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Based on medical record review, document review and staff interviews, the acute care hospital's administrative staff failed to ensure the Emergency Department (ED) staff followed the hospital's policies which required the hospital staff to arrange an appropriate transfer for 1 of 20 reviewed patients (Patient #1), who presented to the emergency department with a psychiatric emergency. Failure to follow the hospital's policy and arrange an appropriate transfer for patients who presented with a psychiatric emergency resulted in the hospital staff discharging Patient #1 to jail, jail staff at 2 separate jails refusing to take Patient #1 due to Patient #1's psychiatric medical condition, and ultimately a sheriff's deputy transporting Patient #1 to another hospital located almost 60 miles away. The acute care hospital administrative staff identified an average of 1,325 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of the policy "Transfer and Emergency Examination Policy (Emergency Medical Treatment and Labor Act - EMTALA)", effective 12/2019, revealed in part:

" ...request of 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 object of the Medical Screening Examination (MSE) is to determine whether an Emergency Medical Condition (EMC) exits."

"The medical record should reflect continued monitoring according to the individual's needs until it is determined whether the individual has an EMC and, if so, until he/she is stabilized or appropriately transferred."

"Psychiatric Stability. Psychiatric patients are considered stable when they are protected and prevented from injuring or harming themselves or others. The administration of chemical or physical restraints for purposes of transferring an individual from one facility to another may stabilize a psychiatric patient for a period of time and remove the immediate EMC but the underlying medical condition may persist and if not treated for longevity the patient may experience exacerbation of the EMC."

"Prior to discharging an individual seeking emergency medical services (except an individual with unstabilized EMC being transferred to another medical facility), a health care practitioner shall document in the individual's medical record that the individual is not an EMC, or the individual's EMC is Stabilized"



2. Review of Patient #1's medical record revealed the following:

a. On 12/14/21 at 11:07 PM, the ED staff documented that Patient #1 presented to the hospital, with a chief compliant of a psychiatric problem. Law Enforcement brought Patient #1 to the hospital after engaging in erratic and bizarre behavior. Per the Law Enforcement Officer, Patient #1's family indicated that Patient #1 was not taking their prescribed medications.

b. On 12/15/21 at 4:25 AM, ITP Psychiatric Nurse Practitioner (PNP) C (a nurse with advanced education in the treatment and management of patients with psychiatric problems) documented that Patient #1 was minimally cooperative while talking to ITP PNP C, answered most questions inappropriately, and did not follow a logical thought pattern. Patient #1 had paranoid thoughts about the intentions of the ED staff and ITP PNP C. Patient #1 was a danger to themselves. ITP PNP C felt Patient #1 required inpatient psychiatric hospitalization for further evaluation and stabilization.


c. On 12/15/21 at 5:05 AM, ED Physician A's documented that Patient #1 experienced bizarre behavior in the hours prior to presenting to the ED. Patient #1 drove from their house, went to a gas station, and the gas station staff found Patient #1 with their pants down. Patient #1 had picked up an unknown dog and claimed the dog belonged to Patient #1. Patient #1 was extremely agitated and aggressive. Patient #1 refused to provide any further information, as "it is none of your business."

ED Physician A further documented that Patient #1 was displaying bizarre behaviors and was extremely agitated. ED Physician A wanted ITP (a provider of tele-psychiatry services, which can assess psychiatric patients and attempt to find inpatient placement for patients) staff to assess Patient #1. In order for the ITP staff to assess Patient #1, ED Physician A ordered the ED staff to administer 20 mg of Geodon (a strong injectable medication used to calm down patients with schizophrenia), 50 mg of Benadryl (an injectable medication which is used to help patients sleep), and 62.5 mg of Ketamine (powerful medication used to sedate patients).

Patient #1 was extremely aggressive and was a threat to the staff and other patients in the ED. ED Physician A ordered the ED staff to discharge Patient #1 to Law Enforcement custody, with the intention of the Law Enforcement officer taking Patient #1 to jail, despite Patient #1's "extremely aggressive" behavior. ED Physician A would not order the ED staff or Law Enforcement staff to remove the handcuffs on Patient #1, due to the risk Patient #1 posed to the safety of the ED staff and patients.


d. On 12/15/21 at 5:03 AM, ED Physician A documented that the Law Enforcement staff could admit Patient #1 to jail.



3. During an interview on 12/28/21 at 4:05 PM, ED RN B revealed Patient #1 presented to the hospital in police custody. Sheriff's Deputy D brought Patient #1 to the hospital for a medical screening and psychiatric evaluation. Patient #1 frequently stood outside their ED room and yelled abusive language at the hospital ED staff. ED Physician A and Sheriff's Deputy D discussed taking Patient #1 to jail from the ED and that if Patient #1 left the hospital, Patient #1 would not cooperate with Sheriff's Deputy D. The only way that Patient #1 could stay at the hospital was if the ED staff chemically sedated Patient #1, and if they sedated Patient #1, Patient #1 could not participate in ITP PNP C's evaluation of Patient #1. ITP PNP C advised that Patient #1 needed inpatient mental health care.


4. During an interview on 12/28/21 at 5:00 PM, ED Physician A revealed Patient #1 presented to the ED in handcuffs. Patient #1 was violent and aggressively screaming in the ED. At the time of Patient #1's ED, the ED contained several other violent patients. Patient #1 was a danger to the ED staff and other patients, so ED Physician A asked Sheriff's Deputy D to stay with Patient #1. ED Physician A ordered the ED staff to administer Benadryl and Haldol (a potent antipsychotic used to help calm and sedate psychotic patients) to Patient #1 to attempt to calm Patient #1's violent and aggressive behavior. Despite the medications, Patient #1 was not safe for Sheriff's Deputy D to remove Patient #1's handcuffs.

ED Physician A then ordered the ED staff to administer droperidol (an antipsychotic medication used as a sedative) and ketamine. Despite the medication, Patient #1 still was aggressive and violent. ITP PNP C informed ED Physician A that Patient #1 required inpatient psychiatric care. ED Physician A decided, after consulting with Sheriff's Deputy D and ITP PNP C, to discharge Patient #1 to jail, while ITP PNP C attempted to find an inpatient psychiatric bed for Patient #1. Patient #1 presented a complex situation, and ED Physician A was afraid Patient #1 would assault the ED staff or another ED patient.


Please refer to A-2409 for additional information.

Based on document review and staff interviews, the acute care hospital's administrative staff failed to ensure the Emergency Department (ED) staff provided 1 of 20 reviewed patients (Patient #1), who presented to the emergency department, with an appropriate transfer. Failure to arrange an appropriate transfer for patients who presented with a psychiatric emergency resulted in the hospital staff discharging Patient #1 to jail, jail staff at 2 separate jails refusing to take Patient #1 due to Patient #1's psychiatric medical condition, and ultimately a sheriff's deputy transporting Patient #1 to another hospital located almost 60 miles away. The acute care hospital administrative staff identified an average of 1,325 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #1's medical record revealed the following:

a. On 12/14/21 at 11:07 PM, the ED staff documented that Patient #1 presented to the hospital, with a chief compliant of a psychiatric problem. Law Enforcement brought Patient #1 to the hospital after engaging in erratic and bizarre behavior. Per the Law Enforcement Officer, Patient #1's family indicated that Patient #1 was not taking their prescribed medications.

b. On 12/14/21 at 11:44 PM, ED RN B documented Patient# 1 was yelling abusive language towards staff and Patient #1 was in police custody.

c. On 12/15/21 at 12:56 AM, ED RN B documented Patient #1 was verbally aggressive, yelling loud enough to be heard throughout the ED and remained in police custody.

d. On 12/15/21 at 1:14 AM, ED RN B documented Patient #1 was yelling abusive language at the ED staff and remained in police custody.

e. On 12/15/21 at 5:05 AM, ED Registered Nurse (RN) B documented Patient #1 was yelling abusive language at the ED staff and remained in police custody (including handcuffs).

f. On 12/15/21 at 4:25 AM, ITP Psychiatric Nurse Practitioner (PNP) C (a nurse with advanced education in the treatment and management of patients with psychiatric problems) documented that Patient #1 was minimally cooperative while talking to ITP PNP C, answered most questions inappropriately, and did not follow a logical thought pattern. Patient #1 had paranoid thoughts about the intentions of the ED staff and ITP PNP C. Patient #1 was a danger to themselves. ITP PNP C felt Patient #1 required inpatient psychiatric hospitalization for further evaluation and stabilization.

g. On 12/15/21 at 5:05 AM, ED Physician A's documented that Patient #1 experienced bizarre behavior in the hours prior to presenting to the ED. Patient #1 drove from their house, went to a gas station, and the gas station staff found Patient #1 with their pants down. Patient #1 had picked up an unknown dog and claimed the dog belonged to Patient #1. Patient #1 was extremely agitated and aggressive. Patient #1 refused to provide any further information, as "it is none of your business."

ED Physician A further documented that Patient #1 was displaying bizarre behaviors and was extremely agitated. ED Physician A wanted ITP (a provider of tele-psychiatry services, which can assess psychiatric patients and attempt to find inpatient placement for patients) staff to assess Patient #1. In order for the ITP staff to assess Patient #1, ED Physician A ordered the ED staff to administer 20 mg of Geodon (a strong injectable medication used to calm down patients with schizophrenia), 50 mg of Benadryl (an injectable medication which is used to help patients sleep), and 62.5 mg of Ketamine (powerful injectiable medication used to sedate patients).

ED Physician A documented "Patient is extremely aggressive and is a threat to staff, and other patients in the entire ED. I will not order the removal of handcuffs for the safety of this ED." ED Physician A ordered the ED staff to discharge Patient #1 to Law Enforcement custody, with the intention of the Law Enforcement officer taking Patient #1 to jail, despite Patient #1's "extremely aggressive" behavior. ED Physician A would not order the ED staff or Law Enforcement staff to remove the handcuffs on Patient #1, due to the risk Patient #1 posed to the safety of the ED staff and patients.


h. On 12/15/21 at 5:03 AM, ED Physician A documented that the Law Enforcement staff could admit Patient #1 to jail.


2. During an interview on 12/28/21 at 4:05 PM, ED RN B revealed Patient #1 presented to the hospital in police custody. Sheriff's Deputy D brought Patient #1 to the hospital for a medical screening and psychiatric evaluation. Patient #1 frequently stood outside their ED room and yelled abusive language at the hospital ED staff. ED Physician A and Sheriff's Deputy D discussed taking Patient #1 to jail from the ED and that if Patient #1 left the hospital, Patient #1 would not cooperate with Sheriff's Deputy D. The only way that Patient #1 could stay at the hospital was if the ED staff chemically sedated Patient #1, and if they sedated Patient #1, Patient #1 could not participate in ITP PNP C's evaluation of Patient #1. ITP PNP C advised that Patient #1 needed inpatient mental health care.


3. During an interview on 12/28/21 at 5:00 PM, ED Physician A revealed Patient #1 presented to the ED in handcuffs. Patient #1 was violent and aggressively screaming in the ED. At the time of Patient #1's ED, the ED contained several other violent patients. Patient #1 was a danger to the ED staff and other patients, so ED Physician A asked Sheriff's Deputy D to stay with Patient #1. ED Physician A ordered the ED staff to administer Benadryl and Haldol (a potent antipsychotic used to help calm and sedate psychotic patients) to Patient #1 to attempt to calm Patient #1's violent and aggressive behavior. Despite the medications, Patient #1 was not safe for Sheriff's Deputy D to remove Patient #1's handcuffs.

ED Physician A then ordered the ED staff to administer droperidol (an antipsychotic medication used as a sedative) and ketamine. Despite the medication, Patient #1 still was aggressive and violent. ITP PNP C informed ED Physician A that Patient #1 required inpatient psychiatric care. ED Physician A decided, after consulting with Sheriff's Deputy D and ITP PNP C, to discharge Patient #1 to jail, while ITP PNP C attempted to find an inpatient psychiatric bed for Patient #1. Patient #1 presented a complex situation, and ED Physician A was afraid Patient #1 would assault the ED staff or another ED patient.

ED Physician A confirmed that the hospital staff did not attempt to arrange to hold Patient #1 against their will via an involuntary court committal.


4. During an interview on 12/28/21 at 5:30 PM, ITP PNP C revealed they assessed Patient #1 in the ED via tele-psychiatry (using a live video/audio meeting system to remotely examine a patient). Patient #1 did not want to cooperate with ITP PNP C's examination. Patient #1 was not safe to go out in public and required inpatient psychiatric care. ED Physician A told ITP PNP C that Patient #1 was very violent. ED Physician A asked about Patient #1 discharging to jail. ITP PNP C informed ED Physician A that ITP PNP C could only provide a consultation and that ED Physician A had to make the final discharge determination. However, Patient #1 required inpatient psychiatric care.

ED Physician A agreed Patient #1 needed inpatient psychiatric care, but the ED lacked the ability to deal with Patient #1's violence and aggression. ITP PNP C informed ED Physician A that Patient #1 needed hospitalization, but ED Physician A felt the ED staff was not equipped to handle Patient #1's violent behavior.


5. During an interview on 12/29/21 at 2:18 PM, Security Supervisor K revealed the the hospital had security staff members available to monitor Patient #1 during Patient #1's stay in the hospital's ED, in addition to Sheriff's Deputy D providing monitoring Patient #1. The security staff members and Sheriff's Deputy D were available to provide supervision to Patient #1, to ensure the safety of Patient #1 and other ED patients, until the hospital staff could arrange an appropriate transfer to another hospital. The hospital's security staff members received training in de-escallation techniques upon their hire with the hospital.


6. During an interview on 12/29/21 at 1:16 PM, Magistrate E revealed that Sheriff's Deputy D contacted Magistrate E regarding Patient #1. Patient #1 had become combative with Sheriff's Deputy D. The hospital ED staff did not want Patient #1 and the hospital was not equipped to handle Patient #1. Sheriff's Deputy D contacted Police Chief J. Police Chief J contacted Magistrate E and informed Magistrate E that Jail I and Jail H had refused to accept Patient #1. Police Chief J and Magistrate E decided that Sheriff's Deputy D should transport Patient #1 to Hospital G, as the UnityPoint Health - Marshalltown ED staff had refused to care for Patient #1.



7. Review of Hospital G's medical record revealed Patient #1 presented to the ED on 12/15/21 at 8:08 AM (approximately 3 hours after discharge from UnityPoint Health - Marshalltown) accompanied by Sheriff's Deputy D. Hospital G's ED provider documented that Patient #1 had recently been discharged from UnityPoint Health - Marshalltown's ED and that the Sheriff's Deputy felt the patient was having psychiatric issues that could not be dealt with at jail, so the officer contacted Magistrate E who instructed Sheriff's Deputy D to bring the patient to Hospital G. At 10:40 AM, Hospital G's ED provider contacted the on-call psychiatrist who ordered medications (Thorazine 100 mg injection) to help control the patient's psychotic symptoms, aggression and irrational behavior. At 12:15, PM Patient #1 was admitted to Hospital G's psychiatric unit and remained calm and sleepy after receiving the Thorazine injection.

Further review of Patient #1's medical record from Hospital G revealed that the staff at UnityPoint Health - Marshalltown had not contacted Hospital G to arrange an appropriate transfer prior to Patient #1's discharge from UnityPoint Health - Marshalltown's ED. UnityPoint Health - Marshalltown's medical record showed Patient # 1 presented to the ED in the company of Sheriff's Deputy D with an un-stabilized psychiatric emergency medical condition (EMC), with reports of erratic and bizarre behavior, and that Patient #1's family indicated Patient # 1 was "not taking [their] medication and [they are] really unstable." Patient #1's medical record from Hospital F indicated that the staff at UnityPoint Health - Marshalltown did not attempt to obtain an involuntary court committal for Patient #1. ITP PNP C examined Patient #1 while in UnityPoint Health - Marshalltown's ED and determined Patient #1 required inpatient hospitalization to treat acute psychosis, an EMC. Prior to arranging transfer to Hospital G (a facility with specialized psychiatric capabilities) to stabilize Patient #1's EMC, UnityPoint Health - Marshalltown staff discharge Patient #1 into the custody of Sheriff's Deputy D, with the intent on taking Patient #1 to jail with a prescription for oral medications Haldol (anti-psychotic), Ativan (anti-anxiety) and Benadryl (sedative) for sedation. The intramuscular medications Patient #1 received in UnityPoint Health - Marshalltown's ED did not control Patient #1's agitation, and there was no indication Patient #1's behavior could be safely controlled in a non-medical setting with oral medications. Discharging Patient #1 without medical professionals to treat this un-stabilized EMC placed Patient #1 at significant risk for further deterioration.