and lithium level in one week. For behavioral health needs you are advised to follow up with the resources listed below: For psychiatry in the (City Name) area contact ... at your earliest opportunity to schedule a new patient appointment ... As an alternative, contact (County Name) Behavioral Health ... They offer psychiatry/medication management and therapy. New patients are seen in their walk-in clinic ... Please note that to be eligible for services you must bring an ID (identification) or a piece of mail with your name and a (County Name) address ... If you are in need of residential treatment to stabilize a crisis contact (Name of Facility) ... (Initials of Another State) ... For your ongoing behavioral health needs and to explore other treatment options for which you are eligible, stay in communication with your (Name) Health care coordinator ... For other services and benefits stay in touch with (Name) with (Organization)." Review of the Counselor Note dated 08/03/2023 at 1245 revealed "Per NP#17, this pt does not require psychiatric hospitalization at this time. NP #17 has spoken to pt's mother/co-guardian, (Name), notifying her of disposition. Pt presents under IVC initiated by EDP (emergency department provider - Name) Pt is psychiatrically cleared. Discharge instructions include referrals for area outpatient providers as well as his NC. A TOC consult has been ordered to facilitate pt's return to the community."

Nurse Note dated 08/04/2023 at 0648 revealed "When patient woke up, he was able to be redirected a couple of times. Now, he is very anxious and agitated and charged out of room a couple of times. One of the times he charged out of room and wrapped his arms around NT (nurse tech) and squeezed her really tight. He also charged out of room and security was able to get him back in his room. Notified (MD #37). New order for 2 mg (milligrams) IM ativan ordered and given ..." Nurse Note dated 08/04/2023 at 2213 "Patient is charging out of room, very anxious, and unable to calm down with verbal de-escalation. Security has been present along with (NT #11's name), MHT. Already given PRN PO (by mouth) ativan and PO zyprexa. Notified (MD #39). New order for 10 mg IM geodon ordered and given." Nurse Note dated 08/04/2023 at 2317 revealed "Patient increasingly aggressive and unable to redirect. Notified (MD #39) New order for 2 mg ativan ordered and given ..."

Nurse Note dated 08/05/2023 at 2057 revealed "Patient is very anxious and agitated. He hit his head really hard multiple times against he (sic) metal part of the door. He also squeezed my hand really tight. Notified (MD #35 name). New order for restraints and geodon 10mg IM ordered and given. Restraints placed with security and staff present." Nurse Note dated 08/05/2023 at 2241 revealed "Patient continues to scream and move up and down in the bed in restraints. Notified (MD #35 name). New order for Ativan 2mg IM ordered and given ..."

Review of the ED Provider Note dated 08/06/2023 at 0809 revealed " ... Currently, the patient is awake, standing in doorway, requesting to go home ...Recent changes in the last 24 hours include recurrence of agitation last night requiring Ativan and restraints. Plan: Current plan if for placement ... is under involuntary commitment." Nurse Note dated 08/06/2023 at 2049 revealed "Patient had been speaking with his sitter, repetitive questions per normal. Patient then suddenly started screaming and banging his hands on the room glass. Security and sitter at bedside and patient placed on bed. Sitter now sitting in room speaking quietly with patient. PRN given as ordered." Nurse Note date 08/06/2023 at 2054 revealed "Pt screaming and kicking staff at bedside. Pt agitated and continues to jerk at restraints."

Nurse Note dated 08/07/2023 at 0331 revealed "Patient continuously pushing past sitter to exit room. Several security guards needed for redirection to place back in bed." Review of the ED Provider Note dated 08/07/2023 at 0902 revealed "... Recent changes in the last 24 hours include had some aggressive behavior last night. Plan: Current plan is for waiting for mom to pick patient up ... is under involuntary commitment." Review of the Nurse Note dated 08/07/2023 at 1131 revealed "I have spoke with Patient #6's mother this morning and am awaiting a call back. Attempted to call dad with the call going straight to voicemail. (County initial) PD has been contacted to go to the father's home to make him aware that Patient #6 is ready for discharge and that if he does not come get his son, he will be arrest (sic) for abandonment. If I have not received a return call from mother within the hour, I will contact the police department in her area as well since her and dad are equal guardian and both a (sic) refusing to come get him." Nurse Note dated 08/07/2023 at 1150 revealed (County initial) PD has make (sic) contact patient's dad (Dad's name). Dad is denying avoiding hospital phone calls even though he has been including (sic) calls from me. (County initial) PD asked that I give the dad a deadline so he can arrange for Patient #6 to be picked up. Dad and (County initial) PD made aware that he has until today at 1700 to pick patient up or we will proceed with abandonment charges. (County initial) PD agrees this is a reasonable request and plenty of time. Officer (Name of officer) had requested that I call him if dad does not arrive by 1700." Nurse Note dated 08/07/2023 at 1345 revealed "Mother has made me aware that she is not picking patient up today and she would like one more day. She believes that ... start (a sta