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Based on policy review, staff and community interviews, and record review the hospital failed to provide 1 of 20 sampled patients (Patient 12) with the necessary treatment to stabilze the patient's emergency medical condition prior to discharge on 6/2/22, 6/3/22 and 6/6/22. Patient 12, a wheelchair bound paraplegic (paralyzed-unable to feel or control any body function from the waist down) presented to the hospital emergency department (ED) multiple times seeking medical care. The failure to follow the hospital's policy and procedures for stabilizing an emergency medical condition has the potential to cause harm up to and including death. The patient was discharged without the ability to meet his basic human needs, including food, clothing, shelter, personal safety, and essential medical care as he continued to present to the ED in an apparent attempt to meet those needs.

Patient 12 initially presented to the ED at Methodist Fremont on 12/9/21 following a pedestrian versus motor vehicle accident that caused life threatening injuries, including a severe traumatic brain injury, and paraplegia (unable to feel or control any body function from the waist down). Patient 12 required continuous hospitalization followed by institutionalization until he was discharged from a long-term care facility to Hospital B on 5/15/22, then discharged against medical advice on 5/28/22, and presented to the ED at Hospital C on 5/29/22.


Findings are:

See A 2407

A. Review of facility policy titled "Emergency Medical Treatment and Active Labor Act" last revised 5/22 states, "an examination within the capability of the Hospital's DED (Dedicated Emergency Department), including ancillary services routinely available to the ED, to determine with reasonable clinical confidence whether an emergency medical condition (EMC) exists. The MSE must be provided by Qualified Medical Personnel (QMP)." Any individual, who is not otherwise a Patient of the Hospital, shall be provided an appropriate MSE within the capabilities of the ED as follows: Upon presentation at a DED of Hospital, and upon a request for examination or treatment for a medical condition. Such a request will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition." "The MSE is an ongoing process in many cases and may require documentation of continued monitoring and evaluation." The policy continued, if an EMC exists, treatment must be provided until the EMC is resolved or stabilized. "If the MSE reveals that the individual has an EMC, the hospital shall provided either: Within the capabilities of the staff and facilities available at the Hospital, provider further medical examination and treatment as required to Stabilize the EMC; or Appropriate Transfer to another medical facility in compliance with this policy." "Admission as Inpatient. The Hospital's admission of the individul with an EMC as an Inpatient in good faith in order to Stabilize the EMC satisifies the Hospital's responsibility to provide further examination and treatment of the EMC."

B. The hospital failed to follow the policy titled "Emergency Medical Treatment and Active Labor Act" when the patient presented to the ED multiple times on 5/31/22 (discharged on 6/2/22), 6/2/22 (discharged on 6/3/22), and 6/3/22 (discharged on 6/6/22).


C. During an interview on 8/10/22 at 4:22 PM, the Manager of the (Hotel F) revealed, "I was here when (Patient 12) was found deceased 6/7/22. He was still in his wheelchair in his room still strapped in with the "velcro strap" still around him by his upper stomach/waist/under his arms. He was scooted down and leaning slightly to the left. It looked like he had just wheeled into his room and was facing the TV and passed. It was apparent that he had not touched anything in the room. Both beds were untouched, the bathroom hadn't been touched and his bags were sitting on his bed."

Based on policy review, staff and community interviews, and record review, Patient 12 presented to the emergency department on 5/31/22, 6/2/22 and 6/3/22 with an emergency medical condition. The hospital failed to provide treatment to stabilize the patient emergency condition prior to discharge.

Patient 12 initially presented to the ED at Methodist Fremont on 12/9/21 following a pedestrian versus motor vehicle accident that caused life threatening injuries, including a severe traumatic brain injury, and paraplegia (unable to feel or control any body function from the waist down). Patient 12 required continuous hospitalization followed by institutionalization until he was discharged from a long-term care facility to Hospital B on 5/15/22, then discharged against medical advice on 5/28/22, and presented to the ED at Hospital C on 5/29/22. Patient 12 presented to the ED at Methodist Fremont on 5/30/22 and 5/31/22.

Findings are:

A. Review of a closed medical record showed Patient 12 presented to the ED by ambulance on 5/30/22 at 6:41 AM. The ED physician examined the patient and wrote orders for discharge at 4:00 PM.

B. Review of a 5/31/22 Pre-hospital Care Report (approximately 28 hours after discharge on 5/30/22) showed that 911 was called at 8:13 PM to a public area for Patient 12 who was in a wheelchair with a foot injury. Documentation showed the patient was in an electric wheelchair with his left foot dragging behind him. The patient's oxygen saturation level had dropped to the upper 80s (normal oxygen saturation is 100 - 95%) and was placed on oxygen at 4 liters/minute/nasal cannula. The patient's oxygen saturation level improved and the ambulance crew moved the patient to the cot by direct lift and transported Patient 12 to the ED after controlling the bleeding, cleaning and bandaging his left foot and toes.

Review of the 2nd closed medical record showed Patient 12 presented to the ED via ambulance at 8:24 PM and was triaged as ESI 3 (emergency severity index 3 means Urgent). ED physician D identified that the patient returned to the ED on 5/31/22 for complaints of a UTI, and dragged his feet on the ground and scrapped his toes. He was seen here yesterday diagnosed with a UTI and started on Bactrim. Prior to that he had been hospitalized in Lincoln, they got him a cab to come and stay with a relative, but when he got here was unable to stay with that person and has been sleeping outside for the past couple of days. His toes were cleaned up, he also complained of feeling generally weak but no fevers, no abdominal or flank pain. He is homeless and looking to get into the shelter in town and asks if we can call and try and get him a bed. His exam showed some excoriation to the tip of the penis surrounding the catheter (tube that drains urine from the bladder into a bag outside of the body). Basic labs showed a low sodium of 123 (normal is 134-145). Further documentation showed that "He will probably need social work services while inpatient for his poor living situation and inability to care for himself." ED Physician D diagnosed Patient 12 with hyponatremia (low sodium), failure to thrive in adult, and a urinary tract infection (an emergency medical condition). At approximately 12:12 AM on 6/1/22, the hospital admitted Patient 12 as an inpatient. The evidence in the medical record showed the patient was not admitted in good faith to stabilize his emergency medical condition.

The nursing notes indicated Patient 12 required transfer assistance and was a 2 person maximum assistance using a mechanical lift. The patient did not receive evaluation by physical or occupational therapy for assessment of his ability to perform activities of daily living, or to assess his strength, ability to reposition to avoid constant pressure on his coccyx, buttock, or evaluate for the need of a transfer board enabling him to transfer from his wheelchair to a bed with minimal to no assistance, or to plan for discharge to a facility with the capabilities of caring for a patient with long-term complex medical needs. Review of the Social worker note on 6/1/22 at 12:59 PM revealed, that if the (local shelter) had a bottom bunk the patient would be welcomed back. "But there are no male beds", she suggested either one of the two homeless shelters in Omaha, Nebraska "if the patient would be willing to go back to Omaha." On 6/2/22 at 10:29 AM the Social Worker met with the patient for discharge planning. He was offered transportation to the Omaha Shelter. He was alert & oriented x 3 but having flight of thought. He refused to go to Omaha. He was told to anticipate discharge for today or tomorrow as soon as he was medically stable. There was no documentation that the hospital determined the patient could begin to thrive outside a hospital or long-term care facility, or whether a homeless shelter had the capabilities to meet the patient's physical limitation and needs, and there was no documentation that the hospital evaluated the patient's mental health or why the patient was experiencing "flight of thought" (symptom that may occur as part of mania or psychosis) or the patient's ability to make informed medical decisions or ability to comply with his medication regime, or fluid and dietary requirements related to his hyponatremia. The social worker provided patient with clothing and a food box but no other support. At 2:50 PM the hospital discharged the patient who had an un-stabilized emergency medical condition and was at significant risk for material deterioration. The patient returned to the ED approximately 7 hours later.
C. Review of a 3rd closed medical record which included the 6/2/22 Pre-hospital Care Report showed that when the Ambulance Squad arrived at a local gas station, Patient 12 was found in his electric wheelchair with the complaint that he was emptying his catheter bag and on the way in he hit his left knee on the door, stating he thinks he broke it. The patient was paralyzed from the chest down and couldn't feel anything but was sure it was broke. He had a small abrasion to the left knee and no sign of deformity. He was lifted from his wheelchair and placed on the stretched and taken to the ambulance and transported to the ED at 9:48 PM.

The ED Physician Dr D identified that the patient presented to the ED "because he doesn't have a place to sleep, and has left leg pain." "He was discharged from the hospital just a few hours ago." "He thinks his femur might be broken." "Though he is numb from the chest down at baseline." He was offered to go to Omaha to a homeless shelter but declined and instead was discharged to the street. Exam and X ray of left femur was done and negative. At 2:50 AM we arranged transport to Omaha to the homeless shelter. The patient became belligerent and combative, he destroyed hospital equipment in the room and bent IV pole on the bed. Making vague threats to bomb the hospital. Local law enforcement came, and did not arrest patient citing he does not have the means to make a bomb. At 5:00 AM Dr. D documented the Patient refused transfer to homeless shelter, instead prefers to be discharged to street instead. Continues to be belligerent and harassing, verbally abusing ED staff.

Per the ED nursing notes 6/2/22 at 10:31 PM, Patient 12 stated, "He was discharged from the hospital today and doesn't have a place to live or sleep, and also is hungry." The nurse's note identified his behaviors as agitated, aggressive, impulsive, inappropriate and uncooperative. The patient became belligerent and harassing behaviors, he destroyed hospital equipment in the room and bent an IV pole on the bead. Made threats to bomb the hospital, and wanted the names of everyone working in the ED so he could make sure to blow the staff up.

Per the Nurses Notes on 6/3/22 at 5:01 AM, "FPD (Fremont Police Department) and house supervisor spoke with patient and presented that the patient has received a medical screening exam and can be discharged to the (homeless shelter) in Omaha or be discharged to the streets. Patient REQUESTED TO BE PLACED IN HIS WHEELCHAIR and be discharged to the streets. Patient promised to come to the ED every day for meals." The hospital discharged the patient at 6:13 AM.

The medical record did not contain evidence that the hospital provided the patient with the necessary stabilizing treatment for his emergency medical condition. While in the ED, the patient became acutely agitated including physically damaging equipment and verbally threatening staff. The homeless, paraplegic patient with an acute infection did not receive a psychiatric evaluation prior to discharge in an acutely agitated state, and without a plan for how he would access essential medical care including where he could perform peri-care and catheter care, or if he could manage his own transfer in or out of his wheelchair, or if he had access to food or shelter.

Review of the list of physicians on-call to the hospital showed a psychiatrist was available to the ED staff 24/7 and that the hospital had an adult inpatient behavior health unit.

Review of the 6/3/22 census for the hospital's inpatient psychiatric unit showed 20 bed inpatient psychiatric beds, with a census of 15 patients (5 empty beds) at the time of Patient 12's discharge.

Review of the Behavioral Health Policy/Procedure dated 3/2022 identified the following admission criteria: if the patient poses an actual or imminent danger to self, others, and/or property due to the behavioral manifestations of a psychiatric disorder; The patient lacks a social support system to such a degree that indicated treatment is jeopardized.
Review of a 6/3/22 police report showed that law enforcement and a Co-Responder, a Licensed Mental Health Professional (LMHP) were dispatched to a parking lot at approximately 11:18 AM for a mental health emergency as the local EMS were departing to transport the consumer (patient 12) to Methodist Fremont ED. The report indicated that law enforcement and the LMHP redirected to Methodist Fremont ED and spoke to consumer (Patient 12) in the ED. The report indicated that consumer (patient 12) indicated a history of underlying severe medical conditions and poorly controlled mental illness since he became paralyzed from a serious injury earlier this year. Further documentation showed that consumer (patient 12) was ill-appearing, appeared older than his stated age, was disheveled and was malodorous of urine. Consumer (patient 12) had fleeting eye contact, irritable mood, with a labile affect, psychotic and disorganized behavior; pressured, tangential, and nonsensical speech noted. Signs and symptoms of cognitive impairment were apparent as evidenced by his inability to maintain focus. He was easily distracted and had to be redirected frequently by the LMHP and law enforcement. Consumer (patient 12) expressed delusional beliefs and frequently spoke about various unrelated topics rather than responding to questions. He expressed bizarre ideas about his blood and made statements to the effect Methodist put "meth" in his blood. The report indicated that law enforcement placed patient 12 under emergency protective custody (EPC) and reiterated safety concerns to staff caring for consumer in the ED. The report included information that ED staff would contact Adult Protective Services going forward regarding consumer and that the LMHP recommended a neurocognitive examination for the consumer's traumatic brain injury less than a year ago, in addition to a psychiatric evaluation.

D. Review of a Patient 12's 4th closed medical record showed EMS Pre-Hospital report showed that 911 was called to a public parking lot where "a wheelchair bound homeless person was causing a disturbance and had been taken into police custody." (Patient 12) was extremely agitated about his situation, kept saying that he hasn't had anything to eat for days and has been sitting out in the sun because he has no place to go. Patient was transported to Fremont Hospital at 11:31 AM on 6/3/22.

Review of the receiving ED Physician note at 11:31 AM on 6/3/22 stated the patient was placed under an EPC (Emergency Protective Custody) by the police because the patient was found to be talking gibberish and asked the police officer to shoot him. He gets around in a motorized wheelchair. However, THE WHEELCHAIR WAS A LONER AND HAS NOW BEEN TAKEN AWAY FROM HIM BY THE OWNER. The police feel that the patient is a danger to himself due to inability to care for himself, inability to get around, and also suicidal statements. Upon arrival to the ED the patient was angry, verbally abusive to staff, and shouting obscenities.

Review of the Behavior Health psychiatrist Dr B's initial EPC assessment on 6/3/22 at 1:26 PM, revealed the diagnoses/assessment/plan: 1) Psychosis (Unspecified psychosis not due to substance or known physiological condition) "Patient is disorganized with loose association pressured speech could well represent an incipient manic episode. Nevertheless he was markedly aggressive attempting to break everything he gets his hands on including briefly this physician's arm. The patient has no insight into current difficulties and is presently on emergency protective custody. My recommendation is that he need psychiatric admission emergent treatment.

Review of documentation of Patient 12's stay in the ED from 6/3/22 at 1:26 PM until discharge on 6/6/22 at 4:57 PM included:
-6/3/22 ED Dr F documented, the patient continued to be uncooperative, rude, persistently aggressive and threatening. Very pressured speech, grandiose statements. Unable to de-escalate. Due to concern of danger to self and others was given Haldol, Benadryl and Ativan to calm and stabilize his mood.
-6/4/22 ED Dr E documented the patient would become agitated and threatening, he again required Haldol and Ativan. Psychiatrist Dr H came to the ED at 11:57 AM to see the patient. Dr H added Depakote 500 mg twice a day, Zyprexa 10 mg daily, and documented is under EPC and if the patient is able to calm down, may consider inpatient unit upstairs. Continue the as needed medications.
-6/4/22 ED Dr F documented he will need social work to help with placement as he currently does not have a wheelchair or any way to get around.
-6/5/22 Psychiatrist Dr H came to ED at 10:06 AM to see patient and documented to continue current medications and encourage him to be complaint with medications.
-6/6/22 ED Dr C documented the patient EPC is about to expire. Patient has chronic medical problems including his paraplegia. Social services has been consulted regarding his living status i.e. he has been homeless.
Psychiatric NP A on 6/6/22 at 10:15 AM co-signed by psychiatrist Dr I, documented Psychosis has been resolved with the use of by mouth Zyprexa and Depakote. Patient is reluctant to continue psychiatric medications on discharge, however will go ahead and prescribe Depakote, Zyprexa and Lexapro. Follow up outpatient therapy appointment in 6 days.

Social Worker's note dated 6/6/22 at 2:45 PM documented a team meeting was held to discuss barriers to discharge; no wheelchair (electric wheelchair was a loner and company repossessed it), he is homeless and was recently banned and barred from this hospital. The SW voiced concerns that the patient had been diagnosed with psychosis not related to substances and behaviors did not stabilize until he was prescribed mood stabilizers on 6/4/22 by psychiatry. The Chief Nursing Officer was formulating a plan to have the patient discharged to a local hotel, he will need a w/c and transportation. The hospital secured a room at a local hotel using a credit card. A food box was not available at the time of discharge to send with him. The patient was discharged to the local hotel by the hospital van at 4:57 PM on 6/6/22 for a one night stay, with no plans thereafter.

The medical record lacked evidence that the patient received the necessary treatment to stabilize his EMC and was discharged soon after his order for emergency protective custody ended. The ED record from 6/3/22-6/6/22 lacked documentation of an evaluation by Physical Therapy or Occupational Therapy to assess if the patient was able to transfer himself in and out of his wheelchair or if it was safe to have a gait belt secured around his waist, or whether he could perform his own peri care, or had a plan for how he would access essential medical care. At the time of the patient's discharge on 6/6/22 the 20 bed inpatient psychiatric unit had 18 patients (2 empty beds). The patient had informed the Behavioral Health NP A that he was reluctant to continue the psychiatric mood stabilizing medications he received during this EPC/ED stay and there was concern about what would happen when he was released. Patient 12 was found deceased in the hotel room on 6/7/22 still in the wheelchair with his medications, a gait belt around his chest, and his bag of belongings on the bed untouched.

E. An interview with Psychiatrist Dr B on 7/27/22 at 9:15 AM, indicated that he was the psychiatrist on duty when he came in on his EPC (6/3/22) and Dr B did his initial Mental Health assessment. He had asked the police to kill him or threatened to kill himself. He was very aggressive and tried to break anything he could get a hold of, "including he got a hold of my arm briefly". He had no insight into his current issue. He had psychosis. He needed inpatient psychiatric emergent admission for treatment, but not here at our facility. He needed a "special care" psychiatric facility that was better equipped to handle this type of patient. He stayed in the ED while we tried to find alternate Special Care psychiatric inpatient treatment.

In a written clarification from the initial assessing hospital Psychiatrist (Dr B) on 6/3/22 related to why Patient 12 did not qualify for admission to their psychiatric unit upon admission to ED under the EPC for aggressive behaviors, suicidal thoughts, threats and thoughts of hurting others, Dr B indicated, He assessed the patient in the Emergency Department and through his assessment, the patient was actively aggressive and assaulting staff and because of his aggression, our inpatient Behavior Health Unit did not have the resource capacity to care for him. The words, "special care" is the titling of patients that are of a higher acuity with aggressive behaviors. Our unit does not have the resources such as security directly on the unit, staffing standards consistently to accommodate a higher acuity patient established, and unit design to support segregation easily. This is a recognized titling "special care' throughout our Region. "The decision regarding the patient denial did not even proceed to our unit evaluating bed #'s/capacity/staffing or the fact that the patient had a Ban & Bar initiated, it stopped with Psychiatrist Dr B's assessment of the patient having active aggressive behaviors and that assessment/opinion carried through the weekend with (Psychiatrist Dr H). Monday morning after the patient stabilized, he no longer needed an admission (see admission criteria) as assessed by (BH NP A) and his EPC expired."

F. An interview with the Hospital's Behavioral Health Unit Nurse Practitioner (BH NP A)on 7/29/22 at 9:00 AM, related to the assessment on 6/6/22 at 10:15 AM to determine EPC status which was due to expire at 11:30 AM. BH NP A stated, that she went in and visited with Patient 12 and he was no longer having suicidal or homicidal ideation. Had been taking prescribed psychiatric medications (mood stabilizing medications Depakote, Zyprexa and Lexapro) over the weekend and was no longer agitated and aggressive. His cognitive state was alert and oriented. He told her he could take care of himself and he had been living at a local hotel (Hotel A that rented rooms by the month) with a friend and he wanted to go back there. He had appointments with housing authority on 6/8/22 and was going to do that. "He was no longer having suicidal or homicidal thoughts, phoned the County Attorney and discussed no longer a harm to self or others and had no reason for a Board of Mental Health Commitment on him so let the EPC drop and the County Attorney agreed." When asked if she verified that he could care for himself or in fact had been currently living at that hotel (Hotel A). "I had no reason to question that information. From a psychiatric status I had no reason to keep him."

G. An interview with Psychiatrist Dr H that was the on call psychiatrist on 6/4/22 and 6/5/22 that saw Patient 12 in the ED. On 6/4/22 Psychiatrist Dr H initiated Depakote and Zyprexa, he seemed to be calming, on 6/5/22 he was cooperative, did say he didn't like taking medications. Asked Dr H if he felt he was ready for discharge? "No I wouldn't of discharged him on Sunday, that was the last day I saw him. I knew his EPC would end tomorrow and (Psychiatrist Dr B) and his team would evaluate him then."

H. An interview with the CNO on 8/1/22 at 11:15 AM related to the 6/3/22-6/6/22 EPC stay for Patient 12 revealed, "We had a care conference on 6/6/22 around 2:30 PM with (ED RN Director), (Social Worker), (BH NP A), (BH CM) and (Clinical Leader) about discharge plan for him. His EPC had dropped. Discussed patient: BH NP A said, "no longer suicidal or homicidal," Barriers: financial barriers, transportation, no longer has electric wheelchair, food, meds. We got him a hotel room for the night at the (Hotel F), arranged transportation with the facility van, provided him 30 day supply of medications, a manual wheelchair - he requested a gait belt around his waist, which was provided, he had just had food, we gave him some clothes, set him up with appointments with his primary care physician and a behavioral health appointment. He was dismissed in the manual wheelchair with the gait belt around his waist via our van to the hotel (Hotel F) with the meds and his belongings. "We did find out that he was found passed away at the hotel the next morning."

I. An interview with the ED RN Director on 8/1/22 at 12:35 PM related to Patient 12's 6/6/22 discharge. "We gave him a manual wheelchair and a cushion. He had asked for a gait belt for around his waist and someone else provided that." Asked ED RN Director if anyone checked if the patient could transfer self in and out of the manual wheelchair, or if the arm of the manual wheelchair arm could come off? "I do not know if the arm of the wheelchair came off or if anyone checked if could transfer out of it, but I know that he was comfortable once he was in it. I also know he could wheel it, he positioned himself in bed and had strong upper body."

J. An interview with the Manager of the (Hotel F) at 8/10/22 at 4:22 PM revealed, "I was here when (Patient 12) was found deceased 6/7/22. He was still in his wheelchair in his room still strapped in with the "velcro strap" still around him by his upper stomach/waist/under his arms. He was scooted down and leaning slightly to the left. It looked like he had just wheeled into his room and was facing the TV and passed. It was apparent that he had not touched anything in the room. Both beds were untouched, the bathroom hadn't been touched and his bags were sitting on his bed."







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