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Based on record review and staff interviews, the facility failed to follow policies established to ensure patients receive an appropriate medical screening to determine if a patient has an emergency medical condition for two (Patients # 27 and #21) of 37 patients sampled. The Emergency Department census was 21 on 5/3/10 at 1:20 PM.

Review of policy # CC4100 titled, "Examination, Treatment, and Transfer of Patient with Emergency Medical Conditions" dated 11/16/99, with a revision date of 3/1/10, showed the following:
-the facility will offer an appropriate medical screening examination to determine if an emergency medical condition exists (bullet one);
-the facility will provide treatment to stabilize an emergency medical condition (bullet one);
-the physician is responsible for completion of the screening examination (bullet four);
-an emergency medical condition is defined as a psychiatric disturbance, suicidal or homicidal thoughts or gestures that place the individual in a condition where the individual may cause harm to self or others (page three, section five c);
-an appropriate medical screening examination is the process required to reach the point at which it can be determined whether a medical emergency does or does not exist (page 4, second column, second paragraph).

Review of policy #TX2090 titled, "Guidelines for Mental Health Patient Admitted to a Non Mental Health Unit" dated 10/24/05, with a revision date of 1/19/09, showed patients with a court order, on a 96 hour hold, or who are a danger to themselves or others will have continual observation until deemed no longer a danger to self or others by the physician (Page 1 bullet 6). The policy also states patient who are admitted on a 96 hour hold or court order are the responsibility of the hospital and patients are not to leave (page 1 bullet 8). After patients are brought into a room, staff are to stay with the patient and a skin search is done (page 2 bullet 1). 15 minute visual observation is to be maintained and documented in the EMR (page 2 number 2).

1. Review of the electronic medical record (EMR) printed on 5/3/10 revealed Patient #27 presented to the Emergency Department (ED) on 4/25/10 at 12:17 AM with a 96 hour court ordered detention signed by a local Judge. The court order indicated patient # 27 had a mental disorder and presented a likelihood of serious harm to self or others and was to be admitted to the Mental Health Unit for evaluation and treatment. The patient was subsequently discharged from the ED by ED physician K.

During an interview on 5/13/10 at 3:51 PM, ED physician K confirmed he did not contact the on-call psychiatrist before discharging patient #27. ED physician K stated that he usually consults the psychiatrist for admission " to err on the side of safety of the patient. " ED physician K stated that he did not know that a Judge had ordered an involuntary detention and that had he known, " I would have contacted the psychiatrist. " ED physician K stated he did not see the medical record documentation by the ED nurse specifying patient # 27 had a court order for a 96 hour hold. ED physician K stated " I don ' t know if I missed something, I get a little confused with that part of the documentation. "

During an interview on 5/4/10 at 8:59 PM., triage nurse J stated he/she was aware that patient # 27 presented to the ED with a 96 hour court ordered hold.

During an interview on 5/4/10 at 5:09 PM., Staff E, Mental Health Unit (MHU) team leader stated if a patient comes to the hospital with a 96 hour court ordered hold, MHU staff read the patient their rights and document it in the patient's medical record. Copies of the court order are made and placed in the patients ED chart.

During an interview on 5/4/10 at 8:50 PM., RN I stated he/she discharged patient #27 after MD K cancelled the 96 hour hold.

The hospital failed to follow their policy and discharged a patient that presented to the ED with a court order for involuntary detention prior to providing an appropriate and sufficient examination. Refer to tag A2406 for further details.

2. Review of the EMR printed on 5/3/10 revealed Patient #21 presented to the ED on 4/17/10 at 7:24 PM. At 7:37 PM, ED triage nurse H documented (page 1 of the EMR) the patient was "battling depression and states he is afraid he will do something to harm himself. Pt states drank 3 beers, hasn ' t taken any of his medications. " At 7:44 PM (page 7 of the EMR) ED staff entered an order for " Consult Mental Health " . At 7:46 PM (pages 7-9 of the EMR) ED staff entered orders for multiple urine and blood tests on patient # 21. At 8:30 PM, a second ED nurse, RN S documented (page 10 of the EMR) that patient # 21 was not in his room, in the waiting area or in the restroom. The hospital failed to follow their policy and did not provide as required, an appropriate medical screening examination to patient # 21.

During an interview on 5/4/10 at 7:45 PM., RN H stated he/she was the triage nurse on 4/17/10 when Patient #21 came to the ED. RN H stated the patient was taken to a room by the ED technician and RN H contacted the ED resource nurse to notify them of the patient's mental health status. RN H states ED technicians are to wait with mental health patients in their room until the primary nurse does a "face to face" (a process by which the nurse is required to come in and visually assess the patient). RN H does not know if this happened with Patient #21. Refer to tag A 2406 for further details.

Based on record review and staff interviews, the hospital failed to provide an appropriate medical screening to determine if an emergency medical condition existed for two patients (Patients' #27 and #21) of 37 sampled patients. The Emergency Department census was 21 on 5/3/10 at 1:20 PM.

1. Review of the electronic medical record (EMR) printed on 5/3/10 revealed Patient #27 presented to the Emergency Department (ED) on 4/25/10 at 12:17 AM. with a 96 hour court ordered detention signed by a local Judge. The court order indicated patient # 27 had a mental disorder and presented a likelihood of serious harm to self or others and ordered law enforcement to transport him to Heartland Hospital for detention, evaluation, and treatment. The application to the court for the 96 hour detention indicated patient # 27 "would do what he had to do", with "likelihood of serious harm to self and possibly others". At 12:18 AM, ED triage nurse J documented (page 5 of the Electronic Medical Record (EMR) that patient # 27 presented to the ED due to a "96 hour court order for psychotic symptoms" ..."I'm afraid of hurting someone else". At 12:26 AM, an unidentified staff member ordered (page 20 of the EMR) a Mental Health Consult. At 12:42 AM, nurse P, came to the ED from the Mental Health Unit and documented (page 33 of the EMR) she read patient # 27 his rights for the court ordered involuntary admission and a copy of the rights were given to the patient. At 12:57 AM, ED nurse T, documented (page 7 of the EMR) that a security officer stayed and observed patient # 27 one on one. At 1:47 AM, ED nurse H, documented on the patient's safety checklist (page 14 of the EMR), that patient # 27 had a security alarm band on and was in sight observation at all times while in the ED. At 3:59 AM, ED nurse H documented (page 8 of the EMR) that a sitter (a staff member assigned to continuously observe a patient) replaced the security officer at patient # 27's bedside. At 7:25 AM, ED nurse H documented (page 33 of the EMR) she spoke with ED physician K, who cancelled the local Judge ' s order for a 96 hour involuntary detention. At 7:33 AM, ED nurse H documented (page 9 of the EMR) she discharged patient # 27 from the ED to home.

During an interview on 5/4/10 at 7:45 PM, ED nurse H stated that Patient #27 came to the ED on 4/25/10 with police and a 96 hour court ordered hold. ED nurse H stated she verified with another nurse whether patient # 27 was a " 96 hour hold or if it was court ordered. " ED nurse H stated she could not recall who told her " it was just a hold. "

During an interview on 5/4/10 at 8:50 AM, ED nurse I stated she discharged patient #27 after she was told, "ED physician K had cancelled any type of 96 hour hold." ED nurse I stated that the ED physician is responsible for contacting the mental health unit to arrange for a mental health evaluation.

During an interview on 5/13/10 at 3:51 PM, ED physician K confirmed he did not contact the on-call psychiatrist before discharging patient #27. ED physician K stated that he usually consults the psychiatrist for admission " to err on the side of safety of the patient. " ED physician K stated that he did not know that a Judge had ordered an involuntary detention and that had he known, " I would have contacted the psychiatrist. " ED physician K stated he did not see the medical record documentation by the ED nurse specifying patient # 27 had a court order for a 96 hour hold. ED physician K stated " I don ' t know if I missed something, I get a little confused with that part of the documentation. "

Review of a second EMR printed on 5/3/10 revealed Patient #27 returned to the ED on 4/25/10 at 11:11 AM, approximately 4 hours after discharge. ED physician V documented in the medical record that ED physician K had examined patient # 27 during the first visit and " the thing of it is, [ED physician K] saw him [patient # 27] and discharged him on his own recognizance." According to the medical record documentation, ED physician V consulted with physician W, the on-call psychiatrist who determined patient # 27 required inpatient admission for further examination and treatment.

According to the statutorily mandated Quality Improvement Organization (QIO) review performed on 6/2/10, patient # 1 presented to the ED with a court order signed by a Judge for a 96 hour hold because of a psychotic episode, that he was out of touch with reality, and had commented that he was afraid he would harm others. Patient # 27 did not receive an appropriate or sufficient medical screening examination before discharge from the ED.


2. Review of the EMR printed on 5/3/10 revealed Patient #21 presented to the ED on 4/17/10 at 7:24 PM. At 7:37 PM, ED triage nurse H documented (page 1 of the EMR) the patient was "battling depression and states he is afraid he will do something to harm himself". At 7:44 PM, an unidentified staff member ordered (page 7 of the EMR) a Mental Health Consult and several lab tests (page 8 and 9 of the EMR). At 8:30, RN S documented (page 10 of the EMR) the patient was not found in the exam room, was believed to have left without being seen, and the resource nurse was notified of this.

During an interview on 5/4/10 at 5:44 PM., Staff G, Patient Access Representative stated he/she went to Patient #21's room at 8:47 PM to update insurance information, found the room empty, and was told by an unknown ED staff member the patient had left.

During an interview on 5/4/10 at 7:45 PM., RN H stated he/she was the triage nurse on 4/17/10 when Patient #21 came to the ED. RN H stated the patient was taken to a room by the ED technician and RN H contacted the ED resource nurse to notify them of the patient's mental health status. RN H does not know if the ED technician waited with the patient until the primary nurse took over the care of the patient.

Review of the EMR printed on 5/3/10 revealed Patient #21 returned to the ED on 4/17/10 at 10:00 PM with a 96 detention application escorted by law enforcement. The detention application indicated Patient #21 presented a likelihood of serious harm to self or others and ordered law enforcement to transport him to Heartland Hospital for detention, evaluation, and treatment. The application also indicated Patient #21 "made statements to his family about killing himself by walking in front of traffic on the highway". On 4/18/10 at 12:30 AM, RN T read Patient #21 his/her "Notice of Rights of Involuntary Patient".