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Based on interview and record review, the facility failed to provide a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#7 and #8) of 20 Emergency Department (ED) patient records reviewed. The facility also failed to stabilize two patients (#1 and #12) with a psychiatric emergency, within its capacity and capability, of 20 ED patient records reviewed. The ED has an average of 2817 visits per month.

Please refer to A-2406 and A-2407 for details.

Based on interview and record review, the facility failed to provide a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#7 and #8) of 20 Emergency Department (ED) patient records reviewed. The ED has an average of 2817 visits per month.

Findings included:

1. Review of the facility's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)," dated 05/2016, showed that:
- A physician or nurse practitioner will perform a MSE on every patient presenting to the ED requesting emergency medical treatment in a uniform manner to determine if an EMC exists.
- If after the MSE, an EMC is deemed to exist, the hospital will provide medical treatment within its capacity and capabilities to stabilize that EMC.
- A patient is stable for discharge when (for psychiatric patients) it is determined the patient is no longer considered a threat to himself/herself or others.

2. Review of Patient #7's ED record showed he presented to the ED on 03/09/18 at 10:37 PM, with complaints of "feeling suicidal right now." Staff C, Registered Nurse (RN), documented that the patient felt hopeless and helpless because his wife wanted a divorce and thought she may be pregnant. Staff B, ED Physician, documented that the patient had a history of depression without previous thoughts of suicide, and when he asked the patient if he wanted to be admitted for psychiatric care or discharged with outpatient treatment and medication, and the patient chose to be discharged home. The patient was discharged at 11:33 PM, less than one hour after he arrived.

During an interview on 05/31/18 at 11:40 AM, Staff C, RN, stated that Patient #7 "had no tools to work though the situation." Staff C stated that psychiatric SW was on-call and available for evaluation, which was used from time to time when "they (the patients) say the right things." Staff C added that neither psychiatric SW nor the on-call psychiatrist were called in or consulted for Patient #7, and the patient was discharged.

During an interview on 05/31/18 at 12:54 PM, Staff D, ED Physician stated that Patient #7 had thoughts of suicide but Staff D didn't feel that the patient was at risk to himself. "I did not feel that he was suicidal. I believe that he was melancholy because his wife didn't want him anymore. He was feeling useless and not important to his wife." Staff D informed the patient that a local community behavioral health office offered walk-in clinics, prescribed the patient medications, and discharged the patient, who walked home. Staff D stated that he had the ability to consult with a psychiatrist but did not, that the only time psychiatric SW could be accessed after hours was for psychiatric transfers that required a 96 hour court ordered hold, and even if they were available, he would not have consulted them for Patient #7.

During an interview on 06/04/18 at 1:00 PM, Staff H, Psychiatrist, stated he was not consulted on Patient #7 when he came to the ED..

Review of a March 2018 Physician Call Coverage Schedule, showed that a psychiatrist was on-call and available to the ED on 03/09/18. A note at the bottom of the call schedule showed that Staff H, Psychiatrist, could be contacted for emergencies.

Review of a Psychiatric SW schedule showed that a SW was on-call and available to the ED on 03/09/18.

3. Review of court documents showed that on 03/19/18, an application for evaluation was obtained for Patient #8, after the patient obtained injuries that were not present prior to his placement in an isolated cell (indicates they were self-inflicted), and then spread feces on his wounds and stated it was a process for healing. A court-ordered 96-hour detention was issued for Patient #8 to be detained, evaluated and treated for up to 96 hours by the local hospital, unless further detention and treatment was necessary.

Review of Patient #8's ED record, showed he presented to the ED on 03/22/18 at 10:50 AM, in custody from a local jail with a 96-hour court-ordered hold. The patient had a psychiatric history of depression with patient reported psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), and intermittent "strange behavior" for the previous two weeks while incarcerated. He refused food or drink and would not sleep while he was in the "hole" (isolated jail cell), and would insert his finger into his rectum and wipe feces on himself. Staff E, Advanced Practice Registered Nurse-Certified Nurse Practitioner (APRN-CNP), did not find the patient to be suicidal, homicidal or psychotic, and documented that jail staff escorts were informed that it may be a long wait to admit the patient to the behavioral health unit, and instructed them that one of the jail staff would need to stay with the patient until admission occurred. Staff E further documented that jail staff contacted their supervisor and chose to leave with the patient, who was fit for confinement (absence of a medical or psychiatric emergency).

During an interview on 05/31/18 at 10:17 AM, Staff I, ED RN stated that Patient #8 was upset and had made some comments while in jail about suicide, and had placed his finger in his rectum and wiped feces on himself. The patient was not evaluated by a psychiatric SW or psychiatrist. and was discharged to jail staff to return another time for further care. "Apparently this happens frequently at night. They will send patients with 96 hour holds back to jail." Staff I was unaware if the patient ever returned for inpatient psychiatric care.

During an interview on 06/05/18 at 9:24 AM, County Jail Administrator J, stated that Patient #8 was evaluated at the hospital ED, and "they sent him back. He never received inpatient (psychiatric) care."

During an interview on 05/31/18 at 1:51 PM, Staff E, APRN-CNP, stated that Patient #8 presented to the ED from jail, with a 96-hour court-ordered hold, a history of depression and substance abuse, as well as patient reported psychosis (abnormal thinking and perceptions). The patient had been in solitary ("the hole", isolated cell), and while in solitary, refused to eat, drink or take his medications, and had spread feces on himself. Staff E stated that she did not believe the patient was actively psychotic, suicidal or homicidal, but needed to see a psychiatrist. There wasn't an available bed on the behavioral health unit, "we were busy," and didn't know how long it would be before a psychiatric bed was available for the patient, so the patient was discharged and the jail staff took the patient back to jail. The patient was not seen by the on-call psychiatrist or psychiatric SW, and Staff E did not know if the patient was ever returned to the hospital for psychiatric care. Staff E added that ED physicians and APRN-CNPs could evaluate psychiatric patients and override a 96-hour court-ordered hold, but she did not override Patient #8's.

During an interview on 05/31/18 at 12:20 PM, Staff J, ED Physician, stated that he saw Patient #8, who was confused, but was not psychotic. "We decided that he needed psychiatric help, but they (jail staff) wanted to take him (back to jail). They have secure facilities, specialized area that is safe ....He would be safe in the area that he was going to." Staff J stated that ED Physicians could fulfill a psychiatric evaluation for a 96-hour court-ordered hold, but other times, it required more evaluation than just the ED Physician. Staff J added that the facility had psychiatric SW that could be utilized, or the on-call psychiatrist.

During an interview on 06/04/18 at 1:00 PM, Staff H, Psychiatrist, stated that:
- When Patient #8 came to the ED under a 96-hour hold, the fact that there was not an available bed at the time shouldn't matter, and that jail staff could have stayed with the patient until he was place in the locked unit.
- Ideally, it was "best to bring everyone into the psychiatric unit."
- Psychiatric SW or the on-call psychiatrist were available for consult.

Review of a Psychiatric SW schedule showed that a SW was on-call and available to the ED on 03/22/18.

Review of a March 2018 Physician Call Coverage Schedule, showed that a psychiatrist was on-call and available to the ED on 03/22/18.

The facility failed to provide an appropriate MSE to Patients #7 and #8, when they failed to utilize psychiatric SW and/or and on-call psychiatrist, in the evaluation of patients who presented with psychiatric presentation.

2407
Based on interview and record review, the failed to stabilize two patients (#1 and #12) with a psychiatric emergencies, within its capability and capacity, of 20 Emergency Department (ED) patient records reviewed. The ED has an average of 2817 visits per month.

Findings included:

1. Review of the facility's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)," dated 05/2016, showed that:
- A physician or nurse practitioner will perform a Medical Screening Examination (MSE) on every patient presenting to the ED requesting emergency medical treatment in a uniform manner to determine if an EMC exists.
- If after the MSE, an Emergency Medical Condition (EMC) is deemed to exist, the hospital will provide medical treatment within its capacity and capabilities to stabilize that EMC.
- The ED can provide the patient with treatment necessary to stabilize the condition, the hospital can admit the patient as an inpatient for further stabilizing care or if unable to stabilize the patient, can transfer the patient appropriately to a facility that has the capability to stabilize the patient.
- A patient is stable for discharge when (for psychiatric patients) it is determined the patient is no longer considered a threat to himself/herself or others.

2. Review of a police report showed that on 05/25/18, law enforcement responded to a residence after Patient #1 was reported to have broken a window, used the glass to cut his wrist and took a handful of pills. The patient was transported to the ED.

Review of Patient #1's ED record, showed that he presented to the ED by law enforcement on 05/25/18 at 10:28 AM, after reported ingestion of unknown medications. Staff E, Advance Practice Registered Nurse-Certified Nurse Practitioner (APRN-CNP) documented that the patient had a history of bipolar disorder (unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks) and attention deficit hyperactivity disorder (inattention and/or hyperactivity-impulsivity that interferes with functioning or development) and had not taken his psychiatric medication for one year. The patient had multiple, horizontal, superficial (top layers of the skin) abrasions (scrapes) to the right forearm, was anxious, labile (easily fluctuating behaviors) with rapid, pressured speech (fast, erratic and difficult to interrupt or understand), and had suicidal thoughts with a plan. The patient was assigned an inpatient psychiatric room and awaited admission, when the patient eloped at 6:53 PM, from the ED.

Review of a Daily Staff Log dated 05/25/18, showed that there were three Psychiatric Unit admissions throughout the day.

Review of a form titled, "Documentation Request from the Department of Health," showed that Patient #1 was admitted to one of the inpatient psychiatric beds, and during nurse to nurse report, was when the patient eloped.

During an interview on 05/31/18 at 1:34 PM, Staff E, APRN-CNP stated that Patient #1 had two self-inflicted abrasions to his right forearm and had ingested pills. The patient had a psychiatric history, was inconsistent in events that had occurred, his speech was pressured, he was anxious and Staff E determined the patient needed to be admitted for inpatient psychiatric care. A 96-hour court-ordered hold was signed by a judge while the patient remained in the ED, so law enforcement left the patient, and the patient eloped from the ED prior to placement in the psychiatric unit.

Review of the facility's policy titled, "Emergency Department Suicidal Risk Assessment and Intervention Guidelines," dated 03/2018, showed that a patient who has been identified on the suicide risk assessment as currently having suicidal ideation, has a plan to harm self, or has already made an attempt to harm self and who has been determined to be in immediate danger of harming self, should be observed 1:1 (one staff member assigned to one patient) within arm's reach. Observation is continuous and patients will be no further than arm's length of reach by a single identified person at all times.

During an interview on 05/31/18 at 12:20 PM, Staff J, ED Physician, stated that Patient #1 came in with psychosis and suicidal thoughts, and eloped. Staff J stated "I think it would have been very difficult to keep the patient in here," but confirmed that the patient was not monitored 1:1.

During an interview on 05/31/18 at 10:48 AM, Staff F, ED Registered Nurse (RN) and Charge Nurse, stated that Patient #1 was agitated, argumentative with law enforcement, and rubbed his feet back and forth on the ED floor to make high pitched screeching noises. He had superficial scratches on his wrist, and requested several times to leave, but Staff F never expected the patient to elope, even though he repeatedly asked if he could leave. Staff F added that since the patient wasn't a "huge suicidal risk," he was not monitored 1:1, but if he was an immediate danger to himself, then he would have been monitored by someone continuously within arm's length.

Review of Patient #1's ED record showed that the patient was returned to the ED on 05/26/18 at 9:13 AM (14 hours after he eloped) and admitted under the 96-hour court-ordered hold for severe major depression. A History and Physical dated 05/26/18, completed sometime before 6:25 PM, showed that when the patient was admitted, he was placed on suicide precautions.

3. Review of Patient #12's ED record, showed she presented to the ED on 01/07/18 at 1:12 PM, with thoughts of suicide and cuts to her inner forearm from a kitchen knife. Staff A, ED Physician, documented that the patient had been treated for depression for two years, with medication changes two weeks ago. The patient felt hopeless and depressed, wanted to die, and did not feel safe home alone. Intake Assessor (corporate-wide staff who facilitate bed placement throughout all sister facilities, located off-site) L, documented that although there was not a psychiatric bed in the facility, there was one at a sister facility (would require transfer). Staff A documented that since there were no available psychiatric beds to admit the patient to, the patient was discharged home "in stable condition."

During an interview on 06/04/18 at 3:02 PM, Staff A stated that Patient #12 had been treated for depression for several years, did not feel better after recent psychiatric medication changes, had cut her wrists a few days before she came to the ED, and he wasn't sure if she needed inpatient psychiatric care. The patient contracted for safety and was discharged to her mother.

During an interview on 05/31/18 at 12:54 PM, Staff D, ED Physician, stated that if a patient was on medication or if there was an increase in the dosage and it did not help, or they were getting worse, then the patient had failed outpatient therapy and should be admitted.

During an interview on 06/04/18 at 9:40 AM, Staff B, RN stated it wasn't typical for a patient to be discharged home after they stated they wanted to die, and if a patient verbalized that they were suicidal and were voluntary, they could not go home.

During an interview on 06/04/18 at 1:00 PM, Staff H, Psychiatrist, stated, "If she (Patient #12) was suicidal with a plan, she cannot go home, and if she was insisting on going home, then I would pursue a 96-hour hold."

The facility failed to stabilize Patients #1 and #12's psychiatric emergencies within the capability and capacity of the hospital. Patient #1 should have been monitored 1:1 to prevent elopement so that the patient could be stabilized, and Patient #12 should have been transferred to a sister facility with available inpatient psychiatric beds for stabilization.