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Based on interview, record review of Emergency Department (ED) and Obstetric (OB) logs, policy review, 72 hour returns to the ED, medical record review, complaint and grievance logs, staffing, and physician on-call schedules, the hospital failed to provide a medical screening examination (MSE) sufficient to determine the presence of a medical and or psychological emergency, within its capacity and capability, for one patient (#14) who presented to the Emergency Department (ED) with suicidal ideations. The ED had an average of 2,277 emergency visits per month.

The hospital had the capabilities and capacity, including the use of tele-psychiatry to provide a medical screening examination sufficient to determine whether an emergency medical condition existed, prior to discharging patient #14.

Please refer to A2406 for details.



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Based on record review and interview, the hospital failed to provide a medical screening examination (MSE) sufficient to determine the presence of a medical and or psychological emergency, within its capacity and capability, for one patient (#14) who presented to the Emergency Department (ED) with suicidal ideations (thoughts of killing self). A total of 23 patient ED records were reviewed out of a sample selected from November 21 through December 19, 2016. The ED had an average of 2,277 emergency visits per month.

Findings included:

1. Record review of the facility's policy titled, "Mental health Screening Examination in the Emergency Department," dated 11/08/16, showed:
- Psychiatric patients (behavioral health conditions) expressing suicidal gestures, if determined dangerous to self or others, are considered to have an Emergency Medical Condition (EMC).
- A mental health screening examination (MHSE) is performed on psychiatric patients to determine if an EMC exists.
- The ED Physician will evaluate the patient and determine the need for an additional MHSE.
- If the ED Physician determines additional mental health screening is indicated, it may be provided by other Qualified Medical Personnel (QMP) including social workers, clinical psychologists, and psychiatric evaluation nurses (PEN, evaluate through telemedicine) or psychiatrist.

2. The hospital's capabilities include seven psychiatrists with telepsychiatry (ability to perform a psychiatric assessment or examination by audio and video communication) capabilities, appointed to the hospital's medical staff on 11/08/16.

3. Record review of Patient #14's discharged medical record showed the 15 year old patient presented to the ED by Law Enforcement on 12/02/16 at 9:50 PM, with an affidavit, complaining of alleged sexual abuse and suicidal ideation. Staff I, ED Charge Nurse, documented that the patient was at risk for suicide, after the patient reported she had thoughts of killing herself within the past week. Staff F, ED Physician, examined the patient, who exhibited a depressed mood, reported she had been sexually abused for the past three weeks, and "is thinking about suicide". ED physician F documented that patient's history included depression and three weeks prior a transfer from Mercy Hospital-Lebanon ED to Psychiatric Hospital B for a mental health evaluation for suicidal ideations. ED Physician F determined Patient #14 required a psychiatric examination as evidenced by documentation in the medical record indicating a call placed to Psychiatric Hospital B to arrange for a transfer. Prior to arranging a transfer for examination and treatment at Psychiatric Hospital B, ED Physician F wrote orders to discharge Patient #14. The discharge plan was for the State's case worker to take the patient to Hospital C for a sexual assault exam by a pediatric Sexual Assault Nurse Examiner.


During an interview on 12/20/16 at 8:20 pm, ED physician F stated he was responsible for determining and stabilizing medical and psychiatric emergencies, and believed patient # 14 needed inpatient psychiatric care. ED physician F stated he did not know if patient # 14 received psychiatric care or what happened to the patient after she was discharged from the ED, and should have made sure DFS was aware that patient # 14 needed more care for her suicidal ideations.

During a telephone interview on 12/21/16 at 9:55 am, Law Enforcement Officer (LEO) L stated that patient # 14 was very distraught and upset, and found at a friend ' s home after she jumped out of a moving vehicle. LEO L stated the patient made statements about being suicidal and alleged that she had been sexually assaulted, so he took the patient to the ED and contacted the Division of Family Services (DFS). After he signed the paperwork, privacy was kept to the patient and social worker. LEO L stated he stayed with the patient until the patient left the hospital with the DFS case worker. He said he never heard anything from the hospital staff about admitting the patient for psychiatric care.

During an interview on 12/20/16 at 9:07 AM, DFS Case Worker G, stated that patient #14 did not report to her that she was suicidal and did not show signs for suicide, but "I am not a trained medical professional". DFS case worker G stated there was no discussion by the hospital with her regarding placement of patient #14 into a behavioral health hospital and that after receiving a SANE exam at Hospital C, the patient was placed in foster care.













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