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Based on review of medical records, policies and procedures, ambulance report and interviews, it was determined that the facility failed to provide an appropriate medical screening exam that was within the hospital ' s capabilities prior to discharging an individual with an unstable psychiatric emergency condition on her second emergency department visit for 1 (#15)of 20 sampled patients. Refer to findings in Tag A-2406.


Based on review of policy and procedure, facility rules and regulations, medical records, and interviews, it was determined that the facility failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required prior to discharge in order to stabilize the emergency psychiatric condition of 1 (#15) of 20-sampled patients. Refer to findings in Tag 2407.

Based on review of medical records, policies and procedures, ambulance report and interviews, it was determined that the facility failed to provide an appropriate medical screening exam that was within the hospital 's capabilities prior to discharging an individual with an unstable psychiatric emergency condition on her second emergency department visit for 1 (#15) of 20 sampled patients.


Findings include:

The Emergency Department (ED) Nurse documented on 8/4/2015 at 11:14 p.m. that patient #15 reported that she had been at Grady Memorial Hospital on the previous night and wanted to go to a rehabilitation facility. The patient also reported a history of Bipolar disorder and " Endorses SI/HI (suicidal ideation -thoughts of wanting to kill oneself)/homicidal ideations (thoughts of harming others)/ hallucinations. The patient was alert and oriented and vital signs (heart rate, blood pressure, and respirations) were stable. The ED nurse also documented that the patient was placed on 1 on 1 observation (a person sitting or standing in direct sight or in arms reach observing a patient). The ED nurse documented on 12/05/2015 at 12 midnight that patient #15 was agitated and rude, and " yelling intermittently " at the staff , " stating that she wants to leave one minute then next stating that ...y ' all don ' t do nothing for me. " The Licensed Mental Health Clinician (LMHC) documented on 8/5/2015 at 12:09 a.m., that the LMHC attempted to engage (to talk) with patient #15 to assess for her psychiatric needs and other presenting issues. Further documentation by the LMHC revealed that the patient exhibited agitation and refused to speak with the LMHC. The LMHC documented " Please refer to Psych (Psychiatric) resident ' s note for assessment and disposition. " Documentation by the attending ED physician on 8/5/2016 at 12:32 a.m. indicated in part, " Upon co-signature of the ED provider note, I attest that I have seen the patient face- to -face encounter and have participated in all supervisory aspects of the care of this patient for this visit ...58 y.o. (year old) ... here likely for secondary gain. Second visit in ECC (Emergency Care Center) today. No acute medical complaints. .. Risk ...Number of Diagnosis and Management Options: The number of diagnosis and mgmt. (management) options is extensive because the pt (patient) has a new problem requiring additional workup. " Review of Psychiatry Resident note dated 8/65/2015 at 12:56 a.m. revealed in part, " History of Present Illness ... presented herself to Grady with SI without a plan ...On assessment, patient is irritable, uncooperative with linear (straight, direct) thoughts. She is loud at times, screaming " Angels " and " Demons " . Patient endorses AH (auditory Hallucinations- hearing voices instructing one to act in specific ways) states " I hear my mother telling me to kill myself " ... she is vague about whether she wants treatments for her addiction. Patient is homeless ...she has taken Depakote (used to treat manic episodes related to Bipolar disorder) and Zyprexa (medication to treat psychotic symptoms) in the past has not taken her medications in several years. " The section titled " Medical Decision Making " indicated in part, " Patient ...with Cocaine Use Disorder, SIMD (Substance Induced Mood Disorder) with SI in the context of psychosocial stressors, primarily homelessness ...Denied SI/HI, reported AH, but did not appear distressed...has mild chronic elevated risk of suicide given homelessness ...but low acute risk of suicide as she presents herself for treatment and participate in treatment plan ...Patient should be discharged to self with appropriate SAC (Substance Abuse Center) resources and follow -up at mental health clinic .....Medical UDS (urine Drug screen) +(positive) Cocaine 8/3 (first visit) ...Psychiatric: 1.SIMD; 2.Cocaine Disorder, severe; 3. BPD 1, by history-No Indication for 1013( a classification for a patient needing emergency in-patient mental health treatment), at this time, ...no reason to send to CIS (Crisis Intervention Services); Discussed OP (out-patient) follow-up at a drug dependence program for OP medication titration ... "


Review of the ambulance report (Pre-hospital Care Report Summary) dated 8/5/2015, revealed that the EMS unit responded to Grady Hospital at 01:29 a.m., " PSYCHIATRIC/ABNORMAL BEHAVIOR/SUICIDE ATTEMPT THREATENING SUICIDE. " ... Subjective: Significant weight loss ...Pt states she is losing a too much weight and making her go crazy. Pt (#15) states that she feels stressed ... Events leading up to: Pt. states she was discharged from Grady Hospital. ...Pt states that she has been losing a lot of weight and that Grady does not want to treat her properly ... " ...I think something is wrong. " Pt appears rather calm and agrees to transport to another acute care hospital. "

The medical record from the acute care hospital where Patient #15 was transported to was reviewed, and revealed that Patient #15 arrived to the other acute care hospital on 8/5/2015 at 2:12 am. The patient ' s arrival complaint was " Suicidal. " Further review indicated that a Suicide Risk assessment was completed on 8/5/2016 at 2:45 a.m. The patient ' s suicide risk was listed as a high risk, " Greater than 100. " The suicide interventions were to notify the Medical Doctor, Consult Psych assessment team, remove the patient ' s gown and place Patient #15 in direct observation. A urine drug screen and urinalysis laboratory tests were ordered. The LAPC-NC documented that a Mental Health Evaluation was completed (11:48 am-12-55 pm) and patient #15 was calm during time of contact and was nonthreatening. Continued review revealed that the patient was seeking in-patient treatment for substance abuse treatment. The mental health evaluator documented that the patient was informed that she would be sent to both mental health and substance abuse. The patient reported to the mental health evaluator that she did have SI but no plan; and homicidal ideations toward the people in her neighborhood. The patient ' s homicidal ideation was listed as, " if they ever angered me, I would think about stabbing them." The ED physician documented at 5:00 p.m. that laboratory results and transfer to a psychiatric hospital were pending. The results of the laboratory tests were listed as positive for cocaine. Patient #15's "Clinical Impression" Suicidal thoughts, Lower Urinary Tract Infection and Bipolar Disorder. During patient #15 ' s stay at the hospital face to face assessments were completed daily by the ED Physician. The patient was 1013 ' d on 8/6/2015 at 3:32 a.m.
Patient #15 's disposition was listed as transferred on 8/7/2015 to a Behavioral Health facility for mental health and substance abuse treatment.

An interview was conducted on 8/18/2015 at 10:10 a.m., with the Registered Nurse (RN) #15 who provided care for patient #15 when she presented to the ED on 8/4/2015. RN #15 She also stated that Patient (#15) did complain of weight loss. In reviewing the chart, RN#15 stated that apparently the Behavioral Resident had seen the patient on the first visit when the patient was in the Red Zone. RN#15 stated that he/she attempted to do discharge education. The patient was screaming loudly and threw the discharge papers in RN #15's face, and that resource information had previously been given to patient #15. All patients are given mental health information/crisis line. He/She stated that the patient was mean to everyone and refused help.

An interview was conducted on 08/18/2015 at 10:20 a.m. via telephone with the Psychiatric Resident (Employee #5), who has been employed at the facility for two (2) months and works between the psychiatric unit and the Emergency Department. The physician recalled the patient and stated that she/he did the initial assessment. She/he stated the patient was irritable, uncooperative and requested help for substance abuse. Psychiatric Resident (Employee #5) further stated that on the patient's discharge he/she gave the patient a list of resources, the name of a drug dependence program, and a prescription for Depakote. The patient was bipolar, not manic or psychotic, was uncooperative but pleasant. She/he did not order any special observations, the patient did not meet 1013. There was no threat to harm self or others, the patient was able to care for herself. She/he stated that he/she approved the patient for discharge and the ED attending physician co-signed.


Review of facility policy entitled, " EMTALA - Medical Screening, Treatment, Examination Central log On call Coverage, and Signage, " with an origination date 04/2015, revealed that any person who came to the hospital for examination or treatment would receive an appropriate medical screening examination within the capacities of the Hospital, including the use of ancillary services, to determine whether the patient had an emergency medical condition.
Review of the facility ' s Policy and Procedure entitled, " General EMTALA Definitions and Requirements with an origination date April 2015, revealed in part, " Emergency Medical Condition ( " EMC " ) means ...3. With respect to an individual with psychiatric symptoms: a. that acute psychiatric or acute substance abuse symptoms are manifested by; or b. that individuals are expressing suicidal or homicidal thoughts or gestures and are determined to be danger to self or others. "

Based on the above findings, the facility failed to ensure that an appropriate Medical Screening Examination was provided as Patient #15 presented to Grady Memorial Hospital on 8/4/2015 with stated complaints of suicidal ideations and auditory hallucinations. Patient #15 was discharged from the ED on 8/5/2015 in a disruptive and psychotic condition.

Based on review of policy and procedure, facility rules and regulations, medical records, and interviews, it was determined that the facility failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required prior to discharge in order to stabilize the emergency psychiatric condition of 1 (#15) of 20-sampled patients.

Findings include:

Review of facility policy entitled " EMTALA - Medical Screening, Treatment, Examination Central log, On call Coverage , and Signage origination date 04/2015 revealed in part, " Establishing Medical Stabilization. The determination of whether an individual is stable is not based on the clinical outcome of the individual ' s medical condition ... Stable for discharge ...The EMC (emergency medical condition) that caused the individual to present to the ED must be resolved. "
The facility ' s Medical Staff Rules and Regulations, dated April 9, 2015, directed the following: Determination of whether a patient should be admitted or provided treatment on an outpatient basis is left to the discretion of the examining physician with consultation. For protection of the patient and the medical and nursing staff, care should be taken to meet the needs for psychiatric treatment of the potentially suicidal patient. The Attending of such patient should, whenever indicated, request admission of such patient to the psychiatric services or consultation from a psychiatric or a behavioral Health Clinician.

Documentation in the medical record indicated that Patient #15 returned to the ED a second time on 08/04/2015 at 11:14 p.m. Review of the medical record revealed that Patient #15 reported that she was at the facility the night before and wanted to be sent to a rehab facility, has a history of bipolar and endorses suicidal ideations [Thoughts]/homicidal ideations [thoughts]/hallucinations.
On 08/05/2015 at 1200 a.m., the record indicated that the patient was agitated and rude, yelling at everyone intermittently, stating that he/she wanted to leave one minute, then the next stating that "this hospital sucks and y'all don't do nothing for me." On 08/05/2012 at 12:56 a.m., the Psychiatric Resident (Credentialing file#5) documented that the patient was irritable, uncooperative, with linear (straight, direct) thoughts, the patient was loud at times, screaming " Angels and Demons! ", endorsed auditory hallucinations (hearing voices) " I hear my mother telling me to kill myself." reported vague previous suicide attempt, took a bottle of sleeping pills; active cocaine use, with most recent use yesterday. The patient is vague about whether she wants treatment for her addiction. He patient reports she has a history of bipolar disease and has taken Depakote (medication to treatment mania or hyperactivity associated with symptoms of mental illness) and Zyprexa (medication to treat psychotic symptoms of mental illness) in the past but has not taken her medications in several years. She denies symptoms of mania. Patient reports previous physical abuse history from mother as a child, endorses nightmares, avoidance, hallucinations. The note indicates that the patient was positive for suicidal ideas. Resident #5 further noted: On assessment, the patient ' s appearance was disheveled, mood: "I need medicine, thought content linear, future oriented, thought content: Hallucinations endorsed, denied delusions, denied suicidal and homicidal ideations. Patient's final diagnosis: SIMD (substance induced mood disorder), cocaine use disorder: severe, bipolar disorder, by history. The note further indicated the patient's condition was noted as; stable and unchanged. The attending ED physician #6 endorsed (counter signed) the discharge order. On 8/5/2015 12:12 am LCP noted: MHC attempted to engage (talk to) the patient. The psychiatric assessment notes: Patient exhibits agitation and refuses to speak with LMHC (Licensed Mental Health Clinician)-(Same as LCP) Documentation in the medical record on 8/05/2015 at 12:32 a.m. noted: 58 year old female here for likely secondary gain. Second visit in ER today. No acute medical complaints. Patient #15 ' s risk level was recorded as " high " because they have a severe exacerbation, progression, or side effect of treatment of a chronic illness or they have an acute illness or injury that poses a threat to life or physiologic function. The note further indicated, number of diagnosis and management options: the number of diagnosis and management options is extensive because the patient had a new problem requiring additional workups. Complexity of medical decision making: given the above information the complexity of medical decision making is high.

8/18/2015 at 10:10 a.m., in the Conference room: Interview: RN#15 was the nurse and did remember this patient. States that he/she was confused because patient had just been there earlier in the day for a medical discharge. Stated he/she always checks for previous visit and any tests done so as not to repeat the tests. The patient had come back (2nd visit) with complaint of SI and HI. During the interview, RN#15 said that patient (#15) stated that the hospital did not do anything for her. RN #15 stated that the patient said that she wanted to go to drug rehab. The patient refused to talk with the Licensed Mental Health Clinician (LMHC) (Same as Mental Health Clinician). The LMHC would have been the one to help the patient get into drug rehab program but patient would not cooperate. He/she reported that the patient stated that she had recently smoked crack. Staff questioned whether this was this a mental health issue or a drug issue. The patient did verbalize SI/HI but refused to talk to staff. When the patient was asked if she had a plan, Patient #15 just continued to reply SI/HI. RN # 15 stated that she/he believed Patient #15 was there for secondary gain to stay in the hospital. She also stated that Patient #15 was seen by a psychiatric resident, a medical Dr (ER MD), and a LMHC. RN #15 further stated that it was determined that patient #15 did not meet criteria for a 1013 admission. RN #15 recalled that the entire time the patient was in the psychiatric observational area (BODICE), she was under close observation being watched by a Nurse, LPC, Mental Health Assistant (HA), and, a special observation tech. RN#15 felt that the patient was there for secondary gain and that she did not feel uncomfortable with the decision for the patient to go home. Discharge was set by Resident #5, psychiatric resident and co-signed by ED attending physician (# 6). On 08/05/2015, while still in the vicinity of the facility, the patient called an ambulance and was taken to a local hospital where she/he was examined, treated and transferred to a psychiatric treatment facility.

An interview was conducted on 08/18/2015 at 10:20 a.m., via telephone with the Psychiatric Resident (#5) who has been employed at the facility for two (2) months and works between the psychiatric unit and the ED. The Psychiatric Resident (#5) recalled the patient and stated that she/he did the initial assessment. She/he stated the patient was irritable, uncooperative and requested help for substance abuse. Resident #5 further stated that on the patient's discharge he/she gave the patient a list of resources, program Park Place (main drug dependence program). The patient was bipolar, not manic or psychotic, was uncooperative but pleasant. She/he did not order any special observations, and the patient did not meet 1013 requirements (a classification for a patient needing emergency in-patient mental health treatment). There was no threat to harm self or others, the patient was able to care for herself. He/she stated that he/she approved the patient for discharge, and the ED attending physician co-signed. The Psychiartic Resident #5 further stated that he/she reviewed labs, CT, and a hip x-ray. He/she felt that the patient was trying to get admitted and had no acute psychiatric events. He/she further stated the patient walked out without complaints.

Interview with the attending ED physician (Credentialing file #6) an on 08/18/2015 at 11:30 a.m. in a conference room, physician #6 stated that he/she had a brief encounter with the patient. The (Psychiatric) resident (doctor #5) presented the patient to him/her. He/she stated that the patient stood on the bed, yelling, was sensible during conversation, followed directions easily. The attending ED physician further stated that he/she read the note and saw that the patient initially complained of suicidal ideations (SI/HI) but he didn't hear the patient say that. That day the patient was calm and conversational. ED physician did an assessment on the patient, and the patient denied SI/HI and delusions, denied medical problems and was fine. The ED physician stated he/she assessed the patient's heart, lungs, they were fine, documented immediately, but did not ' sign the note right away. The next day he/she read the note and signed it. He/She also stated the Psychiatric Resident was involved and saw no issues with the patient. The Psychiatric Resident # 5 clicked discharge in the computer and he cosigned it to discharge the patient. Later he stated he read that the patient was agitated. "When I told the patient she was going home the patient was disrupting the other people in the room in the ER. "

Licensed Professional Counselor (LPC) #14 was interviewed on 08/18/2015 at 2:10 PM in the conference room. He/she recalled that patient (#15) was in 407 in the Behavioral Observation area. The LPC related that he/she went to assess the patient to determine risk to self and others and to assess the patient's history and any psychiatric needs. He/she further stated the patient was in bed with head covered (Same as MHC-Mental health Counselor). "The patient was not interested in talking to me and said go and talk to the Physician". The LPC stated that during an assessment she/he tried to see what she/he can do to help the patient. "This patient was very loud and did not express any suicidal ideations (thoughts of harming his/herself) or homicidal ideations" (thoughts of harming others). The LPC stated that had the patient expressed SI/HI then she/he would have insisted on having the patient stay at the hospital. He/she stated that there was no need to have the patient on special observation (when a patient is watched closely). The patient was more interested in sleeping. She/he stated that the LPC's role in discharge was to do assessments and make recommendations, and try to help a patient with psychiatric needs. He/she would have been the one to have helped Patient (#15) with getting into a drug and alcohol rehab, but the patient was not cooperative and would not say what her needs were or answer questions.

The facility failed to ensure that stabilizing treatment was provided as required for Patient #15 on 8/5/2015 as evidenced by discharging the patient with psychosis and auditory hallucinations. Patient #15 was not stable for discharge. The patient was discharged from Grady Memorial Hospital and then presented to another acute care facility and was admitted because of suicidal ideations.