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Based on review of medical records, Medical Staff Bylaws Rules and Regulations, staff interview, and policies, it was determined that the facility failed to provide an appropriate medical screening exam and necessary stabilizing treatment for Patient # 1's emergency psychiatric condition when she presented to the Emergency Department on 1/14/20 with complaints of auditory hallucinations and drug abuse.

Findings were:

Cross refer to tag A-2406 as it relates to the facility's failure to provide an appropriate medical screening exam to Patient # 1 who presented to the facility's emergency department (ED) on 1/14/20 with complaints of auditory hallucination and a current history of drug abuse.

Cross refer to tag A-2407 as it relates to the facility's failure to provide necessary stabilizing treatment for Patient # 1's emergency psychiatric condition when she presented to the Emergency Department on 1/14/20 with complaints of auditory hallucinations and a current history of drug abuse.

Based on a review of medical records, interviews, and policies, it was determined that the facility failed to provide an appropriate medical screening exam to Patient # 1 who presented to the facility's emergency department (ED) on 1/14/20 with a psychiatric complaint.

FINDINGS:

MEDICAL RECORD REVIEWS:
A review of Patient #1's ED visit on 1/14/2020, revealed that Patient #1 presented as a walk-in to the ED at 3:46 p.m. with psychiatric complaints. At 4:25 p.m., Registered Nurse (RN) EE triaged Patient #1 as a level 2 emergent priority. RN EE noted that Patient #1 reported hearing voices since 2013 and that she needed Risperidone because she has been out of her medication since 2015. RN EE noted that Patient #1 reported that she just "chit chats with the voices". RN EE further noted that Patient #1 denied suicidal or homicidal ideations. RN EE changed Patient #1 to a level 3 urgent priority. RN EE noted that Patient #1 was currently hearing voices, had mood changes, and altered mental status. Patient #1's vital signs were: temperature 98.5 - pulse 118 - respirations 18 - blood pressure 108/57 - oxygen saturation 100%. A review of the Environmental Patient Safety Checklist revealed the checklist was completed by an RN and Sitter at 5:30 p.m.

At 5:39 p.m., Physician DD noted that Patient #1 reported hearing things. The physician noted that Patient #1 denied pain and reported that she had a history of schizophrenia (a mental disorder characterized by delusions, hallucinations, and disorganized speech and behavior). Physician DD noted that Patient #1 reported taking Risperidone (used to treat bipolar disorder) since 2015. The physician also noted that Patient #1 reported that the voices she was hearing told her to come to the ED to get Risperidone and that she was in the ED for a medication refill. Physician DD noted that when Patient #1 was questioned as to whether she follows up with a psychiatrist, the patient's "response did not make sense". In addition, Physician DD noted that Patient #1 denied any further complaints or symptoms and was constantly responding to internal stimuli. Physician DD noted that a review of systems was negative with the exception of the patient hearing things. Physician DD noted that Patient #1 reported having no known drug allergies and no home medications. Physician DD also noted that Patient #1's physical examination was normal with the following exceptions: hearing and seeing things, abnormal judgment and insight, confusion, flight of ideas, loose associations, delayed response to stimuli, and wandering thought process.

On 1/14/2020 at 5:36 p.m., Physician DD signed a '1013' (Georgia's form that allows a patient to be held for up to 72 hours when the patient has been determined to pose a threat to self or others by a medical professional) due to psychosis (mental disorder characterized by a disconnection from reality), erratic behavior (patients with bipolar disorder can have episodes of inflated self-esteem), delusions (false beliefs), paranoia (irrational fear), and aggressive behavior. A review of Physician orders and lab results revealed the following:
--Urine Drug Screen - was positive for Amphetamine (a stimulant),
--Suicide Risk Observation level - every 15-minutes Observations were documented from 1/14/2020 at 5:30 p.m. until 1/15/2020 at 12:15 p.m.,
--Behavioral Health Consult was performed on 1/14/2020 at 7:45 p.m.

At 5:54 p.m., RN EE noted that Patient #1 was in a psychiatric room and that all environmental safety checks had been performed. The nurse noted that Patient #1 was confused and that the "1013" had been signed and implemented. In addition, documentation revealed video monitoring was initiated. At 5:58 p.m., Patient #1 signed the Consent for Treatment and receipt of Patient Rights information.

At 6:38 p.m., Physician DD noted that a re-evaluation of Patient #1 revealed the patient was awake, alert, and oriented, in no distress, and stable. The physician noted that Patient #1 was cleared medically and had been placed on a "1013" due to psychosis, agitation, aggressive behavior, delusions, paranoia, and hearing things.

A review of the Environmental Patient Safety Checklist revealed the checklist was completed by an RN and Sitter at 7:00 p.m. At 7:03 p.m., nurses' notes revealed Patient #1 was medically cleared. Nurses' notes indicated Patient #1 was evaluated by a Behavioral Health Counselor. At 7:35 p.m., Patient #1's friend and sister's phone numbers were noted.

At 7:45 p.m., the Behavioral Health Assessment revealed Patient #1 reported not seeing a psychiatrist since 2013 for a history of Schizophrenia and that she needs her Risperidone tonight so she can go to Social Security and get disability. The assessor noted that Patient #1 reported living with a friend and that she occasionally used methamphetamines (a powerful, highly addictive stimulant that affects the central nervous system) but was able to control usage. At 7:47 p.m., nurses' notes revealed the ED staff were working on finding an accepting facility. At 10:26 p.m., physician notes revealed the evening psychiatric rounds were made and that Patient #1's placement was pending.

On 1/15/2020 at 7:40 a.m., RN EE noted that Patient #1's suicide risk was moderate.

At 9:58 a.m., RN EE noted that per the Psychiatric Physician (at a different hospital who had not evaluated the patient), Patient #1 does not meet the criteria for inpatient, does not need to be on a "1013", and can be discharged home with Risperidone. At 11:56 a.m., Physician DD noted that Patient #1 was resting comfortably, and that the patient denied suicidal or homicidal ideations. In addition, Physician DD noted that Patient #1 denied any hallucinations and that she admitted to last using methamphetamines on 1/14/2020. Physician DD noted that she felt Patient #1 was safe to be discharged home and that the Behavioral Health assessor was in agreement. Physician DD noted that she would restart Patient #1 on Risperidone, offer the patient a follow-up and that Patient #1 was informed to return to the ED if symptoms worsened.

At 12:05 p.m., RN EE noted that the "1013" was rescinded. At 12:10 p.m., the nurse noted that Patient #1's belongings had been returned and that the Patient #1 denied suicidal and homicidal ideations. RN EE further noted that Patient #1 was discharged home in a stable and improved condition. The discharge forms indicated that Patient #1's discharge diagnoses were methamphetamine abuse and psychosis. RN EE noted that Patient #1 received written and verbal instructions regarding her diagnoses, lab results, substance abuse, need for follow-up, and when to return to the ED. RN EE also noted that a prescription was provided for Risperidone 0.5 milligrams 1 tablet by mouth every day. RN EE noted that Patient #1 verbalized understanding of discharge instructions including taking "medications as prescribed and to quit using meth". The discharge forms were signed by Patient #1. RN EE noted that Patient #1 left the ED unaccompanied and that the patient's discharge vital signs were: pulse 88 and respirations 16.

STAFF INTERVIEWS:
During a telephone interview on 9/22/2020 at 3:50 p.m., Physician DD confirmed that she was working in the ED on 1/14/2020 during the day shift (Patient #1's second ED visit). Physician DD stated she did not remember Patient #1. Physician DD said that sometimes patients are held in the ED because they are aggressive. Physician DD stated these patients are placed on a '1013' for their safety. The physician said that patients being held in the ED are assessed twice a day for their safety. Physician DD explained that the ED physicians communicate with the psychiatric assessors to determine whether a patient needs to be transferred to an inpatient psychiatric facility or whether the '1013' can be rescinded and the patient discharged home. Physician DD explained that if the patient has calmed down and is cooperative when reassessed, the '1013' is rescinded.

During an interview on 9/23/2020 at 9:45 a.m., RN EE confirmed that she was working in the ED on 1/14/2020 from 7:00 a.m. to 7:00 p.m. (Patient #1's second ED visit). RN #EE stated she does not remember Patient #1. RN EE explained that when a physician orders a patient to be placed on a '1013', lab tests are ordered, and the patient is medically cleared prior to the psychiatric evaluation. RN EE said that the psychiatric evaluation is completed by a psychiatric assessor either face to face or by telemedicine. RN EE went on to explain that the psychiatric assessor and the ED physician discuss the plan of treatment and determine whether the patient is to be transferred to an inpatient psychiatric facility or whether the '1013' can be rescinded. RN EE confirmed that the electronic medical record automatically time stamps all entries and late entries have the automatic time stamp and the time of the actual action.

During an interview on 9/23/2020 at 9:45 a.m., RN EE confirmed that she was working in the ED on 1/14/2020 from 7:00 a.m. to 7:00 p.m. (Patient #1's second ED visit). RN #EE stated she did not remember Patient #1. RN EE explained that when a physician orders a patient to be placed on a '1013', lab tests are ordered, and the patient is medically cleared prior to the psychiatric evaluation. RN EE said that the psychiatric evaluation is completed by a psychiatric assessor either face to face or by telemedicine. RN EE went on to explain that the psychiatric assessor and the ED physician discuss the plan of treatment and determine whether the patient is to be transferred to an inpatient psychiatric facility or whether the '1013' can be rescinded. RN EE confirmed that the electronic medical record automatically time stamps all entries and late entries have the automatic time stamp and the time of the actual action.

A review of the facility's policy titled EMTALA-Georgia Medical Screening Examination and Stabilization Policy revised 2/13 revealed the purpose of the policy is to establish guidelines for providing appropriate medical screening examinations ("MSE") and any necessary stabilizing treatment or an appropriate transfer for the individual as required by the Emergency Medical Treatment and Labor Act (EMTALA ). The policy revealed an EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition, or a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition. An appropriate MSE, within the capabilities of the hospital's DED (including ancillary services routinely available and the availability of on-call physicians), shall be performed. The MSE must be completed by an individual qualified to perform such an examination to determine whether an emergency medical condition (EMC) exists. Qualified Medical Personnel. QMP may include licensed or certified clinical social workers, advanced practice registered nurses (APRNs), physician assistants (PAs), registered nurses, psychologists, and other professionals delineated as such in the hospital's governing bylaws if the scope of the EMC is within the individual's scope of practice. The individual shall be continuously monitored according to the individual's needs until it is determined whether the individual has an EMC, and if he or she does, until he or she is stabilized or appropriately admitted or transferred.

The hospital failed to provide an appropriate medical screening examination to determine Patient #1 was no longer in need of psychiatric care. When a transferring physician refused to accept Patient #1 the hospital discharged the patient home.

Based on review of medical records, Medical Staff Bylaws Rules and Regulations, staff interview, and policies, it was determined that the facility failed to provide necessary stabilizing treatment for Patient # 1's emergency psychiatric condition when she presented to the Emergency Department on 1/14/20 with complaints of auditory hallucinations and drug abuse.

FINDINGS:

MEDICAL RECORD 1/14/20

Review of Patient #1's Emergency Department (ED) visit on 1/14/2020, revealed the patient presented as a walk-in to the ED at 3:46 p.m. with psychiatric complaints at 4:25 p.m. Registered Nurse (RN) EE triaged Patient #1 as a level 2 emergent priority. RN EE noted that Patient #1 reported hearing voices since 2013 and that she needed Risperidone because she has been out of her medication since 2015. RN EE noted that Patient #1 reported that she just "chit chats with the voices". RN EE further noted that Patient #1 denied suicidal or homicidal ideations. RN EE changed Patient #1 to a level 3 urgent priority. RN EE noted that Patient #1 was currently hearing voices, had mood changes, and altered mental status.

At 5:39 p.m., Physician DD noted that Patient #1 reported hearing things. Physician DD noted that Patient #1 denied pain and reported that she had a history of schizophrenia (mental disorder characterized by delusions, hallucinations, and disorganized speech and behavior). Physician DD noted that Patient #1 reported not taking Risperidone (used to treat bipolar disorder) since 2015. The physician also noted that Patient #1 reported that the voices she was hearing told her to come to the ED to get Risperidone and that she was in the ED for a medication refill. Physician DD noted that when Patient #1 was questioned as to whether she follows up with a psychiatrist, the patient's "response did not make sense". In addition, Physician DD noted that Patient #1 denied any further complaints or symptoms and was constantly responding to internal stimuli. Physician DD noted that a review of system was negative with the exception of the patient hearing things. Physician DD noted that Patient #1 reported having no known drug allergies and no home medications. Physician DD also noted that Patient #1's physical examination was normal with the following exceptions: hearing and seeing things, abnormal judgement and insight, confused, flight of ideas, loose associations, delayed response to stimuli, and wandering thought process. Patient #1 was medically cleared for psych.

On 1/14/2020 at 5:36 p.m., Physician DD signed a 1013 (Georgia's form that allows a patient to be held for up to 72 hours when the patient has been determined to pose a threat to self or others by a medical professional) due to psychosis (mental disorder characterized by a disconnection from reality), erratic behavior (patients with bipolar disorder can have episodes of inflated self-esteem), delusions (false beliefs), paranoia (irrational fear), and aggressive behavior.
Review of Physician orders and lab results revealed the following:
--Urine Drug Screen - was positive for Amphetamine (stimulant),
--Suicide Risk Observation level - every 15-minutes Observations were documented from 1/14/2020 at 5:30 p.m. until 1/15/2020 at 12:15 p.m.,
--Behavioral Health Consult was completed on 1/14/2020 at 7:45 p.m.,

At 5:54 p.m., RN EE noted that Patient #1 was in a psychiatric room and that all environmental safety checks had been performed. The nurse noted that Patient #1 was confused and that the 1013 had been signed and implemented. In addition, documentation revealed video monitoring was initiated. At 5:58 p.m., Patient #1 signed the Consent for Treatment and receipt of Patient Rights information.

At 6:38 p.m., Physician DD noted that a re-evaluation of Patient #1 revealed the patient was awake, alert, and oriented, in no distress, and stable. The physician noted that Patient #1 was cleared medically and had been placed on a 1013 due to psychosis, agitation, aggressive behavior, delusions, paranoia, and hearing things.

On 1/14/20 at 7:20 p.m., a Licensed Professional Counselor (LPC) initiated a telehealth behavioral health assessment on Patient # 1. Patient # 1 reported she had not seen a mental health provider since 2013 and reported she had a history of schizophrenia. Patient # 1 admitted to daily use of methamphetamines (drug often used illegally as a stimulant and may be used as a prescription drug to treat narcolepsy and maintain blood pressure). Patient # 1 reported having auditory hallucinations. The Behavioral Health Assessment revealed Patient #1 reported not seeing a psychiatrist since 2013 for a history of Schizophrenia and that she needs her Risperidone tonight so she can go to Social Security and get disability. The assessor noted that Patient #1 reported living with a friend and that she occasionally used meth but was able to control usage. The LPC recommended transfer to an inpatient psychiatric unit. The findings were discussed with Medical Doctor (MD) DD. Telehealth report revealed the findings had been discussed with Medical Doctor (MD) DD. Patient # 1 was approved by MD DD to remain on a 1013. Patient #1 was disorganized, paranoid, guarded, and hearing voices.

On 1/14/20 at 7:47 p.m., nurses' notes revealed Patient # 1 was to remain on the 1013 and ED staff were working on finding an accepting facility.

At 10:26 p.m., physician notes revealed that the evening psychiatric rounds were made and that Patient #1's placement was pending.

On 1/15/2020 at 7:40 a.m., RN EE noted that Patient #1's suicide risks was moderate.
Environmental Patient Safety Checklist was completed by an RN and a Sitter on 1/15/2020 but there was no time noted.

At 9:58 a.m., RN EE noted that per the Psychiatric Physician at a psychiatric hospital (this physician had not evaluated the patient) Patient #1 did not meet the criteria for psychiatric inpatient status, did not need to be on a 1013, and could be discharged home with Risperidone and a follow-up.

At 11:56 a.m., Physician DD noted that Patient #1 was resting comfortably, and that the patient denied suicidal or homicidal ideations. In addition, Physician DD noted that Patient #1 denied any hallucinations and that she admitted to last using methamphetamines on 1/14/2020. Physician DD noted that she felt Patient #1 was safe to be discharged home and that the Licensed Professional Counselor was in agreement. Physician DD noted that she would restart Patient #1 on Risperidone, offer the patient a follow-up, and that Patient #1 was informed to return to the ED if symptoms worsened.

At 12:05 p.m., RN EE noted that the 1013 was rescinded. At 12:10 p.m., the nurse noted that Patient #1's belongings had been returned, and that the patient denied suicidal and homicidal ideations. RN EE further noted that Patient #1 was discharged home in a stable and improved condition. The discharge forms indicated Patient #1's discharge diagnoses were methamphetamine abuse and psychosis. RN EE noted that Patient #1 received written and verbal instructions regarding her diagnoses, lab results, substance abuse, need for follow-up, and when to return to the ED. RN EE also noted that a prescription was provided for Risperidone 0.5 milligrams 1 tablet by mouth every day. RN EE noted that Patient #1 verbalized understanding of discharge instructions including taking "medications as prescribed and to quit using meth".

The discharge forms were signed by Patient #1 on 1/15/20 at 12:10 p.m. RN EE noted that Patient #1 left the ED unaccompanied and that the patient's discharge vital signs were: pulse 88 and respirations 16.

MEDICAL STAFF
A review of the Medical Staff Bylaws, Rules and Regulations adopted 12/14/17 revealed the purposes and responsibilities of the Medical Staff are to provide a formal organizational structure through which the Medical Staff shall carry out its responsibilities and govern the professional activities of its members and other practitioners and to provide mechanisms for accountability of the Medical Staff to the Board of Trustees. All physicians appointed to the medical staff may be eligible to provide screening and stabilization according to delineation of clinical privileges.

STAFF INTERVIEWS:
During a telephone interview on 9/22/2020 at 3:50 p.m., Physician DD confirmed that she was working in the ED on 1/14/2020 during the day shift (Patient #1's second ED visit). Physician DD stated she does not remember Patient #1. Physician DD said that sometimes patients are held in the ED because they are aggressive. Physician DD stated these patients are placed on a 1013 for their safety. The physician said that patients being held in the ED are assessed twice a day for their safety. Physician DD explained that the ED physicians communicate with the psychiatric assessors to determine whether a patient needs to be transferred to an inpatient psychiatric facility or whether the 1013 can be rescinded and the patient discharged home. Physician DD explained that if the patient has calmed down and is cooperative when reassessed, the 1013 is rescinded.

During an interview on 9/23/2020 at 9:45 a.m., RN EE confirmed that she was working in the ED on 1/14/2020 from 7:00 a.m. to 7:00 p.m. (Patient #1's second ED visit). RN #EE stated she does not remember Patient #1. RN EE explained that when a physician orders a patient to be placed on a 1013, lab tests are ordered, and the patient is medically cleared prior to the psychiatric evaluation. RN EE said that the psychiatric evaluation is completed by a psychiatric assessor either face to face or by telemedicine. RN EE went on to explain that the psychiatric assessor and the ED physician discuss the plan of treatment and determine whether the patient is to be transferred to an inpatient psychiatric facility or whether the 1013 can be rescinded. RN EE confirmed that the electronic medical record automatically time stamps all entries and late entries have the automatic time stamp and the time of the actual action.

During an interview on 9/23/2020 at 12:40 p.m., ED Director AA confirmed that RN CC (nurse who provided care for Patient #1 during first visit) was on sick leave and unavailable for an interview. ED Director AA explained that discharge vital signs are time stamped with the time the nurse enters the data and not the actual time that the vital signs were taken. ED Director AA also explained that once Patient #1 was determined stable for discharge by Physician DD and a psychiatric assessor, the patient was discharged home in stable condition. ED Director AA said that if a patient needs assistance with transportation home, a Social Worker can help the patient make arrangements, but Patient #1 did not verbalize any discharge transportation needs.

POLICY REVIEW
A review of the facility's policy titled EMTALA-Georgia Medical Screening Examination and Stabilization Policy revised 2/13 revealed the purpose of the policy is to establish guidelines for providing appropriate medical screening examinations ("MSE") and any necessary stabilizing treatment or an appropriate transfer for the individual as required by the Emergency Medical Treatment and Labor Act (EMTALA ). The policy revealed an EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition, or a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition.

The individual shall be continuously monitored according to the individual's needs until it is determined whether the individual has an EMC, and if he or she does, until he or she is stabilized or appropriately admitted or transferred.
Stabilizing Treatment Within Hospital Capability. The determination of whether an individual is stable is not based on the clinical outcome of the individual's medical condition. An individual has been provided sufficient stabilizing treatment when, the physician treating the individual in the DED has determined within reasonable clinical confidence no material deterioration of the condition is likely, within reasonable medical probability.

The hospital failed to provide stabilizing treatment to Patient #1's psychiatric medical condition. When a physician refused to accept the patient as an inpatient, the hospital discharged the patient home.