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Based on review of facility policy, medical record review and interview, the facility failed to resolve the EMC (Emergency Medical Condition) for 1 patient (Pt #1) of 20 Emergency Department (ED) patients reviewed.

The findings include:

During an unannounced Emergency Medical Treatment and Labor ACT (EMTALA) investigation of complaint #TN00076980, the facility was found to not be in compliance with the Responsibilities of Medicare Participating Hospitals in Emergency Cases at 42 CFR Part 489.20 and 489.24.

For documentation purposes:

Facility A: Cookeville Regional Medical Center is located at 1 Medical Center Blvd, Cookeville, TN.
Facility B: Livingston Regional Hospital is located at 315 Oak St, Livingston, TN 38570.

Medical record review revealed Pt #1 presented to the ED via ambulance following a MVA (Motor Vehicle Accident) on 10/11/2025 at 2:16 AM. Pt #1 was combative at the accident site and refused to speak to EMS (Emergency Medical System). Once in the ED, Pt #1 continued to refuse to speak with the ED Staff and they were unable to complete a CSSR (Columbia Suicide Severity Rating) Scale. Pt #1 had a trauma work up completed which was negative for any acute findings. A few hours after arrival, Pt #1 began "yelling about Satan and God and [recently deceased public figure]...crying and hollering about Jesus wasn't going to forgive her and having hyper religious speech." The staff were unable to calm Pt #1. Further review revealed a CON (Certificate of Need for Emergency Involuntary Admission) Part 1 was completed on 10/11/2025 at 5:55 AM, with the reason of "Acutely psychotic and manic. Might be a danger to herself."

Medical record review revealed Telepsychiatry assessed Pt #1 on 10/11/2025 at 11:58 AM. During the assessment, Pt #1 reported she became "...confused and disoriented while driving...had all types of errands to run...was following her usual routes but began to feel tired and overwhelmed..." Pt #1 stated she was not trying to harm herself. Continued review revealed the patient was rated at a moderate risk for suicide on the CSSR. The Telepsychiatrist Notes documented Pt #1 was agreeable to voluntary stay at a psychiatric hospital and was also agreeable to a discharge. Patient #1 was alert and oriented at that time. The recommendation was to discharge home and follow up with current psychiatrist. Further review revealed on 10/11/2025 at 1:28 PM, the Telepsychiatrist was notified due to collateral information received from a family friend stating "...she (Pt #1) has had these episodes in the past and was unstable..." The decision was made to transfer Pt #1 to an inpatient psychiatric hospital. Part 2 of the CON was completed on 10/11/2025 at 4:03 PM.

Review of the medical record revealed the hospital attempted to find placement for Pt #1 but were unsuccessful. On 10/11/2025 and 10/12/2025, Pt #1 declined SI (Suicidal ideations) and remained calm. On 10/13/2025 at 1:52 PM, the ED Provider/ED Medical Director saw Pt #1 and stated "...Patient is no longer deemed a danger to harm herself or others. Her involuntary hold has been revoked..." Another Telesychiatrist revealed Pt #1 stated she was another person with a different birthday. The Telepsychiatrist recommend discharge home. Pt #1's husband was coming from Florida to pick Pt #1 up. While waiting on the husband, Pt #1 stated she wanted to leave. The hospital arranged a hotel, food, medication and a ride to go to the hotel. On 10/14/2025 at 12:00 AM the ride arrived, and Pt #1 became irrational, refused to take the ride, and she walked away without her belongings.

Cross Refer to A 2407.

Based on review of facility policy, medical record review from Hospital A, medical record review from Hospital B, review of a police report and interviews, the facility failed to provide an appropriate and ongoing medical screening examination for patient (Pt #1) of 20 Emergency Department (ED) patients reviewed.

The findings included:

Review of the facility's policy titled, "Emergency Medical Treatment and Active Labor Policy," dated 7/2023, revealed "...Any individual who comes to CRMC requesting emergency services is entitled to and will receive a Medical Screening Examination performed by the individuals qualified for such examination to determine whether an Emergency Medical Condition exists...The transferring hospital provides medical treatment within its capacity and capability that minimizes the risks to the individuals health...Emergency Medical Treatment and Active Labor Act [EMTALA]...obligates hospitals to provide a medical screening, treatment and transfer of individuals with Emergency Medical Conditions...Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual...in serious jeopardy...serious impairment to bodily functions...or serious dysfunction of any bodily organ or part...Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists...the Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either stabilized or appropriately transferred...Stable for Discharge: A patient is stable for discharge when, within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care...could reasonably be performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions. In the case of a patient who is suffering from psychiatric conditions, the patient may be considered to be stable for discharge when he/she is no longer considered to be a threat to himself/herself or to others...a medical screening examination is not an isolated event...the Hospital must offer to transfer the patient if it is has exhausted all of its resources in trying to stabilize the patients Emergency Medical Condition...Stabilization, with respect to an Emergency Medical Condition, means to either provide such medical treatment of the condition necessary to assure within reasonable medical probability that no material deterioration of the condition is likely to result from, or occur during, the transfer of the individual...a patient will be deemed stabilized if the treating physician attending to the patient in the hospital has determined within reasonable clinical confidence that the Emergency Medical Condition has resolved...the determination of whether they are medically stable...for purposes of transferring a patient with psychiatric condition, the patient is considered Stable for Transfer when he/she is protected and prevented from injuring himself or others..."

Medical record review of ED Patient Log dated 10/11/2025 at 2:16 AM, revealed Pt #1 presented to the ED via ambulance following a MVA (Motor Vehicle Accident).

Medical record review of the Triage Note dated 10/11/2025 at 2:16 AM, revealed "...pt restrained driver...ran into light pole...pt initially speaking with EMS [Emergency Medical Service] on scene and walked out of vehicle and c/o [complaining of] low back pain, then became combative with PD [Police Department]. Pt refused to speak with EMS and only responded to painful stimuli. Pt given 1mg [milligram] of Narcan [medication for opiate overdose] by EMS with no effect. Pt asked for warm blanket upon arrival to ED then refused to answer any other questions..."

Medical record review of Nurses Daily Focus Assessment Notes dated 10/11/2025 at 2:41 AM revealed RN A (Registered Nurse) was unable to assess a Suicide Screen due to Pt #1 not answering questions.

Medical record review of a Provider Note dated 10/11/2025 at 5:31 AM, revealed Pt #1 was involved in an MVA after "...hitting a pole at an undetermined rate of speed...patient will not answer questions...is alert and awake... Patient had a urine drug screen that was positive for cannabis..."

Medical record review of the Daily Focus Assessment Report dated 10/11/2025 at 5:45 AM - 6:00 AM, revealed Pt #1 "...yelling about Satan and God and [recently deceased public figure]...crying and hollering about Jesus wasn't going to forgive her and having hyper religious speech. Attempted to calm pt down and redirect but pt kept getting upset and back to hyper religious speech..."

Medical record review of a CON (Certificate of Need) for Emergency Involuntary Admission Part 1 dated 10/11/2025 at 5:55 AM, revealed it was initiated by the ED Provider stating, "Patient appears to be acutely psychotic and manic Patient might be a danger to herself."

Medical record review of Medication Administration Record dated 10/11/2025 at 6:08 AM, revealed Ativan (anti-anxiety medication) 1 mg (milligram) IV (intravenously) was administered to Pt #1.

Medical record review of the Daily Focus Assessment Report dated 10/11/2025 at 6:25 AM, revealed "pt more calm after Ativan given, pt still fixated on hyper religious speech..."

Medical record review of Nurses Daily Focus Assessment Notes dated 10/11/2025 at 7:15 AM, revealed RN B was unable to assess a Suicide Screen due to Pt #1 not answering questions. "Remains on 1:1 Precautions."

Medical record review of Nurses Daily Focus Assessment Notes dated 10/11/2025 at 11:56 AM, revealed RN B spoke to Pt #1's daughter who stated "...the family is not coming to get her...she has to find somewhere to go...mother is unsafe and is not allowed to come by family until she goes inpt [inpatient] and gets help...she [daughter] doesn't care where she goes...until she gets help..."

Medical record review of a Telepsychiatry Consult Note dated 10/11/2025 at 11:58 AM, revealed "...Patient presents for psychiatric evaluation following a motor vehicle incident that occurred after she became confused and disoriented while driving. She states that she 'had all types of errands to run' and was following her usual routes but began to feel tired and overwhelmed. She reports that the scenery kept changing, and she pulled over to rest, after which she got hit... She describes feeling confused by how things were unfolding and notes that the 'scenery was changing' in a way that felt unusual or disorienting...she reports visual hallucinations but denies auditory hallucinations, suicidal ideation, homicidal ideation, or any intention to harm herself, stating explicitly that she was not trying to kill herself... Patient reports taking Risperdal [antipsychotic medication] 2mg daily...She expresses willingness and agreement to voluntary inpatient psychiatric hospitalization for further stabilization, sleep restoration, and medication management. Pt also amenable to discharge...Past Psychiatric History - Bipolar 1 [mental health condition defined by at least one severe manic episode, lasting at least a week or requiring hospitalization, causing extreme mood swings, high energy, and impaired thinking, often alongside depressive episodes, and can also involve psychosis]...Orientation: AO x4 [alert and oriented to person, place, time, and situation]...CSSRS [Columbia-Suicide Severity Rating Scale] Moderate Risk...Plan includes [making changes in medications], and outpatient follow-up for medication management and therapy. Inpatient care was initially considered but deferred due to logistical barriers and lack of acute safety risk... RECOMMENDATIONS: Discharge to home...increase Risperdal...start Trazodone [Medication for depression and sleep] 50mg...Follow-up with current psychiatrist...Follow-up with current psychotherapist..."

Medical record review of Nurses Daily Focus Assessment Notes dated 10/11/2025 at 12:44 PM, revealed "...Physician asked this nurse [RN B] to contact QLER [company for the Telepsychiatrist] psychiatrist to speak with him about pt has as a friend who works in the medical psych [psychiatric] field has called requesting pt go inpt psych as family is afraid of pt and would like her to receive treatment prior to coming home..."

Medical record review of a Telepsychiatry Consult Note- Addendum dated 10/11/2025 at 1:28 PM, revealed "...Spoke with the attending physician who provided me with additional collateral information. A family friend who is familiar with patient, called and reported that patient has these episodes frequently. Attending physician and team are willing to assist in finding a facility for patient even though she does not have insurance and is from out of state...Now recommending Inpatient Psych hospitalization..."

Medical record review of Nurses Daily Focus Assessment Notes dated 10/11/2025 at 2:47 - 3:00 PM, revealed a call was made to the Mobile Crisis Line (response team for people with psychiatric emergencies) to work on getting Pt #1 placed into a psychiatric facility but stated they were "...unsure if a facility will take out of state insurance...requesting 6404 [legal involuntary commitment to psychiatric facility] on pt to refer to [State Psychiatric Facility] as insurance is out of state and does not cover inpt psych..."

Medical record review of Nurses Daily Focus Assessment Notes dated 10/11/2025 at 4:00 PM, revealed Pt #1 "...attempted to elope, code purple [an alert for staff/security to respond for a patient elopement] activated and security at bedside, pt returned to bed without incident..."

Medical record review of a CON for Emergency Involuntary Admission Part 2 dated 10/11/2025 at 4:03 PM, was completed by an ED Provider and indicated Pt #1 "...has schizophrenia and manic episode."

Medical record review of Nurses Daily Focus Assessment Notes dated 10/11/2025 at 4:22 PM, revealed "...patient yelling in room, being argumentative and disruptive..."

Medical record review of Medication Administration Report dated 10/11/2025 at 4:24 PM, revealed Zyprexa (antipsychotic) 10 mg IM (intramuscular) was administered to Pt #1.

Medical record review of Nurses Daily Focus Assessment Notes dated 10/11/2025 at 6:00 PM, revealed Pt #1 was "...crying...confused...impulsive...anxious...restless..."

Medical record review of Provider Progress Note dated 10/11/2025 at 6:12 PM, revealed Pt #1 was "...resting comfortably in bed. Psychiatry evaluated patient recommended admission or discharge. We were able to get in touch with family. They have concerns that patient is a high elopement risk, has been off her medication for some time...asking for admission for psychiatric hospitalization at this time...6404 was written for patient. While pending placement patient had an episode where she attempted to get up from her bed and threw a drink on a security officer..."

Medical record review of a Mobile Crisis Consult dated 10/11/2025 at 11:44 PM, revealed Pt #1 was evaluated and "During...assessment client [Pt #1] was in and out of sleep...reported she was in Indiana and left to go to a gas station and could not find her way back...'I took a turn and all of a sudden I was in Tennessee'...Client reports she has Bipolar 1 and is not compliant with medications...reports she attempted suicide 12 years ago by trying to run into the back of a semi-truck...reports wanting to do it this way so her kids believed it was an accident and not suicide and no one else could get hurt in the process...denies SI...unreliable to verbalize for safety and has no way home...spoke with husband who reports client goes in and out of manic episodes and wants her to get help...reports...client left him in the restaurant...reports client had left after she was tired stating she was going to take a nap in the car...reports he went to the bathroom then came back out and she was gone...recommend 6404 [Involuntary Commitment] on client due to client not wanting a CSU (Crisis Stabilization Unit)...to be referred to [State Psychiatric Facility]..."

Medical record review of Nurses Daily Focus Assessment Notes dated 10/12/2025 at 1:04 AM, revealed Pt #1 was calm and cooperative but was confused on place and time.

Medical record review of Nurses Daily Focus Assessment Notes dated 10/12/2025 at 7:01 PM, revealed Pt #1 was anxious but cooperative. RN A stated "Pt presents as semi delusional...reports her name is not [Patients #1's name] and is trying to assume someone else's identity. She reports her name is [name of the sitter in the room]...and the [other patient] in the room has a similar date of birth to the date of birth the patient gave...it is safe to assume the patient is trying to assimilate information from what is going on in the room due to her history of Bipolar. MD made aware...Pt is cooperative besides wearing her wrist band that identifies her...Pt called husband and reported she thought someone told her that her husband was in the lobby. Pt redirected to her room and is cooperative at this time..."

Medical record review of Nurses Daily Focus Assessment Notes dated 10/12/2025 at 8:12 PM, revealed RN A stated Pt #1's husband called and stated Pt #1 "...told him that a nurse told the patient that her husband was in the lobby and he was calling to clear up any confusion about that because he is in Florida and currently working...to come...he also mentioned he has a medical team working on getting her placed somewhere because he does not want her to end up in a shelter..."

Medical record review of Medication Administration Record dated 10/12/2025 at 11:57 PM, revealed Zyprexa 10 mg orally and Ativan 1 mg was given for agitation to Pt #1.

Medical record review of Nurses Daily Focus Assessment Notes dated 10/13/2025 at 11:46 AM, revealed "...Crisis [Mobile Crisis] called and notified that the physician here wants to speak to the physician at [State Psychiatric Facility] that the results have been faxed multiple times...and have not heard from [State Psychiatric Facility]...Pt husband calling frequently upset that he is not able to come get her, reassured staff is working on getting her seen..."

Medical record review of Nurses Daily Focus Assessment Notes dated 10/13/2025 at 1:51 PM, revealed Pt #1 was placed in the queue to be reassessed by Telepsychiatry as requested by Provider A. "...Per Physician...pt is denying any suicidal, homicidal ideations or hallucinations requesting to have her husband come get her so she can get treatment in Florida."

Medical record review of a CON for Emergency Involuntary Admission Part 2 dated 10/13/2025 at 1:50 PM, revealed the CON was rescinded by Provider A

Medical record review of Discharge Paperwork dated 10/13/2025 at 1:52 PM, revealed there was education given to Pt#1 about MVA and Muscle Pain. There was education regarding resources for SI. Pt #1 was instructed to do a follow up with the General Surgeon in 1-2 days and the PCP (Primary Care Provider) in 3-6 days. There was not any printed education regarding following up with psychiatry or medication. There is a signed copy by Pt #1 indicating she received the discharge instructions not dated or timed.

Medical record review of a Provider Progress Note by Provider A dated 10/13/2025 at 1:52 PM, revealed Pt #1 was "...without suicidal or homicidal ideations for the last 2 days. Patient has been able to ambulate around the department without difficulty...patient re-evaluated with telepsychiatry...Patient is no longer deemed a danger to harm herself or others. Her involuntary hold has been revoked. Contact her husband and arrange for patient to be picked up from Florida..."

Medical record review of Nurses Daily Focus Assessment Notes dated 10/13/2025 at 2:20 PM, revealed Pt #1's husband notified the ED he would arrive the next day to pick up the Pt #1.

Medical record review of a Telepsychiatry Progress Note dated 10/13/2025 at 2:24 PM, revealed Pt #1 was stating "...I'm not [her legal name]...(patient states that she is [different individual with different date of birth])...there's no wristband - they took it off and they never gave it back." Continued review of the Telepsychiatry note revealed "...States that she is in Tennessee...paranoia or hallucinations...Denies any suicidal or homicidal ideation... States that she does not have a psychiatrist...Patient is alert and initially confused, disoriented to self, but oriented to place, time, situation...eventually confusion subsides...Suicide Risk...Low Risk...Patient initially disoriented to self but becomes oriented during evaluation...Husband intends to retrieve patient. Recommendations: Patient may be discharged to home once medically cleared..."

Medical record review of Nurses Daily Focus Assessment Notes dated 10/13/2025 at 3:00 PM, revealed Pt #1 was become anxious stating "she is tired of being here...pt notified...husband can not come until tomorrow...she notified nurse she was tired of her, staff in the room for safety..." Pt #1 decided she did not want to wait on her husband.

Medical record review of Nurses Daily Focus Assessment Notes dated 10/13/2025 at 4:00 PM, revealed Pt #1 was "...smiling, calm, cooperative, no anxiety or agitation noted, this nurse asked social worker to help get [Pt #1] put in hotel, social worker is setting up hotel for two days, getting food, clothing and taxi will be set up...called husband and update..." Further assessment documented Pt #1 was alert and oriented.

Medical record review of Nurses Daily Focus Assessment Notes dated 10/13/2025 at 5:00 - 6:00 PM, revealed Pt #1 was given clothing and a bag of food to take with her. Pt #1's medications were also obtained to be given to her at discharge. Pt #1 was educated on medications and when to take them, and she signed her discharge paperwork. Pt #1 stated "...she is happy to be leaving, and husband will be here tomorrow to get her..."

Medical record review of Nurses Daily Focus Assessment Notes dated 10/13/2025 at 8:00 - 8:56 PM, revealed "Patient husband called the hospital to speak to patient. Husband is currently in Florida...husband told patient he would be leaving...in morning, patient says she was under the impression that he was already in TN [Tennessee] and got upset and hung up with husband...then said she wanted to call him back...told husband he needed to leave tonight and hung up...Patient...called daughter...RN [RN A] spoke to daughter... was verbally upset with nurse at the fact that her mother was being discharged to a hotel...implied that her mother made suicidal statements to the daughter on the phone and that her mother was talking about demons. RN attempted to report to the daughter that the pt was evaluated by the medical director of the ER and psychiatry consult was completed earlier today....attempted to explain that the pt started getting upset when she found out the husband was not going to be at the hotel until tomorrow afternoon and that she thought the husband was already in Tennessee or on his way..." RN A spoke with the daughter and Pt #1, and it was decided Pt #1 could stay in the ED until her husband was able to get there. Pt #1's daughter was ok with this and Pt #1 "... is calm and happy with the decision..." Pt #1 didn't want to go to the hotel stating "...she doesn't trust being alone..."

Medical record review of Nurses Daily Focus Assessment Notes dated 10/13/2025 at 10:50 PM, revealed Pt #1 approached RN A and stated she wanted to go to the hotel and wait for her husband there. "...Pt reports she spoke with her daughter...and husband and they are ok with that plan...attempted to call daughter and left message...Pt alert and oriented X 4. Pt in discharged status and 6404 has been rescinded by [Medical Director/Provider A]...called cab and discharged patient to lobby to wait..."

Medical record review of Nurses Daily Focus Assessment Notes dated 10/13/2025 at 11:45 PM to 10/14/2025 at 12:00 AM, revealed Pt #1 was taken outside to get in a cab. Pt #1 got into the cab and then refused to go stating the driver was drinking alcohol. RN A was unable to convince Pt #1 it was not alcohol. A police officer was onsite, and RN A asked if they would take Pt #1 to the hotel and they agreed. Pt #1 was agreeable until she found out she had to ride in the back of the police vehicle. At this time Pt #1 "...turned around and walked away from this RN [RN A], Security, and [Police Department] officer. RN [RN A] attempted to get pt to come back in the hospital to rest inside. Pt blatantly refused and walked away leaving the bags with her belongings..."

Medical record review of Nurses Daily Focus Assessment Notes dated 10/14/2025 at 5:06 AM, revealed RN A contacted the hotel to see if Pt #1 checked in and it was determined she did not.

A review of a police report dated 10/14/2025 at 11:46 AM, revealed Pt #1 was found by a police department in a different county after stealing a car. She was found at a gas station and was disoriented and believed the car was given to her as charity to use. "[Pt #1] was confused about her identity and believed that the hospital had changed her identity...she did not appear to understand why she was being detained...did not have the capacity to provide simple details as her current location or a timeline of events that led her to [another county]..." Pt #1 was taken to Hospital B for an evaluation, and it was decided the husband was coming to pick the patient up and "...the best action at this time was to have [husband] return to Florida with [Pt #1] so she could be treated by her regular doctor..." Further review of a second police report dated 10/14/2025 at 7:15 PM, revealed the police department was dispatched to Hospital B. "...Upon my arrival to the hospital, she had been through a mental evaluation and determined that she was no harm to herself or others...while talking to officers and security outside, she started causing a disturbance inside. She was standing in the middle of the waiting room with a phone next to her ear yelling into it, saying the police have her surrounded, send help, they got me. The people in the waiting room were crowded up in the corner and against the wall trying to distance themselves from her...given her actions inside the hospital, she was charged with disorderly conduct and theft of property..."

Review of a medical record from Hospital B dated 10/14/2025 at 2:31 PM, revealed Pt #1 was brought to the ED via Law Enforcement for altered mental status. "...Patient presents with confusion, disorientation to place...began at an unknown time...Patient has no apparent associated signs or symptoms...it is unknown whether or not the patient has had similar symptoms in the past...reports she was at [Hospital A] recently after an MVA...brought in by [police department] after stopping her in a stolen vehicle...acting erratic so brought here for a medical clearance...." At 5:47 PM, the medical clearance was completed, and Pt #1's husband was present and "...will take Patient to get her back to Florida and her mental health providers..."

An interview on 11/17/2025 at 4:00 PM, with the Facility A's Risk Manager, revealed there was an investigation completed on this event, "...a friend of the [Pt #1's] daughter called to file a grievance...we took her concerns...we told her we could not give her specifics, but we would be willing to speak to her husband...we looked at this event as a possible unsafe discharge...she told us [Pt #1] stole a vehicle from the hospital [at Facility B] and she went to jail...we looked into this and it did not happen at our hospital....when she was discharged here we offered a ride in an UBER and she refused...a police officer said she would take [Pt #1] to the hotel and she walked off...[Pt #1] ended up in [another county] and stole a car...after this the police took her to [Hospital B] and she was cleared and discharged to the jail...I called [Hospital B] and spoke to the Risk Manager who gave me this information...our ED Medical Director [Provider A] acutely cleared her for discharge...the husband was agreeable to her discharge and he wanted her to go to the hotel which the hospital paid for... we couldn't get her services in Tennessee... there is documentation they tried to get her admitted to [State Mental Health Facility] but they declined..." The Risk Manager started an investigation on 10/13/2025. She stated she talked to Pt #1's husband but did not follow up with the complainant due to not being a family member and the inability to share information with her.

An interview on 11/18/2025 at 9:00 AM, with the Risk Manager, revealed "...we did not see this as an unsafe discharge after the investigation...there was a plan in place and there was good communication with the appropriate plans...there were attempts to place her, but she had a place to go because her husband was coming to get her...I was told by the friend [Pt #1] went to jail...I called the jail and spoke to an LPN [Licensed Practical Nurse]...she told me [Pt #1] was doing ok and said, 'does someone know when they are psychotic?' She stated she felt the behaviors she was seeing were on purpose and mindful...she was not acting out or aggressive...they were monitoring her..."

An interview on 11/18/2025 at 10:00 AM, with Provider A, revealed she was the attending physician the last 2 days of Pt #1's stay in the ED. Provider A stated Pt #1 came in following an MVA. She stated the ambulance had reported "odd behaviors" at the crash site. Provider A stated she knew when Pt #1 was admitted she would not answer any questions. "...She [Pt #1] was cleared twice by Telepsych and the ED providers said it was OK to discharge...her husband was coming to get her...the hospital arranged a hotel for her...an UBER was arranged and she refused that...a police officer...agreed to take her to the hotel and she refused and then left the facility...I do not remember any bad behaviors from her...she was quirky and had an odd affect...she was calm and cooperative while I had her...I did a suicide assessment on her each day I had her and she denied SI...I never heard the wreck was purposely caused..." Provider A explained if a patient is to be involuntarily committed the Mental Health Nurse will make arrangements for this. "If the patient has insurance we wait and see if it is approved...if they do not have insurance Mobile Crisis has to be consulted to evaluate and find placement... if a patient does not have insurance and needs to be involuntarily committed, they will stay here until there is a placement somewhere...we tried multiple facilities and no one accepted her because she didn't have insurance...They looked into [State Psychiatric Facility] but she was declined there too...She [Pt #1] would not have qualified for placement for involuntary commitment because she had 2 clears from TelePsych and she was not a danger to herself or others..."

An interview on 11/18/2025 at 10:20 AM, with the Manager of the ED, revealed he reviewed this case after a complaint and stated they did not find any problems and felt the appropriate process was followed. "...Pt #1 came in as a trauma from an MVA...She received all the trauma scans, and they were negative. She made a comment to someone she had nowhere to go...there was a call from a family friend at some point stating they felt the patient was a high risk and they wanted her committed...they initially did a 6404 but it was eventually rescinded because TelePsych cleared her twice and was not recommended for inpatient...they did restart her medications during her visit in the ED and her mental status cleared some...she was deemed a moderate risk for SI while she was in the ED, but that does not necessarily mean you will be involuntarily committed...The hospital filled her prescriptions, got a hotel room, and gave her a bag of food and snacks...The patient left the hospital awake and stable..." The manager stated there is a Mental Health Nurse in the ED 24/7, and they are responsible for helping with placement and discharge planning. They made attempts to get her placed for both involuntary and voluntary status and were unable to find placement due to Pt #1 not having insurance.

An interview on 11/18/2025 at 10:55 AM, with RN A, revealed he is a full-time psychiatric nurse in the ED. One of his roles is to help with placement of psychiatric patients when needed. He stated if a patient has TN Care (Tennessee Medicaid program) or no insurance, he must call Mobile Crisis to evaluate the patient for involuntary commitment after the patient is medically cleared. RN A stated he remembers Pt #1 coming from out of state and she had an MVA. RN A stated the state trooper told him the patient reported she got confused and ran off the road into a pole. "We were told it possibly was on purpose." RN A stated they are to perform a suicide risk assessment using the CSSRS each shift. He stated he had Pt #1 the last 2 nights she was in the ED, and he does not remember her ever endorsing SI. He stated there was a friend of the family who was a NP (Nurse Practitioner) who claimed Pt #1 hit the pole on purpose. RN A stated Pt #1 was discharged prior to him coming on duty on 11/13/2025. "She was going to be discharged to a hotel room the hospital paid for, her medications were filled by the hospital. There was communication with the patient's husband, and he would be arriving the next day...We arranged for an UBER to pick her up... She stated she would not go with the driver because he was drinking and driving, and she didn't feel safe...There was a police officer there and I asked if she [police officer] could take the patient to the hotel and she accepted. When we tried to put her in the back seat of the car, she [Patient #1] found that unacceptable and walked off the property leaving her belongings and medications...I took these to the front desk in case she came back to get them. I tried to get her to stay but she would not stay...She was alert and oriented when discharged. She was stressed but she was able to make her own decisions..."