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Based on document review and staff interview, the Acute Care Hospital (ACH's) administrative staff failed to ensure the Emergency Department (ED) staff followed the ACH's policies and provide all available and appropriate stabilizing treatment for 1 of 22 patients reviewed (Patient #11) who presented to the ED and requested care from 11/01/2019 through 04/21/2020. Failure of the ACH's ED staff to follow the ACH's policies and provide all available and appropriate stabilizing treatment within its capabilities resulted in the staff discharging Patient #11 to home, while Patient #11 continued to display symptoms of an altered mental status. The ACH staff's failure resulted in the patient returning to his home and within a few hours after returning home, committing suicide by gun. The ACH's administrative staff identified an average of 1,482 patients per month who presented to the ACH's ED and requested emergency medical care.


Findings include:

1. Review of the policy "LL.026 EMTALA - Medical Screening and Treatment of Emergency Medical Conditions" revised 08/2018, revealed in part, "For the purpose of discharging a patient with psychiatric condition(s), the patient is considered to be stable for discharge when they are no longer considered to be an imminent threat to themselves or others. Also, a psychiatric patient is considered stable when they are protected and prevented from injuring or harming themselves or others."

2. Review of the policy "Suicide Screening, Ongoing Assessment, and Safety Precautions", revised 06/2019, revealed in part, "...this policy is to describe the process for assessing all patients....for the risk of suicide...Risk factors: Psychosocial factors:...schizophrenia, anxiety...Environmental Factors: easy access to firearms". IV. Care at Discharge revealed "...assure patients are provided with the "Suicide Risk Resources" document which details professional agents that can be contacted in crisis".

3. Review of Patient #11's medical record revealed:

a. Patient #11 presented to Ottumwa Regional Health Center's dedicated emergency department on 04/16/2020 at approximately 9:35 PM for treatment of suicidal ideations and interrupted thought process. ED Triage Nurse A documented Patient #11 exhibited tremors, paranoia, and bizarre behavior. ED Triage Nurse A administered the Columbia Suicide Severity Rating Scale (see below) as part of the triage assessment. The Columbia Scale rated Patient #11 a moderate suicide risk. ED Triage Nurse A removed Patient #11's personal belongings, had Patient #11 change into scrubs, and moved him to room 5 (a safe room used for mental health patients that did not contain any cords, sharp objects, or other items used for self-harm).

(The Columbia Suicide Severity Rating Scale is an internationally recognized suicide risk assessment questionnaire. Questions range from "In the past month have you wished you were dead or wished or could go to sleep and not wake up" through "Are you currently having any thoughts of killing or harming yourself?" Yes responses determine interventions, such as having a 1:1 sitter at the bedside.)

b. Columbia Suicide Screening documentation 04/16/2020 at 9:35 PM by ED Triage Nurse A revealed: yes answers to each of the questions: "in the past month have you wished you were dead", "in the past month have you actually had thoughts of killing yourself", "in the past month have you been thinking about how you might do this"

c. Under "General Nurse's Note" at 9:36 PM, ED Triage Nurse A noted that Patient #11's wife stated "5 years ago patient was hospitalized for Bipolar-Schizophrenia, refused to take prescribed medications...patient has not been "right" for the past 5 years, refuses to see a counselor or psychiatrist and has worsened the last "few" days." ED Triage Nurse A documented Patient #11's wife stated "she and the children are not staying at home...due to his behavior and "mind blocking". Patient #11's wife stated that patient has been driving around aimlessly, got lost, and "blacks out".

d. Ongoing Behavioral Health assessment documentation revealed on 04/16/2020 at 10:00 PM by ED Triage Nurse A "patient condition assessment" remained "unchanged". Ongoing signs and symptoms of behavioral health: "suicidal ideations, tremors, bizarre behavior, paranoia".

e. Ongoing Behavioral Health assessment documentation revealed on 04/16/2020 at 11:31 PM, by ED Triage Nurse A, "patient condition assessment" remained "unchanged". Ongoing signs and symptoms of behavioral health: "suicidal ideations, tremors, bizarre behavior, paranoia".

f. Review of the by Tele-Psychiatrist Provider C, electronically signed on 04/16/2020 at 10:32 PM, "...diagnosed with schizophrenia...mostly thought blocking...no plan or intent to kill himself. [Patient #11] is willing to take medication." "Recommendations: Safe for discharge. Follow up with therapist and psychiatrist. Abilify 5 [milligrams (mg) by mouth each day]."


2. During an interview on 04/27/2020 at approximately 2:00 PM, ED Provider B revealed Patient #11 presented to the ED with complaints of "strange" behavior the last few days. Patient #11's wife informed ED Provider B that Patient #11 had a previous diagnosis of Schizophrenia about 4 or 5 years ago with no follow-up or medications, as Patient #11 refused follow up treatment and refused to take any medications. ED Provider B stated that Patient #11 was agreeable to take medication (Abilify 5 mg) before leaving hospital, that he never voiced suicidal ideations, and his wife was agreeable to take Patient #11 to his parents house, because she was not comfortable staying with him. ED Provider B stated that Patient #11 did not make threats of harm, but did exhibit odd behavior. ED Provider B and Tele-Psychiatry Provider C felt Patient #11 was not a threat to himself or others, and because he was willing to take the medication, he discharged Patient #11.

3. During an interview on 4/28/20 at 1:00 PM, Tele-Psychiatry Provider C revealed they assessed Patient #11 over the computer. Patient #11 had thoughts of jumping into a pond earlier in the evening, prior to Tele-Psychiatry Provider C's assessment. Tele-Psychiatry Provider C spoke with ED Provider B, and spoke with Patient #11's wife. Tele-Psychiatry Provider C indicated in their experience, if a patient had thoughts of killing themselves, the patient would tell the medical staff. Tele-Psychiatry Provider C did not feel Patient #11 was attempting to deceive the medical staff members about having suicidal thoughts. However, Patient #11's wife was not comfortable with Patient #11's behavior. Tele-Psychiatry Provider C did not feel Patient #11 showed signs of suicidal thoughts and Patient #11 was agreeable to taking medication. Tele-Psychiatry Provider C felt Patient #11 could safely discharge home, with medication and outpatient mental health treatment.

4. During an interview on 4/29/20 at 8:50 AM, Patient #11's wife revealed Patient #11 was paranoid following an involuntary hospitalization approximately 5 years earlier and Patient #11 would not take medication or agree to treatment. On the night of 4/16/20, Patient #11 was again acting "scary and that something wasn't right" with Patient #11. Patient #11 was having suicidal thoughts and was afraid. With much effort, Patient #11's wife convinced Patient #11 to go to the hospital. When Patient #11 presented to the hospital, Patient #11 told the hospital staff about the suicidal thoughts.

Due to the infection control measures placed in relation to Covid-19, Patient #11's wife could not stay in the ED with Patient #11. Patient #11's wife felt ED Provider B was not pleasant to talk to and was verifying information she had previously provided to the hospital. Patient #11's wife feared the information about Patient #11's suicidal thoughts was not relayed to ED Provider B and that Patient #11 would say or do whatever he could to avoid being hospitalized. When the nursing staff told Patient #11's wife they were discharging him, the wife stated she was surprised and hesitant, but trusted the hospital staff knew what they were doing. Patient #11's wife stated she was going to take Patient #11 to his parent's house, but he refused and she was afraid to go against Patient #11's wishes, so she took Patient #11 home.


5. Review of a report from the Wapello County Sheriff's Office revealed they received a call for service on 4/17/20 at 10:38 AM (approximately 10 hours after Patient #11 left the hospital) due to Patient #11's family member finding Patient #11 dead from a self-inflicted gunshot wound.


Please refer to A-2407 for additional information.

Based on document review and staff interviews, the Acute Care Hospital (ACH) Emergency Department (ED) staff failed to provide all available and appropriate stabilizing treatment for 1 of 22 patients reviewed (Patient #11) who presented to the ACH's ED and requested care from 11/01/2019 through 04/21/2020. Failure of the ACH's ED staff to provide all available and appropriate stabilizing treatment within its capabilities resulted in staff discharging Patient #11 to home, while Patient #11 displayed symptoms of an altered mental status. The ACH staff's failure resulted in the patient returning to his home and within a few hours after returning home, committing suicide by gun. The ACH's administrative staff identified an average of 1,482 patients per month who presented to the ACH's ED and requested emergency medical care.


Findings include:

1. Review of Patient #11's medical record revealed:

a. Patient #11 did not have insurance coverage and was uninsured.

b. Patient #11 presented to Ottumwa Regional Health Center's dedicated emergency department on 04/16/2020 at approximately 9:35 PM for treatment of suicidal ideations and interrupted thought process. ED Triage Nurse A documented Patient #11 exhibited tremors, paranoia, and bizarre behavior. ED Triage Nurse A administered the Columbia Suicide Severity Rating Scale (see below) as part of the triage assessment. The Columbia Scale rated Patient #11 a moderate suicide risk. ED Triage Nurse A removed Patient #11's personal belongings, had Patient #11 change into scrubs, and moved them to room 5 (a safe room used for mental health patients that did not contain any cords, sharp objects, or other items Patient #11 could use to hurt themselves).

(The Columbia Suicide Severity Rating Scale is an internationally recognized suicide risk assessment questionnaire. Questions range from "In the past month have you wished you were dead or wished or could go to sleep and not wake up" through "Are you currently having any thoughts of killing or harming yourself?" Yes responses determine interventions, such as having a 1:1 sitter at the bedside.)

c. Columbia Suicide Screening documentation 04/16/2020 at 9:35 PM by ED Triage Nurse A revealed: yes answers to each of the questions: "in the past month have you wished you were dead", "in the past month have you actually had thoughts of killing yourself", "in the past month have you been thinking about how you might do this"

d. Under "General Nurse's Note" at 9:36 PM, ED Triage Nurse A noted that Patient #11's wife stated "5 years ago patient was hospitalized for Bipolar-Schizophrenia, refused to take prescribed medications...patient has not been "right" for the past 5 years, refuses to see a counselor or psychiatrist and has worsened the last "few days." ED Triage Nurse A documented Patient #11's wife stated "she and the children are not staying at home ... due to his behavior and 'mind blocking'". Patient #11's wife stated that patient has been driving around aimlessly, got lost, and "blacks out".

e. ED Physician B examined Patient #11 and documented that Patient #11 exhibited bizarre behaviors and "appears to be somewhat paranoid." Patient #11 informed ED Physician B that Patient #11 "had a 'squabble' with wife earlier tonight and became somewhat frustrated." Patient #11 "started to have suicidal [thoughts and the suicide] plan was to jump into [their] private pond." Patient #11 intermittently had suicidal thoughts, but Patient #11's mind would "stall." Patient #11 denied previously attempting suicide, but asked ED Physician B "does the [coronavirus] make you have these [suicidal and strange] thoughts?

Patient #11 came to the ED voluntarily and Patient #11 reported feeling "as though [Patient #11] is having thought blocking, [Patient #11] will think about things and suddenly [their] mind will simply stop." Patient #11 asked ED Physician B if "perhaps [Patient #11] could be the 'antichrist.'" Patient #11 then informed ED Physician B "I know I am not the antichrist, but I feel at times that I have Christ with me and that at other times that the 'antichrist' is there."


f. Ongoing Behavioral Health assessment documentation revealed on 04/16/2020 at 10:00 PM by ED Triage Nurse A "patient condition assessment" remained "unchanged". Ongoing signs and symptoms of behavioral health: "suicidal ideations, tremors, bizarre behavior, paranoia".

g. On 4/16/2020 at 10:33 PM, ED Triage Nurse A documented Patient #11 refused to provide the name and phone number of a pharmacy. Patient #11 denied having a pharmacy they used to fill prescriptions. ED Triage Nurse A informed Patient #11 that the ED Physician may prescribe medications for Patient #11. Patient #11 stated Patient #11 "will not accept a prescription" and "adamantly" refused to provide ED Triage Nurse A with information about a pharmacy.

h. ED Triage Nurse A documented on 4/16/2020 at 10:36 PM that ED Triage Nurse A spoke with Patient #11's wife. Patient #11's wife "stated the patient has not been right for the past 5 years, refuses to see a counselor or psychiatrist, and [Patient #11's bizarre behavior] has worsened the last few days. Patient #11's wife "states that patient [#11] has been driving around aimlessly, gets lost, and blacks out." Patient #11's wife agreed to allow ED Triage Nurse A to share the information with ED Physician B and Tele-Psychiatry Provider C.

i. ED Triage Nurse A documented updating Tele-Psychiatry Provider C on 4/16/2020 at 10:44 PM about the information Patient #11's wife provided and that Patient #11 refused to provide information about a pharmacy.

j. Tele-Psychiatry Provider C began Patient #11's mental health examination over the computer at 11:10 PM, with the examination ending at 11:30 PM. Patient #11 reported that Patient #11 "cannot think and that [Patient #11's] mind 'blocks.'" During the examination Patient #11 "will stop talking and report that [they] cannot think." Patient #11 thought they "may have been diagnosed with schizophrenia (a serious mental disorder in which people interpret reality abnormally, and requires life-long treatment) in 2015." Patient #11 could not remember what medication the physician prescribed at the time they diagnosed Patient #11 with schizophrenia.

Patient #11 had a "vague suicidal or parasuicidal thought today" and that Patient #11 currently "does not have a plan or intent" to commit suicide and "does not want to die." When Tele-Psychiatry Provider C documented the review of Patient #11's psychiatric symptoms, Tele-Psychiatry Provider C documented that Patient #11 denied any manic symptoms, any symptoms of depression, psychotic symptoms including delusions (beliefs which conflict with reality), denied any symptoms of anxiety, or symptoms of a borderline personality disorder.

Tele-Psychiatry Provider C ordered Ability 5 mg tablets (an anti-psychotic medication used to treat symptoms of schizophrenia which include hallucinations, delusions, and disorganized thinking). Tele-Psychiatry Provider C recommended the ED staff discharge Patient #11, as Patient #11 was "safe for discharge," Patient #11 needed to "follow up with therapist and psychiatrist" as an outpatient, and take Ability 5 mg tablets each day.


k. Ongoing Behavioral Health assessment documentation revealed on 04/16/2020 at 11:31 PM, by ED Triage Nurse A, "patient condition assessment" remained "unchanged". Ongoing signs and symptoms of behavioral health: "suicidal ideations, tremors, bizarre behavior, paranoia".

l. ED level of Direct Observation Criteria documentation on 04/16/2020 at 11:31 PM, by ED Triage Nurse A, revealed: Suicide Risk--"Patient does not have a plan" Homicidal--"no evidence", Elopement--"no evidence", psychosis/cognitive impairment--"no evidence", Direct Observation level--"Line of Sight".

m. Review of the Direct Observation Record, completed on 04/16/2020 from 9:42 PM to 11:45 PM and on 04/17/2020 from 12:00 AM to 12:30 AM at 15 minute intervals, with all entries showing Patient #11's behavior: Awake/Calm and observation: in Line of Sight. The documentation form included an area for the hospital staff to indicate why they observed the patient, but the staff did not indicate why they observed Patient #11 or document what behavior the patient displayed.

n. ED Triage Nurse A documented Patient #11 took a 5 mg tablet of Abilify at 11:25 PM, and Patient #11 departed the ED at 12:32 AM on 4/17/20.

o. The evidence in Patient #11's medical record showed that Patient #11 posed a risk to themselves (a psychiatric emergency), meeting the criteria for admission to the hospital's 14 bed psychiatric unit that offered a full range of highly specialized mental health services to meet the needs of adults 18 years of age and older.

The ED staff assessed Patient #11 as at "moderate" risk for suicide, Patient #11 began to "feel suicidal after a 'squabble' with [their] wife earlier tonight and became frustrated, Patient #11's suicide plan was to jump into a pond on Patient #11's property, and Patient #11 intermittently had suicidal thoughts but Patient #11's mind would "stall." Patient #11 reported feeling stress, anxiety, change in mental status, agitation, delusions, and tremors, but denied the symptoms to Tele-Psychiatrist C during the examination.

Patient #11's wife reported to the ED staff that Patient #11 was non-compliant with treatment for mental illness over the past 5 years, that Patient #11's mental health had recently deteriorated, and that "she and the family do not feel comfortable staying around the patient." The medical record lacked evidence the ED staff adequately assessed Patient #11's access to firearms (per Patient #11's wife, Patient #11 had many firearms in the home) or other means of self-harm, or the family's ability to closely monitor Patient #11 after discharge.



2. During an interview on 04/27/2020 at approximately 2:00 PM, ED Provider B revealed Patient #11 presented to the ED with complaints of "strange" behavior the last few days. Patient #11's wife informed ED Provider B that Patient #11 had a previous diagnosis of Schizophrenia about 4 or 5 years ago with no psychiatric follow-up or medications, as Patient #11 refused follow up treatment and refused to take any medications. Patient #11 did not make threats of harm, but exhibited odd behavior. Patient #11 was evaluated by the Tele-Psychiatry provider (a physician who uses video conferencing to perform a psychiatric assessment on the patient) who determined Patient #11 exhibited psychosis but was not a threat to harm himself or others. ED Provider B indicated Patient #11 was agreeable to take medication (Abilify 5 mg) before leaving hospital, never voiced suicidal ideations, denied any intent to harm himself or others, and Patient #11's wife was agreeable to take Patient #11 home to his parents, as she was not comfortable staying with him. ED Provider B spoke with Tele-Psychiatry Provider C. They felt Patient #11 was not a threat to himself or others, and since he willingly took the medication, he was discharged.


3. During an interview on 4/28/20 at 1:00 PM, Tele-Psychiatry Provider C revealed they assessed Patient #11 over the computer. Patient #11 had thoughts of jumping into a pond earlier in the evening, prior to Tele-Psychiatry Provider C's assessment of Patient #11. Tele-Psychiatry Provider C assessed Patient #11, spoke with ED Provider B, and spoke with Patient #11's wife. Tele-Psychiatry Provider C indicated in their experience, if a patient had thoughts of killing themselves, the patient would tell the medical staff. Tele-Psychiatry Provider C did not feel Patient #11 was attempting to deceive the medical staff members about having suicidal thoughts. However, Patient #11's wife was not comfortable with Patient #11's behavior. Tele-Psychiatry Provider C did not feel Patient #11 showed signs of suicidal thoughts and Patient #11 was agreeable to taking medication. Tele-Psychiatry Provider C felt Patient #11 could safely discharge home, with medication and outpatient mental health treatment.

4. During an interview on 04/27/2020 at 2:37 PM, ED triage Nurse A revealed Patient #11 presented to the ED on April 16, 2020 at approximately 9:32 PM with complaints of mind blocking. Patient #11 stated that he had "squabbled" with his wife, that he had thoughts of jumping in his pond, he had thoughts and then his mind would "block" and his thoughts would leave. Patient #11 wondered if the coronavirus could cause this as he indicated he had a cough. ED Triage Nurse A asked Patient #11 to change into scrubs (as is the policy for patients presenting with behavioral issues), he was placed in a SAFE room (where the nursing staff removed any cords, sharp objects, or other items a patient could use to hurt themselves), obtained Patient #11's vital signs, and obtained urine and blood specimens. The most memorable thing was that Patient #11's behavior was "bizarre", "hard to describe", "but it was just bizarre". The Columbia SAFE-T screening tool was completed which placed the patient at level of moderate risk. The ED physician was notified and an evaluation was set-up with the Tele-Psychiatry provider.

Due to Covid-19 infection control policies, Patient #11's wife was not able to accompany him into the ED and left the facility. Patient #11's wife was contacted by phone for questions, to speak with the providers, and about discharge plans, and Nurse A recommended that the wife speak with Tele-Psychiatry Provider C if she had any questions. Patient #11's wife stated that she was not comfortable being around Patient #11 and would not be staying with him due to his bizarre behavior, nor would their children. Patient #11 appeared calm and cooperative, however, there was something "odd" that didn't seem right. Patient #11 was discharged from Ottumwa Regional Health Center at 12:32 AM on April 17, 2020.


5. During an interview on 4/29/20 at 8:50 AM, Patient #11's wife revealed Patient #11 was paranoid following an involuntary hospitalization approximately 5 years earlier and Patient #11 would not take medication or agree to treatment for Patient #11's paranoia. On the night of 4/16/20, Patient #11 was again acting "scary and that something wasn't right" with Patient #11. Patient #11 was having suicidal thoughts and was afraid. With much effort, Patient #11's wife convinced Patient #11 to go to the hospital. When Patient #11 presented to the hospital, Patient #11 told the hospital staff about the suicidal thoughts.

Due to the infection control measures placed in relation to Covid-19, Patient #11's wife could not stay in the ED with Patient #11. Patient #11's wife felt ED Provider B was not pleasant to talk to and was verifying information she had previously provided to the hospital. Patient #11's wife feared the information about Patient #11's suicidal thoughts was not relayed to ED Provider B and that Patient #11 would say or do whatever he could to avoid being hospitalized. When the nursing staff told Patient #11's wife they were discharging Patient #11, Patient #11's wife was surprised and hesitant about Patient #11's condition, but trusted the hospital staff to know what they were doing.


6. Review of a report from the Wapello County Sheriff's Office revealed they received a call for service on 4/17/20 at 10:38 AM (approximately 10 hours after Patient #11 left the hospital) due to Patient #11's family member finding Patient #11 dead from a self-inflicted gunshot wound.