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

The findings included:

1. The hospital's Dedicated Emergency Department (DED) failed to provide 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 Emergency Medical Condition (EMC) existed for 1 of 30 sampled DED patients who presented to the hospital for evaluation and treatment. (Patient #3)

~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A 2406.

Based on policy and procedure review, medical record review, and physician and staff interviews, the hospital's Dedicated Emergency Department (DED) failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 30 sampled DED patients who presented to the hospital for evaluation and treatment. (Patient # 3)

The findings included:

Review of the "Emergency Medical Treatment and Labor Act - EMTALA" policy, revised 09/05/2018 revealed "...DEFINITIONS: ... D. 'Emergency Medical Condition' 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual....in serious jeopardy.... G. 'Medical Screening Examination (MSE): The screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist.... PROCEDURE: MEDICAL SCREENING EXAMINATION: A. Any individual who presents to the Emergency Department (ED) or other locations .... meeting the definition of a DED and requests examination or treatment (request is made by or on behalf of the individual) will undergo a MSE to determine whether such individual is experiencing an EMC [Emergency Medical Condition]. ..."

Medical record review of a "Pre-Arrival Summary" for Patient #3, dated 06/22/2019 at 0551, revealed "...SI, Axillary [under the arm] temp 97.0. Been in and out of river all night. Abrasions on arms. ..." Review of EMS (Emergency Medical Services) Notes, assessment date and time 06/22/2019 at 0514, revealed "... Primary Impression Hypothermia [cold temperature] Secondary Impression Suicide attempt.... Signs & Symptoms Behavior/Emotional State - Suicidal ideations Generalized Symptoms - Hypothermia.... Alcohol/Drugs Patient Admits to Drug Use....EMS called ref [as written] possible animal attack. Upon our arrival male subject was awake in fetal position on porch. Subject was wet he states he had been in the river, he states he was attempting to commit suicide. He states he just walked into the river he could not bring himself to jump off the bridge. The patient was moved via stretcher to EMS unit, unable to acquire oral temp. Axillary Temp is 97, EMS placed patient on stretcher and moved without incident to EMS unit. En route EMS began passive rewarming with hot packs and cabin temp. The patient admits to walking into the river with intention of committing suicide, and the abuse of Meth [methamphetamine, an addictive stimulant] and barbiturates [drugs that act as central nervous system depressants] this evening. He states he passed out on the porch was unsure how long he had been there....full report to rec [receiving] RN (Registered Nurse) and pt turned over to same... ." Review of "ED Triage Full" Note, entered 06/22/2019 at 0611, revealed "...Stated Reason for Visit: .... EMS and pt [patient] stated he was in the river for an extended period of time. Pt stated he did meth at 2200 last night and takes barbituates [sic] prescribed for panic attacks. Denies HI/SI [homicidal ideations, suicidal ideations], was thinking about jumping off bridge r/t [related to] disappointed for doing meth again ....Thoughts of Harming Self/Others or BH [Behavioral Health] Complaint: Yes. ..." Vital signs at triage were Temperature [T] 98 orally, Heart Rate [HR] 83, Respiratory Rate [RR] 18, Blood Pressure [BP] 149/82, Oxygen Saturation 98% on room air, and a pain score of 4 [on a scale from 0-10 where 10 is worst pain]. Review of a home medication list revealed the following medications: Escitalopram [Lexapro - drug that can treat depression and anxiety], Lorazepam [drug used to treat anxiety], and melatonin [used to help with sleep]. Review of "Medical History - ED Triage Hx2" revealed "... Mental Health History ED : Bipolar [mental health condition], Substance abuse. ..." Further review of Triage revealed "Mental Health Status - ED Triage v5....Scale for Suicide Risk Assessment : CSSRS [Columbia Suicide Severity Rating Scale] - Adult Assess CSSRS Adult? Yes Behavioral Health Emergency : CSSRS indicates Low Risk of Harm, required BH OP [behavioral health outpatient] Appointment.... CSSRS Screener - Adult 1. Have you wished you were dead or wished you could go to sleep and not wake up? : Past month, no 2. Have you had any actual thoughts of killing yourself? : Past month, no 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? No CSSRS Calculation : 0 ED CSSRS Screen : Low Risk. ..." Review of the CMP [Comprehensive Metabolic Panel], collected at 0611, revealed normal results except for elevated total bilirubin of 1.90 [reference range {RR} 0.20 - 1.20] and elevated AST of 56 [RR 5-34]. Review of Hematology results, collected at 0611, revealed an elevated WBC [White Blood Count] of 13.5 [RR 3.2-11.5] and Hemoglobin of 17.5 [RR 14.0-17.0], along with some abnormal differential results. Review of Toxicology results revealed an Acetaminophen Level that was less than 3.0 [RR 1-.0-30.0], a positive Urine Drug Screen for Amphetamines, Methamphetamines, Benzodiazepines, Cannabinoid, and Fentanyl. Lab result review revealed an Ethanol level below 10 [RR 0-10] and a Salicylate level below 5 [RR 0-30.0]. Review of "Behavioral Health Referral/Triage" note, service date and time 06/22/2019 at 0737, revealed "Behavioral Health Referral Type of Referral (BH) : Triage Referral Assess CSSRS Adult? : Yes Patient has Outpatient ACTT [Assertive Community Treatment Team] Services : No OP ACTT Provder [sic] contacted to assist with coordination of care : No BH 30 Day Return (BH) : No Reason for Referral : BHIC [Behavioral Health Intake Clinician] met with pt ....to complete risk assessment and he scored as low risk on the CSSRS. No safety precautions were recommended at this time. Per RN Triage note: [Initials] EMS and pt stated he was in the river for an extended period of time. Pt stated he did meth at 2200 last night and takes barbituates [sic] prescribed for panic attacks. Denies HI/SI, was thinking of jumping off bridge r/t disappointed [sic] for doing meth again..'Pt arrived to the ED as a voluntary admission via LEO [law enforcement officer]/ EMS. BAL [blood alcohol] and toxicology results consistent. Pt alert and O x 4 [oriented to person, place, time, situation] today. Pt denies SI/HI/auditory/visual hallucinations. Patient admits to using methamphetamine on occasion and experiencing similar results each time. He has been reluctant to use community supports or outpatient therapy but admits that he is feeling like this time he needs to go to outpatient therapy at after [sic] the hospital. Patient is a veteran and has used the VA for certain things but would like to use his private insurance for outpatient. He shouldn't is [sic] provided several resources to find an outpatient therapist that would take his insurance on this depart. She [sic] is not experiencing any overt cognitive impairment, nor is he experiencing any perceptual disturbances. His thinking is goal oriented and his speech is linear and coherent. Patient will be contacting his parents for transportation. BHIC consults with ED M.D. [last name] who recommends who rescinds psychiatric evaluation request at this time. Behavioral Health Triage Behavioral Health Triage Screening : No 2. Is the patient currently experiencing auditory or visual hallucinations? : No 3. The patient is showing signs and behaviors consistent with moderate to severe agitation and/or aggression : No 4. The pt is showing signs and behaviors that would indicate a flight risk and/or a significant elopement history : No Recommendation : No Safety Precautions Recommended CSSRS Screener - Adult 1. Have you wished you were dead or wished you could go to sleep and not wake up? : Past month, no 2. Have your had any actual thoughts of killing yourself? : Past month, no 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? : No CSSRS Calculation: 0 ED CSSRS Screen: Low risk." Review of the "ER [Emergency Room] Report" by MD #2, service time 0742, revealed " ...Chief Complaint HARMSELFOTHERS History of Present Illness 35-year-old male reported history of anxiety and previous substance abuse presented through the night after jumping into the river secondary to poor judgment in the setting of methamphetamine use which he confesses to. On interview the patient is clinically sober at this time and has no intent for self-harm or harming other people. Patient denies any hallucinations. He does reveal some abrasions to his anterior abdominal wall as well as his left foot that he sustained during the events of the night but has no other concern. He has been up and ambulatory in the department and feels stable. Review of Systems Per history of present illness otherwise a 10 point review is negative. Social History Alcohol Details Denies .... Substance Abuse Details Current, Methamphetamine .... Physical Exam ....General: Alert, no acute distress HEENT [Head eye ears nose throat] Normocephalic, atraumatic ....Cardiovascular Exam: Regular rate and rhythm ....good pulses throughout Pulmonary Exam: Normal work of breathing, clear breath sounds throughout ....Abdomen: Normal bowel sounds, nondistended, no tenderness to palpation .... Musculoskeletal: Full range of motion ....Skin: Warm and dry without rash, superficial linear abrasions overlying the epigastric area ....left foot also has abrasion without appreciable underlying foreign body Neurologic: No appreciable motor or sensory deficit, a and O [alert and oriented] x 3 [person, place, time] Psych: Appropriate, linear Assessment/Plan 35-year-old male presenting during the [sic] slightly hypothermic in the setting of jumping into a local river while intoxicated with methamphetamines which he confesses to. Diagnostic studies were initiated from triage which I have reviewed. No concerning findings other than obviously pan positive UDS [urine drug screen]. Patient clinically sober at this time with no other physical exam findings or concerns. He is now normothermic [normal temperature]. He can assure me that he is not suicidal or homicidal or hallucinating. Patient stable for discharge with anticipated outpatient mental health follow-up ....Disposition: Discharge Diagnosis/Disposition Amphetamine-type substance use disorder, mild, abuse ....Depart ED Discharge Instructions: Per our discussion your diagnostic testing was generally reassuring at this time. You have assured me that you are not concerned about self-harm or harming other people. Please refrain from continued substance use. Follow-up as an outpatient with your mental health providers. Record review revealed a "RARF - Discharge Disposition" form, time 0813, which stated "Discharge Disposition: Referral Rescinded Legal Status at Disposition : Voluntary .... Referral Rescinded : Non-Psych Discharge Disposition Comments : ED MD [Name] rescinds. ..." At 1010 review revealed a pain score of 0 and at 1018, vital signs were noted as HR 92, RR 17, BP 146/80, Oxygen saturation of 99% on room air. At 1020, review revealed a Discharge Comment that "mom is driving patient home."

Record review did not reveal any evidence that Patient #3 was involuntarily committed [IVC] and did not reveal any IVC paperwork. Record review did not reveal any evidence a psychiatrist was requested or examined Patient #3.

Review of the Death Certificate for Patient #3, on 07/30-31/2020, revealed the initial date signed was 06/26/2019. Review revealed a Medical Examiner Section where "DATE PRONOUNCED" was written as 06/26/2019, "DATE OF INJURY" was documented as 06/23/2019, "PLACE OF INJURY" was listed as "RIVER, [name]" and the description stated "missing-Found in River". The immediate cause of death was initially written in as "Pending", but there was a circle [appearance of a stamp] which noted "CAUSE AMENDED JAN 14 2020 SUPPLEMENT ON REVERSE SIDE". Review of the "SUPPLEMENTAL REPORT OF CAUSE OF DEATH", documented the immediate cause of death as "Drowning" and stated " ...Other significant conditions contributing to death .... Methamphetamine toxicity ..." The "MANNER OF DEATH" section revealed a box filled in beside the word "Suicide" and under "DESCRIBE HOW INJURY OCCURRED" was documented "intentionally entered body of water." Further review of the Supplemental Report revealed the "DATE PRONOUNCED" was listed as 06/26/2019 and the "DATE OF INJURY" was documented as "Unknown". Review revealed the "SUPPLEMENTAL REPORT OF CAUSE OF DEATH" was signed on 12/20/2019.

Review on 07/31/2020 of a document provided by the hospital, titled "REPORT OF INVESTIGATION BY MEDICAL EXAMINER", dated 06/30/2019, revealed "DECEDENT (Name of Patient #3) ....DEATH .... 06/26/2019 ....1400 ....ME [Medical Examiner] NOTIFIED ....06/26/2019 ....1745 ....LAST KNOWN TO BE ALIVE .... 06/23/2019 ....1900 ....MEANS OF DEATH ....Reportedly fishing from riverbank 6/23. Then missing. Found in river 6/26 ....MEDICAL EXAMINER PRELIMINARY SUMMARY OF CIRCUMSTANCES SURROUNDING DEATH The decedent is a 35 year old white male. He was found dead in the [River Name] in [County name] ....He was reported missing by his family on Monday June 24. He wast [sic] last known alive on the previous evening (Sunday) around 1900 when he reportedly called his mother and stated he was fishing and would not be home for dinner. He did not return and the missing person's report was filed as mentioned. Officers responded to the area he was known to fish and discovered his wallet, a chair, and his car keys. His vehicle was reported to be present at the site according to the EMS crew I spoke with. A search ensued both on land and in the river. He was discovered on Wednesday June 26 in the [Name of River] and removed from the river. It was reported to me his body was near the location of his effects on the opposite shoreline. He was pronounced dead at 1400 ....Officers were able to identify the decedent by allowing his Uncle to view the body. He stated that he was able to positively identify the decedent. I spoke with one of the officers present and he was able to relate some facts that were not immediately apparent. The Officer told me that the decedent had been fishing in the same river ....on the previous Thursday. He suddenly arrived at a nearby home and stated he was chased by other individuals and jumped in the river. He requested that 911 be called. EMS and the [County name] Sheriff responded. According to the ....Officer the decedent was transported by [Name] EMS. The Sheriff's Office investigated the claims and found them unfounded. At some point the decedent told EMS that he had planned on harming himself. He was also described as a known substance abuser. Again according to the ....Officer, the decedent was involuntarily committed and was released on Sunday, the day he disappeared. I have requested Medical Records from this admission but thus far they have not been produced. Law Enforcement is under the opinion that the fatal event was most likely suicide. Some family members share this opinion according to the .... Officer. I examined the decedent on the evening he was discovered. This will be an Autopsy case since the event was unwitnessed.... He was dressed in shorts and a T Shirt. He was bearded. I found it reasonable that a family member could identify the decedent visually and he had numerous Sleeve Tattoos and a visible Tattoo on his L [left] leg. There was no obvious signs of trauma noted during my cursory pre Autopsy exam. Active case volume precluded completing the RIME prior to Autopsy so I contacted [location] and relayed by Phone to [name] as many details as possible about the case. I will supplement the RIME if additional pertinent information is noted after reviewing the Medical Records when they are produced. ..."

Review on 07/31/2020 of the Autopsy Report, titled "MEDICOLEGAL AUTOPSY REPORT", reported 12/20/2019, revealed "FINAL AUTOPSY DIAGNOSIS I. Drowning A. Bilateral pleural effusions B. Fluid in sphenoid sinus II. Methamphetamine toxicity III. Decomposition, moderate .... Summary of Findings The cause of death is drowning. A contributing factor is methamphetamine toxicity ....According to the .... Medical Examiner, the decedent had gone missing after reportedly going fishing. Prior to leaving he told his mother that he would not be home for supper. A couple days prior he had intentionally walked into the river. At that time he had told emergency medical services (EMS) that he was attempting to commit suicide by walking into the river because he could not bring himself to jump off the bridge. He reportedly could swim. ..."

Requests for interview of the Triage Nurse and the Nurse who documented the pre-arrival information revealed they no longer were at the hospital and, thus, were not available for interview.

Interview with the DED Medical Director, MD #1, on 07/20/2020 at 1500, revealed patients who come into the ED are screened for suicide risk by the CSSRS. Interview revealed patients do not necessarily get evaluated by a psychiatrist. Interview revealed MD #1 reviewed the medical record. Interview revealed the treating physician had noted the patient was clinically sober and had no intent of harming self or others. Interview revealed there was consultation with psych intake and they felt the patient was safe for discharge. Interview revealed that taking a patient's rights away was a "big deal" and was taken very seriously. Interview revealed MD #2, the physician on duty in the ED when Patient #3 came in, was conservative in care and for him to discharge the patient meant he felt safe to do so. Further interview revealed that according to the documentation Patient #3 was interested in outpatient treatment.

Interview, on 07/29/2020 at 1530, with BHIC #3 [Behavioral Health Intake Clinician] revealed the role was a triage clinician for the ED. Interview revealed BHIC #3 could not recall Patient #3's face. Interview revealed BHIC #3 did the intake assessment for Patient #3 and stated intake staff assessed patients in the ED to determine the best course of treatment and the level of risk in general. Interview revealed an order started the triage, which continued to a full psych assessment unless it is stopped at some point. Interview revealed BHIC #3 consulted with the ED doctor, and the doctor made the decision. "Rescind", she stated, was the language that stopped the process. Interview revealed if a patient was involuntarily committed [IVC] law enforcement would bring paperwork from the magistrate which would be a part of the medical record. Interview revealed this patient was not IVC, that BHIC #3 documented the patient was voluntary and stated that meant she validated the information. If the patient was IVC, BHIC #3 stated, it would have been documented as such in the record and the paperwork would be in the record as well. Interview revealed patients who come via EMS may be more intoxicated initially and once they get into the ED and rest they become more lucid, calmer, and may recant what they said previously. BHIC #3 stated they were fairly conservative, that if there was any doubt the patient may be playing "good patient" they would play it safe. Interview revealed if a patient was lucid, had linear thought and there was no reason to question their stability, then it may not be necessary to get anyone else, such as family, involved. Interview revealed that BHIC #3 felt secure in the knowledge that both she and the MD were conservative and if there had been any questions about safety they would have addressed them.

Telephone interview, on 07/29/2020 at 1615, revealed RN #4 recalled Patient #3. Interview revealed the patient came in on Meth and was disappointed in himself because he had relapsed. Interview revealed he was trying to get clean for his son. Interview revealed the patient stated he had not tried to kill himself, that he had been taking meth and accidentally ended up in the river. Interview revealed RN #4 had questioned with the provider whether they wanted to discharge the patient because he had a flat affect, was solemn and quiet. Interview revealed the only time the patient perked up was when they talked about the patient's child. RN #4 stated they thought the behavior was attributed to having just come down from a "massive meth high" and stated the patient scored low on the CSSRS. Interview revealed RN #4 felt okay with discharging the patient after the discussion. Further interview revealed the patient's family member came to take the patient home. Interview revealed the family member did not express any concerns to the RN about taking the patient home and Patient #3 stated he was ready to go home. At discharge, interview revealed, Patient #3 was provided a sheet of local detox resources, local outpatient resources to keep and use.

Interview, on 07/20/2020 at 0905, with MD #2, revealed only a vague recollection of Patient #3. Interview revealed MD #2 reviewed the medical record. Interview revealed cases such as this one were "unique cases to navigate - sobriety vs. ability to make judgments." MD #2 stated that based on his notes Patient #3 presented as clinically sober at the time of his MSE and adamantly denied suicidal or homicidal ideations. Interview revealed the patient was observed, had sobered up, hypothermia had normalized, and the patient continued to state he had no suicidal ideation. Interview revealed a judgment was made that the patient was reliable, had the judgment to make decisions, and insisted he was safe. MD #2 stated they generally had the ambulance "run sheet" and tried to get corroborating information when possible. MD #2 did not recall specifics but stated in looking at the medical record he could see discrepancy between the EMS report and the CSSRS. Interview revealed he leaned towards being conservative. In response to when a full psych evaluation by psychiatry or tele-psychiatry was obtained, MD #2 stated when patients were blatantly psychotic or continued SI /HI after sobriety. Interview revealed disposition was the ED physician's decision in consult with psych intake. Interview revealed after spending time with patients they sometimes got a different, clearer picture over time.

In summary, review of EMS report revealed Patient #3 stated he had walked into the river attempting to commit suicide. Patient #3 was brought to the Emergency Department on 06/22/2019. The Triage Note stated the patient denied HI/SI but also stated the patient "was thinking about jumping off bridge". In the Emergency Department two CSSRS evaluations indicated the patient had not considered killing himself in the past month and had never done or started or prepared to do anything to end his life. The DED physician stated the patient adamantly denied suicidal or homicidal ideations. No psychiatrist or Tele-psychiatrist was consulted to evaluate Patient #3. Patient #3 was discharged home on 06/22/2019 and was subsequently found dead in a river on 06/26/2019 after last being seen alive on 06/23/2019.