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Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the Emergency Department (ED) staff provided 1 of 20 emergency patients reviewed (Patient #6) with an appropriate medical screening exam (MSE) and an appropriate transfer after presenting to their ED by law enforcement with a request made on their behalf for medical care. Failure to provide an appropriate MSE and an appropriate transfer resulted in Patient #6, a patient with psychosis, schizoaffective disorder, and hypertension having a delay in stabilizing treatment and requiring hospitalization at another hospital until placement in an inpatient behavioral health (BH) facility was found, and could have potentially resulted in Patient #6 causing injury to them self or others. The CAH's administrative staff identified an average of 141 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of the policy "Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department - Emergency Medical Treatment and Labor Act (EMTALA) ...," Last Revised 3/23, revealed in part:

a. " ...The Hospital will provide to any individual ... who 'comes to the Emergency Department' an appropriate Medical Screening Examination (MSE) within the capabilities of the Hospital's dedicated emergency department (DED), including ancillary services routinely available to the DED, to determine whether or not an EMC exists ..."

b. " ...The Hospital will provide an MSE for an individual who ... comes to an on-campus DED, requesting examination or treatment for a medical condition or has such request made on his/her behalf, or if based on the individual's appearance or behavior, the individual appears to need an examination or treatment for a medical condition ..."

c. " ...If an individual has an EMC that has not been stabilized, the individual may be transferred only if the transfer is carried out in accordance with the procedures set forth ... Upon Individual Request ... individual may be transferred, if the individual or the person acting on the individual's behalf is first fully informed of the risks of the requested transfer, the alternatives (if any) to the transfer, and of the Hospital's obligations to provide further examination and treatment sufficient to stabilize the individual's EMC, and to provide for an appropriate transfer ... acknowledges his/her request and understanding of the risks and benefits of the transfer, by signing the 'Patient Transfer Request' section of 'Transfer Consent.'"

2. Review of the policy "Care of the Behavioral Health Patient in the Emergency Department," Last Revised 8/22, revealed in part:

a. "Purpose: To identify patient care needs through systematic assessment, reassessment, and identification of risk for harm to self and others. To establish guidelines to provide a safe environment for patients and staff and ensure patient safety and protection by removing unsafe objects and/or items which may be harmful to the patient or others ..."

b. " ...Safety ... ED staff will: Place Behavioral Health patients in designated behavior-specialty rooms when possible ..."

c. " ...If the patient is deemed to be a present danger to self or others, Security may be requested to stand by until the patient no longer presents as a danger to self or others. 'Danger' includes acts of aggression and/or demonstrating a flight risk ..."

3. Review of the policy "Transfer Consent," Last Revised 9/21, revealed in part:

a. "I have been informed that I have the right to receive, within the capabilities of [Hospital's] staff and facilities: an appropriate medical screening examination ..., and if necessary, an appropriate transfer to another health care facility ..."

b. "Patient Transfer Request: this is to certify that I have been informed that [Hospital] is obligated by law to provide me with a Medical Screening Examination and, if I am found to have an Emergency Medical Condition, any necessary stabilizing treatment that is within the Hospital's capability and capacity. I have also been informed of the risks of being transferred to another facility and the potential benefits of continuing to receive treatment at the Hospital. Nonetheless, I wish to be transferred (or to have the patient transferred). I release Hospital and its agents, employees and physicians from all responsibility for any ill effects or undesirable outcomes which may result from the transfer."

4. Review of Patient #6's medical record revealed:

a. On 6/24/23 at 7:07 AM, Patient #6 presented to the ED by law enforcement for behavior issues, and was assigned to see MD A. RN D documented in Patient #6's medical record that "patient is obviously under the influence of some substance, officer got patient to sit in patient room to get assessed."

b. On 6/24/23 at 7:15 AM, RN D documented that Patient #6 "became extremely agitated and aggressive, screaming that [Patient #6] 'wasn't going to see a foreign Asian doctor and have [them] tell [Patient #6] what [Patient #6] was going to do,' and slamming the room door, slamming a bedside table into walls, charging at staff, and threatening to throw a chair, staff were unable to calm [Patient #6] and [Patient #6] became more aggressive." Law enforcement was notified of staff needing assistance. Patient #6 was at the nurse's station sitting on the floor when law enforcement returned.

c. On 6/24/23 at 7:18 AM, RN D noted in Patient #6's medical records they left without being seen, before triage.

d. On 6/24/23 at 7:20 AM, RN D documented that Patient #6 was "refusing care here and requesting to leave this facility." Patient #6 was removed from the CAH by law enforcement per their request. A "Departure Prior to Dismissal" form was completed by RN D, which also noted Patient #6 was screaming they did not want to be seen at the CAH, they wanted to go to Hospital B, and was picked up by law enforcement per their request.

e. On 6/24/23, Patient #6 refused to have their vital signs taken, have any cares or treatment provided to them, or have an MSE completed by MD A while in the ED. There was no documentation to support that an attempt was made by MD A to provide an MSE or treatment to Patient #6 after law enforcement returned to assist with Patient #6. Patient #6 was removed from the ED by law enforcement 13 minutes after arriving to the ED.

5. During an interview on 8/22/23 at 9:00 AM, Sheriff K recalled transporting Patient # 6 to the ED after being called out for Patient #6 causing damage at their mother's home. Sheriff K reported Patient #6 became combative while in the ED, verbalizing they did not want to be seen at that ED, and wanted to be taken to Hospital B because they had a doctor there.

6. During an interview on 8/17/23 at 3:00 PM, RN D recalled Patient #6 was brought into the ED by law enforcement. RN D reported Patient #6 became agitated, and screaming at staff that they did not want to be there. Patient #6 was charging at staff, pushing a bedside table into the walls, and slamming doors. RN D reported they called law enforcement back to the ED to get Patient #6, as Patient #6 did not want to be seen at their ED, and was reporting Patient #6 wanted to go to Hospital B, because their BH provider was there. RN D reported after Patient #6 was told they did not have to be seen at their ED, Patient #6 was calm, relaxed, and sat down until law enforcement returned.

7. During a follow-up interview on 8/21/23 at 9:42 AM, RN D reported they did not offer to have Patient #6 transferred to Hospital B, or explain the risks and benefits of a transfer to another facility due to Hospital B being a "lateral transfer" (between hospitals with comparable resources). RN D also reported that because Hospital B did not have a BH provider, and that Patient #6's BH provider was at another location in the same town as Hospital B, RN D again said this would be a "lateral transfer," so they couldn't do it.

8. During an interview on 8/23/23 at 10:00 AM, Paramedic I recalled Patient #6 was brought into the ED by law enforcement, place in an exam room, and law enforcement left. Paramedic I reported telling RN D they would obtain Patient #6's vital signs, but when Paramedic I attempted to do this, Patient #6 verbalized they did not want to be touched. Paramedic I recalled Patient #6 pushing the bedside table into the bed and toward Paramedic I, repeating they did not want to be touched. Paramedic I recalled Patient #6 slamming the exam room door. Paramedic I could not recall if Patient #6 verbalized not wanting to been seen in the ED, but did recall Patient #6 verbalizing they wanted to be taken to Hospital B. Law enforcement was called to come back to the ED to assist staff with Patient #6. Paramedic I recalled Patient #6 was calmer when law enforcement was present.

9. During an interview on 8/17/23 at 11:30 AM, MD A recalled they were sleeping when Patient #6 came into the ED, it was early on a Sunday around 6:30 or 7:00 AM, and MD A heard someone yelling, then a loud bang. MD A recalled hearing a patient saying things like "get out," and "get away from me," then they slammed a door, and was swearing. The nurse was trying to get Patient #6's vital signs, but they were saying "get off of me." MD A recalled the nurse trying to explain what they were doing, and that staff were trying to help Patient #6, but they kept yelling and not listening. MD A reported Patient #6 calling them a foreigner, and saying they could not understand my English. MD A also recalled Patient #6 saying they were not going to stay, and staff telling Patient #6 that they could leave. MD A failed to document their encounter with Patient #6 in the medical record.

10. During a follow-up interview on 8/23/23 at 11:17 AM, MD A reported that ED staff told Patient #6 they could transfer to Hospital B, but told Patient #6 to let them ask a few questions, but Patient #6 was swinging their hands, and that is when Patient #6 told MD A their English was bad. MD A recalled Patient #6 went outside and that ED staff did not follow Patient #6 outside. Reporting that law enforcement returned at that time, but did not come back into the ED, and took Patient #6 from the parking lot. MD A recalled watching Patient #6 and law enforcement talking outside on the monitor in the ED, but MD A did not go outside. MD A denied offering Patient #6 any screening or treatment after law enforcement returned to the ED. MD A failed to document that a transfer was offered to Patient #6 or that they attempted to educate Patient #6 on the risks and benefits of being transferred to another ED.

11. During an interview on 8/17/23 at 12:45 PM, LPN G recalled they were at the nurse's station when Patient #6 was brought into the ED by law enforcement. Reporting that when the paramedic went to get Patient #6's vital signs, they became violent, was throwing the bedside table around, and yelling at staff. LPN G reported Patient #6 wanted to be taken to Hospital B.

12. During an interview on 8/22/23 at 9:00 AM, Sheriff K recalled returning to the ED to pick up Patient #6, transporting them to the Sheriff's office, and then having Deputy J transport Patient #6 to Hospital B.

13. During an interview on 8/18/23 at 11:07 AM, Deputy J recalled transporting Patient #6 to Hospital B's ED. Deputy J reported Patient # 6 was initially taken from the ED to the Sheriff's office to decide what the best option was for Patient #6, either taking them to jail or to another hospital for mental health help. It was decided to take Patient #6 to Hospital B, because Patient #6 was verbalizing that was where they wanted to go, and that all their doctors were there, including their therapist. Deputy J also reported they contacted Hospital B to inform them that Patient #6 was being brought to their hospital, and provided them with Patient #6's name, date of birth, and reason for bringing them.

14. Review of Hospital B medical record showed that Patient #6's presented by law enforcement on 6/27/23 at 8:15 AM (55 minutes after leaving CHI Health - Mercy Corning ED) for a psychiatric Evaluation and received an appropriate MSE. Patient #6 remained at Hospital B's ED until he was transferred to an inpatient BH facility on 6/28/23 at 10:19 AM.

15. During an interview on 8/21/23 at 2:40 PM, RN M recalled caring for Patient #6 while in the ED at Hospital B, and that Patient #6 would only talk to law enforcement when they first arrived. RN M reported Patient #6 was in the hallway during his ED stay yelling and screaming at RN M, threw a pen and paper at RN M, and law enforcement was contacted to come back to assist with Patient #6.

16. During an interview on 8/22/23 at 10:35 AM, CRNA N recalled Patient #6 was brought to Hospital B's ED in handcuffs, by law enforcement, and was talking incoherently. Reporting Patient #6's was delusional, theatrical with his movements, was all over the place, and was not able to answer questions and would just keep talking. CRNA N reported Patient #6 would be tolerant with staff one minute and the next minute, they would elevate their voice, being verbally aggressive toward staff. CRNA N reported they did not receive a report from staff at the initial ED for Patient #6, and that an RN from Hospital B contacted the initial ED to inquire about Patient #6.

17. Patient #6's medical record review, and staff interviews showed the CAH failed to attempt any screening or treatment to Patient #6 after law enforcement returned to the ED to assist with Patient #6. This resulted in delaying Patient #6 receiving an appropriate MSE, and could have potentially resulted in Patient #6 causing injury or harm to them self or others.

Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the Emergency Department (ED) staff provided 1 of 20 emergency patients reviewed (Patient #11) with all available and appropriate stabilizing treatment after presenting to the ED seeking medical care. Failure to provide all available and appropriate stabilizing treatment at the CAH's ED resulted in Patient #11 eloping from the ED three times which could have potentially resulted in Patient #11 causing injury to them self or others due to their serious mental illness. The CAH's administrative staff identified an average of 141 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of the policy "Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department - Emergency Medical Treatment and Labor Act (EMTALA) ...," Last Revised 3/23, revealed in part:

a. " ...To Stabilize means: 1. With respect to an emergency medical condition (EMC), that the individual is provided such medical treatment of the condition as is necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur ... The EMC has been resolved"

b. " ...If an EMC is determined to exist, the Hospital will provide the individual either further medical examination and any necessary stabilizing treatment within the capabilities of the staff and the facilities available at the Hospital ..."

2. Review of the policy "Departure Prior to Dismissal (Against Medical Advice) and Elopement Guidelines - Form," Last Revised 11/20, revealed in part:

a. " ...Elopement; unauthorized departure (patient does not have the right to leave either due to a legal hold or because the patient lacks the capacity to make decisions) from any 24-hour care setting, including the ED ..."

b. " ...While a patient may still elope despite best efforts, the hospital can take reasonable measures to prevent a patient from eloping. The least restrictive intervention should be utilized. Staff should utilize all reasonable efforts to verbally redirect or divert patients. All efforts to redirect should be documented in detail. Staff are not expected to place themselves at risk to prevent a patient from leaving. A physical intervention may be appropriate if there is perceived imminent risk to the patient, staff, other patients, or the general public ... The physician should be notified if patients are asking or attempting to leave. The qualified health care provider should then attempt to reassess if the patient has capacity or not and what further measures may be necessary ..."

c. If a patient elopes " ...The physician should be notified immediately. The qualified health care provider should determine if the patient is felt to be a danger to self or others ... If the patient is on an ... legal hold, law enforcement should be notified immediately ... Always notify your supervisor or administrator to identify any other necessary actions. All notification should be documented in detail (the date, time, and name of the individual notified) ..."

3. Review of the policy "Patient Departure Prior to Dismissal," Last Revised 11/20 revealed in part:

a. " ...To prevent and/or respond to elopement: ...Staff will notify the provider ... If the patient lacks capacity, the provider will document this and actions will be taken to identify and appropriate representative. Staff should make reasonable attempts to persuade the patient to stay; guiding principles to determine appropriate interventions may include: staff are not expected to place themselves at risk to prevent a patient from leaving the premise ... The least restrictive measures that achieve the goal of safety should be taken in response to perceived risks. If the patient who lacks capacity physically leaves the premises (elopes), despite best efforts to persuade them to stay ... staff should immediately notify the provider ..."

b. " ... documentation of the event will be noted in the medical record. The patient's representative and/or agency responsible if under a legal hold will be notified of the event ..."

c. " ... Staff will notify department leader, house supervisor, or administrator on call"

d. "Documentation in the patient's medical record should include the following: times when patient was found to have eloped; attempts to locate of contact the patient, as applicable; time when patient returned, as applicable; notification of provider; other notifications and communication, as applicable ..."

4. Review of Patient #11's medical record revealed:

a. On 5/29/23at 7:38 PM, Patient #11 presented to the ED by law enforcement for a mental health evaluation after being found wandering into someone's house thinking they were going to buy it.

b. On 5/29/23 at 7:55 PM, MD A was in the room with Patient #11 and a medical screening examination (MSE) was performed. Documentation by MD A on Patient #11's physical exam noted Patient #11 to be in acute distress, and was alert and disoriented. Patient #11 was noted to be inattentive with auditory and visual hallucinations. Their mood was documented as depressed with labile, blunt, and flat affect. Patient #11's speech was slurred. Patient #11 was noted to be cooperative, but their thought content was paranoid and delusional, their cognition was impaired, and judgement was impulsive. MD A also noted in their progress note that Patient #11 was wanting their IV out and was wanting to leave. MD A documented being concerned for Patient #11's safety. Patient #11 was medically cleared for a psychiatric evaluation and MD A ordered risperidone (medication used to treat mental health) 1mg to be given after their psychiatric evaluation, to calm Patient #11 down.

c. On 5/29/23 at 8:24 PM, RN E documented communication with Patient #11's sister and that law enforcement spoke with Patient 11's sister as well.

d. On 5/29/24 at 8:31 PM, RN E documented that law enforcement called the Magistrate to inquire about committal.

e. On 5/29/23 at 8:38 PM, RN E called the Magistrate to request a 48 hour hold for Patient #11's danger to self and a 48-hour hold was ordered. It was noted in the court ordered 48-hour hold that the court found there was probable cause to believe Patient #11 was seriously mentally impaired and because of that illness, Patient #11 was likely to physically injure self or others if allowed to remain at liberty. It was also noted on the 48-hour hold that hospital staff and MD A reported Patient #11 was in distress, a danger to them self, was talking them self, answering them self, and that Patient #11 was not likely to remain in the hospital voluntarily.

f. On 5/29/23 at 8:51 PM, MD A ordered risperidone one tablet stat, once.

g. On 5/29/23 at 10:05 PM, RN E noted Patient #11 was on a video call with Integrated Telehealth Partners (ITP).

h. On 5/29/23 at 10:46 PM, RN E gave risperidone 1mg tablet to Patient #11.

i. On 5/30/23 at 6:47 AM, RN O documented an initial safety visual check on Patient #11, and noted Patient #11's behavioral and emotional observation was anxious, flat, and restless with one to one observation.

j. On 5/30/23 at 7:50 AM, RN O documented the first psychosocial assessment for Patient #11, noted they had a 48-hour hold, and was an elopement risk with an answer of yes to Patient #11 having a past history of elopement from a hospital, and a current risk of elopement. An initial mental status assessment was done by RN O and they noted Patient #11 was having hallucinations of vampires biting them and using daggers on their chest.

k. On 5/30/23 at 8:00 AM, RN O documented a safety visual check was completed on Patient #11, and noted Patient #11's behavioral and emotional observation was anxious, uncooperative, and restless.

l. On 5/30/23 at 8:28 AM, RN O documented they spoke with MD A about Patient #11's restlessness, and received orders.

m. On 5/30/23 at 8:30 AM, RN O documented MD A was there to reevaluate Patient #11.

n. On 5/30/23 at 8:47 AM, RN O documented risperidone 1mg tablet was given to Patient #11.

o. On 5/30/23 at 9:56 AM, RN O documented a safety visual check was completed on Patient #11, and noted Patient #11's behavioral and emotional observation was calm. RN O noted Patient #11 was one to one observation and was lying down and/or sleeping.

p. On 5/30/23 at 10:58 AM, RN O documented a safety visual check was completed on Patient #11, and noted Patient #11's behavioral and emotional observation was cooperative. RN O noted Patient #11 was one to one observation and was lying down and/or sleeping.

q. On 5/30/23 at 1:00 PM, RN S noted contacting Patient #11's outpatient behavioral health (BH) provider, and Patient #11 was discharged from their care "several months ago due to noncompliance with medication," and the last time Patient #11 would have received an injection, would have been February 2021.

r. On 5/30/23 at 8:00 PM, RN Q documented a second assessment on Patient #11's elopement risk, and an initial suicide/self-injury and harm to others assessment.

s. On 5/30/23 at 11:30 PM, RN Q documented MD A was notified of Patient #11's restlessness, and of current placement status.

t. On 5/30/23 at 11:34 PM, MD A ordered risperidone tablet stat, once.

u. On 5/30/23 at 11:51 PM, RN Q gave risperidone 1mg tablet to Patient #11.

v. On 5/30/23 at 1:12 PM, RN O documented a safety visual check was completed on Patient #11, and noted Patient #11's behavioral and emotional observation was anxious and flat. RN O noted Patient #11 was one to one observation and was lying down and/or sleeping.

w. On 5/30/23 at 2:23 PM, RN O documented a safety visual check was completed on Patient #11, and noted Patient #11's behavioral and emotional observation was calm. RN O noted Patient #11 was one to one observation and was lying down and/or sleeping.

x. On 5/30/23 at 3:11 PM, RN O documented a safety visual check was completed on Patient #11, and noted Patient #11's behavioral and emotional observation was calm. RN O noted Patient #11 was one to one observation and was lying down and/or sleeping.

y. On 5/30/23 at 4:45 PM, RN S documented a safety visual check was completed on Patient #11, and noted Patient #11's behavioral and emotional observation was calm, cooperative, and restless. From 4:45 PM on 5/30/23 until 6:30 AM on 5/31/23, safety visual checks were completed routinely every 15 minutes.

z. On 5/30/23 at 5:15 PM, RN S documented Patient #11 was "out to nurse's station frequently asking if [Patient #11] can leave yet; goes back to room without difficulty when told no."

aa. On 5/31/23 at 8:21, 9:28, 9:58, 10:32, and 11:15 AM, RN O documented a safety visual check were completed on Patient #11, and noted Patient #11's behavioral and emotional observation was calm. RN O noted Patient #11 was one to one observation and was lying down and/or sleeping.

bb. On 5/31/23 at 9:26 AM, RN O documented that ITP staff call to check on Patient #11 and that there was still no acceptance for an inpatient BH facility.

cc. On 5/31/23 at 9:56 AM, RN O documented that court paperwork for Patient #11 was faxed to inpatient BH, they were contacted with a bed assignment for Patient #11, and the accepting provider's information was obtained.

dd. On 5/31/23 at 11:11 AM RN O documented they contacted the inpatient BH's transfer center for an update on Patient #11, and was informed they were waiting on the charge nurse and nurse practitioner at the inpatient BH facility to assign a bed to Patient #11, and to receive the official acceptance of Patient #11.

ee. On 5/31/23 at approximately 12:06 PM, MD A documented in their progress note for Patient #11 that during Patient #11's two days in the ED, Patient #11 eloped three times, and was brought back by law enforcement. MD A also noted Patient #11 to be easily redirected, and was cooperative with staff.

ff. On 5/31/23 at 12:07 PM, RN O documented calling report to the nurse at the receiving inpatient BH facility.

gg. On 5/31/23 at 12:35 PM, order risperidone tablet stat once, 1 occurrence

hh. On 5/31/23 at 1:10 PM, risperidone 1mg tablet given to patient.

ii. On 5/31/23 at 1:11 PM, Patient #11 was transferred to an inpatient BH facility by ground ambulance.

5. During an interview on 8/17/23 at 10:00 AM, RN E recalled caring for Patient # 11 when they were brought into the ED by law enforcement. RN E reported when caring for Patient #11, they were cooperative, not violent, was not making any sense, and was wanting to go home. RN E denied that Patient #11 eloped from the ED during the time they cared for Patient #11, reporting Patient #11 was present in the ED the whole time.

6. During an interview on 8/17/23 at 11:30AM, MD A did not recalled Patient #11.

7. During an interview on 8/28/23 at 3:45 PM, RN O recalled caring for Patient #11 during his ED stay, and during that time Patient #11 walked out of the ED one time. RN O reported Patient #11 was not able to be redirected by staff and he left the property. RN O reported one nurse followed Patient #11 as long as possible, while RN O called to report Patient #11's elopement to law enforcement. RN O was unable to recall if Patient #11 eloped from the ED more than once during their shift. RN O denied putting additional interventions in place after Patient #11 was brought back to the ED by law enforcement after eloping.

8. During an interview on 8/28/23 at 2:00 PM, RN Q recalled Patient #11 eloping from the ED in the middle of the night. RN Q reported Patient #11 was not suicidal, or a danger to them self or others, but recalled they wanted to go home. RN Q reported following Patient #11 out of the hospital, watched him walk into the woods, and called law enforcement to make sure Patient #11 was safe.

9. During an interview on 8/28/23 at 2:30 PM, CNA P recalled Patient #11 being in the ED, and the nurses would try to talk to Patient #11 when they were trying to walk out of the ED, but they would not listen to anyone. CNA P reported Patient #11 eloped from the ED one night, and one nurse and a paramedic followed Patient #11 as long as they could, then contacted law enforcement. CNA was unable to recall additional intervention for Patient #11 after their elopement from the ED.

10. During an interview on 8/28/23 at 4:45 PM, ED Manager recalled Patient #11 was brought to the ED by law enforcement after going into an elderly woman's home thinking they were going to buy it. ED Manager reported Patient #11 was in the ED for a few days until placement was found for them, and Patient #11 would come out of their room frequently, "like every three seconds to fifteen minutes" asking if he could leave. ED Manager recalled Patient #11 getting out of the hospital, but was not completely off the property when law enforcement picked them up, and brought Patient #11 back into the ED. ED Manager reported nursing staff trying numerous distractions for Patient #11, but nothing worked. ED Manager reported Patient #11 had been off his psychiatric medication for approximately two or three years. ED Manager was not able to recall Patient #11 eloping from the ED three times. ED Manager reported they used redirection, distractions, and contacting law enforcement as interventions to decrease Patient #11's risk for elopement, and when Patient #11 was returned to the ED after they eloped, staff continued redirection and tried to occupy Patient #11's time by offering a variety of activities.

11. During a follow up interview on 8/29/23 at 10:25 AM, ED Manager reported they were unable to find any nursing documentation regarding Patient #11 eloping from the ED or any assessment of Patient #11's elopement risk or psychosocial assessment on admission to the ED. The ED nursing staff failed to document Patient #11's elopement risk and psychosocial assessment until the morning after Patient #11 was admitted to the ED (approximately 12 hours after their admission).

12. During a follow up interview on 8/29/23 at 12:00 PM, ED Manager reported they were only able to ascertain the date and time on two of Patient #11's three elopements from the ED. ED Manager reported talking with MD A, who was unable to recall anything about Patient #11's elopements. ED Manager also reported there were no incident reports completed on Patient #11 eloping from the ED. ED Manager reported on 5/30/23 at 8:05 AM Patient #11 left the ED, but did not get off hospital property, law enforcement arrived immediately, and assisted getting Patient #11 back into the ED. ED Manager also reported they contacted dispatch for the local law enforcement and they were able to provide information on one of Patient #11's elopements from the ED, and reported on 5/30/23 at 10:05 PM law enforcement was dispatched for Patient #11 eloping from the ED, 10:06 PM Patient #11 was located, 10:07 PM Patient #11 was convinced by law enforcement to return to the hospital, and at 10:16 PM Patient #11 was back in the hospital and law enforcement left.

13. During an interview on 8/17/23 at 10:45 AM, MD B was unable to recall Patient #11, and reported they see many patients in the ED for mental health and behavioral health issues. MD B reported that patients that come to the ED can just walk out if they do not want to stay.

14. Review of Patient #11's Law Enforcement "Call For Service Record" revealed:

a. On 5/29/23 at 6:51 PM, law enforcement was called out for Patient #11 entering the home of another individual without permission. Patient #11 was located by law enforcement and transported to the CAH ED.

b. On 5/30/23 at 7:45 AM, CAH staff called to report they could not get Patient #11 back inside and they were roaming the parking lot.

c. On 5/30/23 at 7:52 AM, law enforcement had Patient #11 in their truck.

d. On 5/30/23 at 7:54 AM, Patient #11 was back in the hospital.

e. On 5/30/23 at 8:36 AM, law enforcement was notified that Patient #11 kept leaving the ED, they were going to give them medication, and asked that law enforcement send a deputy.

f. On 5/30/23 at 8:43 AM, law enforcement noted they were taking Patient #11 back to the hospital.

g. On 5/30 at 10:05 PM, law enforcement was notified that Patient #11 was leaving the ED again on foot.

h. On 5/30 at 10:06 PM, Patient #11 was located.

i. On 5/30 at 10:07 PM, Patient #11 was convinced to return to the ED.

j. On 5/30 at 10:16 PM, Patient #11 was returned to the ED by law enforcement.

15. Review of Patient # 11's medical record, law enforcements "Call For Service Record," and staff interviews showed that Patient #11 had severe mental illness and was a safety risk to them self and others due to their illness. The CAH failed to provide Patient #11 with all available and appropriate stabilizing treatment including providing treatment for Pa

Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the Emergency Department (ED) staff provided 1 of 20 emergency patients reviewed (Patient #6) with an appropriate medical screening exam (MSE) after presenting to their ED by law enforcement with a request made on their behalf for medical care. Failure to provide an appropriate MSE resulted in Patient #6, a patient with psychosis, schizoaffective disorder, and hypertension having a delay in stabilizing treatment and requiring hospitalization at another hospital until placement in an inpatient behavioral health (BH) facility was found, and could have potentially resulted in Patient #6 causing injury to them self or others. The CAH's administrative staff identified an average of 141 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #6's medical record revealed:

a. On 6/24/23 at 7:07 AM, Patient #6 presented to the ED by law enforcement for behavior issues, and was assigned to see MD A. RN D documented in Patient #6's medical record that "patient is obviously under the influence of some substance, officer got patient to sit in patient room to get assessed."

b. On 6/24/23 at 7:15 AM, RN D documented that Patient #6 "became extremely agitated and aggressive, screaming that [Patient #6] 'wasn't going to see a foreign Asian doctor and have [them] tell [Patient #6] what [Patient #6] was going to do,' and slamming the room door, slamming a bedside table into walls, charging at staff, and threatening to throw a chair, staff were unable to calm [Patient #6] and [Patient #6] became more aggressive." Law enforcement was notified of staff needing assistance. Patient #6 was at the nurse ' s station sitting on the floor when law enforcement returned.

c. On 6/24/23 at 7:18 AM, RN D noted in Patient #6's medical records they left without being seen, before triage.

d. On 6/24/23 at 7:20 AM, RN D documented that Patient #6 was "refusing care here and requesting to leave this facility." Patient #6 was removed from the CAH by law enforcement per their request. A "Departure Prior to Dismissal" form was completed by RN D, which also noted Patient #6 was screaming they did not want to be seen at the CAH, they wanted to go to Hospital B, and was picked up by law enforcement per their request.

e. On 6/24/23, Patient #6 refused to have their vital signs taken, have any cares or treatment provided to them, or have an MSE completed by MD A while in the ED. There was no documentation to support that an attempt was made by MD A to provide an MSE or treatment to Patient #6 after law enforcement returned to assist with Patient #6. Patient #6 was removed from the ED by law enforcement 13 minutes after arriving at the ED.

2. During an interview on 8/22/23 at 9:00 AM, Sheriff K recalled transporting Patient #6 to the ED after being called out for Patient #6 causing damage at their mother's home. Sheriff K reported Patient #6 became combative while in the ED, verbalizing they did not want to be seen at that ED, and wanted to be taken to Hospital B because they had a doctor there.

3. During an interview on 8/17/23 at 3:00 PM, RN D recalled Patient #6 was brought into the ED by law enforcement. RN D reported Patient #6 became agitated, and was screaming at staff that they did not want to be there. Patient #6 was charging at staff, pushing a bedside table into the walls, and slamming doors. RN D reported they called law enforcement back to the ED to get Patient #6, as Patient #6 did not want to be seen at their ED, and was reporting Patient #6 wanted to go to Hospital B, because their BH provider was there. RN D reported after Patient #6 was told they did not have to be seen at their ED, Patient #6 was calm, relaxed, and sat down until law enforcement returned.

4. During a follow-up interview on 8/21/23 at 9:42 AM, RN D reported they did not offer to have Patient #6 transferred to Hospital B, or explain the risks and benefits of a transfer to another facility due to Hospital B being a "lateral transfer" (between hospitals with comparable resources). RN D also reported that because Hospital B did not have a BH provider, and that Patient #6's BH provider was at another location in the same town as Hospital B, RN D again said this would be a "lateral transfer," so they couldn't do it.

5. During an interview on 8/23/23 at 10:00 AM, Paramedic I recalled Patient #6 was brought into the ED by law enforcement, was placed in an exam room, and law enforcement left. Paramedic I reported telling RN D they would obtain Patient #6 ' s vital signs, but when Paramedic I attempted to do this, Patient #6 verbalized they did not want to be touched. Paramedic I recalled Patient #6 pushing the bedside table into the bed and toward Paramedic I, repeating they did not want to be touched. Paramedic I recalled Patient #6 slamming the exam room door. Paramedic I could not recall if Patient #6 verbalized not wanting to been seen in the ED, but did recall Patient #6 verbalizing they wanted to be taken to Hospital B. Law enforcement was called to come back to the ED to assist staff with Patient #6. Paramedic I recalled Patient #6 was calmer when law enforcement was present.

6. During an interview on 8/17/23 at 11:30 AM, MD A recalled they were sleeping when Patient #6 came into the ED, it was early on a Sunday around 6:30 or 7:00 AM, and MD A heard someone yelling, then a loud bang. MD A recalled hearing a patient saying things like "get out," and "get away from me," then they slammed the door, and was swearing. The nurse was trying to get Patient #6's vital signs, but they were saying "get off of me." MD A recalled the nurse trying to explain what they were doing, and that staff were trying to help Patient #6, but they kept yelling and not listening. MD A reported Patient #6 calling them a foreigner, and saying they could not understand my English. MD A also recalled Patient #6 saying they were not going to stay, and staff telling Patient #6 that they could leave. MD A failed to document their encounter with Patient #6 in the medical record.

7. During a follow-up interview on 8/23/23 at 11:17 AM, MD A reported that ED staff told Patient #6 they could transfer to Hospital B, but told Patient #6 to let them ask a few questions, but Patient #6 was swinging their hands, and that is when Patient #6 told MD A their English was bad. MD A recalled Patient #6 went outside and that ED staff did not follow Patient #6 outside. Reporting that law enforcement returned at that time, but did not come back into the ED, and took Patient #6 from the parking lot. MD A recalled watching Patient #6 and law enforcement talking outside on the monitor in the ED, but MD A did not go outside. MD A denied offering Patient #6 any screening or treatment after law enforcement returned to the ED. MD A failed to document that a transfer was offered to Patient #6 or that they attempted to educate Patient #6 on the risks and benefits of being transferred to another ED.

8. During an interview on 8/17/23 at 12:45 PM, LPN G recalled they were at the nurse's station when Patient #6 was brought into the ED by law enforcement. Reporting that when the paramedic went to get Patient #6's vital signs, they became violent, was throwing the bedside table around, and yelling at staff. LPN G reported Patient #6 wanted to be taken to Hospital B.

9. During an interview on 8/22/23 at 9:00 AM, Sheriff K recalled returning to the ED to pick up Patient #6, transporting them to the Sheriff 's office, and then having Deputy J transport Patient #6 to Hospital B.

10. During an interview on 8/18/23 at 11:07 AM, Deputy J recalled transporting Patient #6 to Hospital B ' s ED. Deputy J reported Patient # 6 was initially taken from the ED to the Sheriff ' s office to decide what the best option was for Patient #6, either taking them to jail or to another hospital for mental health help. It was decided to take Patient #6 to Hospital B, because Patient #6 was verbalizing that was where they wanted to go, and that all their doctors were there, including their therapist. Deputy J also reported they contacted Hospital B to inform them that Patient #6 was being brought to their hospital, and provided them with Patient #6's name, date of birth, and reason for bringing them.

11. Review of Patient #6's medical record from Hospital B revealed:

a. On 6/27/23 at 8:15 AM, Patient #6 presented to Hospital B's ED (55 minutes after leaving CHI Health - Mercy Corning ED) by law enforcement for a psychiatric Evaluation and received an approprate MSE.

b. On 6/24/23 at 9:08 AM, Patient #6's blood alcohol level was negative.

c. On 6/24/23 at 9:10 AM, RN M documented that Patient #6 pointed their finger at RN M, stated "You get out of here or I'll make you leave," and law enforcement had to redirect the patient.

d. On 6/24/23 at 9:48 AM, CRNA N documented that Patient #6 was confused about place and time, was talking about random facts, and was unable to complete a thought. CRNA N noted Patient #6 had moments of verbal outbursts and was verbally aggressive, but had not been physically aggressive. CRNA N also noted that Patient #6 had sent a text message to their mother the day before being in the ED threatening to end Patient #6's life, and when asked about feeling suicidal or if they had a plan, Patient #6 did not answer. CRNA N documented that Patient #6 was disoriented, inattentive, anxious with blunt affect, their speech was rapid and pressured, behavior was agitated, they were paranoid and delusional, cognition was impaired, and judgment was impulsive. Patient #6 was noted to be medically stable for a psychiatric evaluation and treatment. Patient #6 was diagnosed with psychosis, schizoaffective disorder, and hypertension.

e. On 6/24/23 at 2:37 PM, documentation from the ITP psychiatric evaluation noted that Patient #6 presented to the ED paranoid, was unable to finish a thought, was disorganized, had flight of ideas, was tangential, and was unable to participate in an assessment. It was also noted in the evaluation that Patient # 6 was given their outpatient medications in the ED earlier in the day, and had been resting after being initially agitated and verbally aggressive on admission to the ED.

f. Patient #6 remained at Hospital B's ED until he was transferred to an inpatient BH facility on 6/28/23 at 10:19 AM.

12. During an interview on 8/21/23 at 2:40 PM, RN M recalled caring for Patient #6 while in the ED at Hospital B, and that Patient #6 would only talk to law enforcement when they first arrived. RN M reported Patient #6 was in the hallway during his ED stay yelling and screaming at RN M, threw a pen and paper at RN M, and law enforcement was contacted to come back to assist with Patient #6.

13. During an interview on 8/22/23 at 10:35 AM, CRNA N recalled Patient #6 was brought to Hospital B's ED in handcuffs, by law enforcement, and was talking incoherently. Reporting Patient #6's was delusional, theatrical with his movements, was all over the place, and was not able to answer questions and would just keep talking. CRNA N reported Patient #6 would be tolerant with staff one minute and the next minute, they would elevate their voice, being verbally aggressive toward staff. CRNA N reported they did not receive a report from staff at the initial ED for Patient #6, and that an RN from Hospital B contacted the initial ED to inquire about Patient #6.

14. Patient #6's medical record review, and staff interviews showed the CAH failed to provide Patient #6 an appropriate transfer to Hospital B after verbalizing several times they wanted to go to Hospital B where their provider was located. The CAH staff failed to show that an attempt was made to explain the risks and benefits of Patient #6 being transferred to another hospital. The CAH staff also failed to attempt any screening or treatment to Patient #6 after law enforcement returned to the ED to assist with Patient #6. This resulted in delaying Patient #6 receiving an appropriate MSE, and could have potentially resulted in Patient #6 causing injury to them self or others.

Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the Emergency Department (ED) staff provided 1 of 20 emergency patients reviewed (Patient #11) with all available and appropriate stabilizing treatment after presenting to the ED seeking medical care. Failure to provide all available and appropriate stabilizing treatment at the CAH's ED resulted in Patient #11 eloping from the ED three times which could have potentially resulted in Patient #11 causing injury to them self or others due to their serious mental illness. The CAH's administrative staff identified an average of 141 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #11's medical record revealed:

a. On 5/29/23at 7:38 PM, Patient #11 presented to the ED by law enforcement for a mental health evaluation after being found wandering into someone's house thinking they were going to buy it.

b. On 5/29/23 at 7:55 PM, MD A was in the room with Patient #11 and a medical screening examination (MSE) was performed. Documentation by MD A on Patient #11's physical exam noted Patient #11 to be in acute distress, and was alert and disoriented. Patient #11 was noted to be inattentive with auditory and visual hallucinations. Their mood was documented as depressed with labile, blunt, and flat affect. Patient #11's speech was slurred. Patient #11 was noted to be cooperative, but their thought content was paranoid and delusional, their cognition was impaired, and judgement was impulsive. MD A also noted in their progress note that Patient #11 was wanting their IV out and was wanting to leave. MD A documented being concerned for Patient #11's safety. Patient #11 was medically cleared for a psychiatric evaluation and MD A ordered risperidone (medication used to treat mental health) 1mg to be given after their psychiatric evaluation, to calm Patient #11 down.

c. On 5/29/23 at 8:24 PM, RN E documented communication with Patient #11's sister and that law enforcement spoke with Patient 11's sister as well.

d. On 5/29/24 at 8:31 PM, RN E documented that law enforcement called the Magistrate to inquire about committal.

e. On 5/29/23 at 8:38 PM, RN E called the Magistrate to request a 48 hour hold for Patient #11's danger to self and a 48-hour hold was ordered. It was noted in the court ordered 48-hour hold that the court found there was probable cause to believe Patient #11 was seriously mentally impaired and because of that illness, Patient #11 was likely to physically injure self or others if allowed to remain at liberty. It was also noted on the 48-hour hold that hospital staff and MD A reported Patient #11 was in distress, a danger to them self, was talking them self, answering them self, and that Patient #11 was not likely to remain in the hospital voluntarily.

f. On 5/29/23 at 8:51 PM, MD A ordered risperidone one tablet stat, once.

g. On 5/29/23 at 10:05 PM, RN E noted Patient #11 was on a video call with Integrated Telehealth Partners (ITP).

h. On 5/29/23 at 10:46 PM, RN E gave risperidone 1mg tablet to Patient #11.

i. On 5/30/23 at 6:47 AM, RN O documented an initial safety visual check on Patient #11, and noted Patient #11's behavioral and emotional observation was anxious, flat, and restless with one to one observation.

j. On 5/30/23 at 7:50 AM, RN O documented the first psychosocial assessment for Patient #11, noted they had a 48-hour hold, and was an elopement risk with an answer of yes to Patient #11 having a past history of elopement from a hospital, and a current risk of elopement. An initial mental status assessment was done by RN O and they noted Patient #11 was having hallucinations of vampires biting them and using daggers on their chest.

k. On 5/30/23 at 8:00 AM, RN O documented a safety visual check was completed on Patient #11, and noted Patient #11's behavioral and emotional observation was anxious, uncooperative, and restless.

l. On 5/30/23 at 8:28 AM, RN O documented they spoke with MD A about Patient #11's restlessness, and received orders.

m. On 5/30/23 at 8:30 AM, RN O documented MD A was there to reevaluate Patient #11.

n. On 5/30/23 at 8:47 AM, RN O documented risperidone 1mg tablet was given to Patient #11.

o. On 5/30/23 at 9:56 AM, RN O documented a safety visual check was completed on Patient #11, and noted Patient #11's behavioral and emotional observation was calm. RN O noted Patient #11 was one to one observation and was lying down and/or sleeping.

p. On 5/30/23 at 10:58 AM, RN O documented a safety visual check was completed on Patient #11, and noted Patient #11's behavioral and emotional observation was cooperative. RN O noted Patient #11 was one to one observation and was lying down and/or sleeping.

q. On 5/30/23 at 1:00 PM, RN S noted contacting Patient #11's outpatient behavioral health (BH) provider, and Patient #11 was discharged from their care "several months ago due to noncompliance with medication," and the last time Patient #11 would have received an injection, would have been February 2021.

r. On 5/30/23 at 8:00 PM, RN Q documented a second assessment on Patient #11's elopement risk, and an initial suicide/self-injury and harm to others assessment.

s. On 5/30/23 at 11:30 PM, RN Q documented MD A was notified of Patient #11's restlessness, and of current placement status.

t. On 5/30/23 at 11:34 PM, MD A ordered risperidone tablet stat, once.

u. On 5/30/23 at 11:51 PM, RN Q gave risperidone 1mg tablet to Patient #11.

v. On 5/30/23 at 1:12 PM, RN O documented a safety visual check was completed on Patient #11, and noted Patient #11's behavioral and emotional observation was anxious and flat. RN O noted Patient #11 was one to one observation and was lying down and/or sleeping.

w. On 5/30/23 at 2:23 PM, RN O documented a safety visual check was completed on Patient #11, and noted Patient #11's behavioral and emotional observation was calm. RN O noted Patient #11 was one to one observation and was lying down and/or sleeping.

x. On 5/30/23 at 3:11 PM, RN O documented a safety visual check was completed on Patient #11, and noted Patient #11's behavioral and emotional observation was calm. RN O noted Patient #11 was one to one observation and was lying down and/or sleeping.

y. On 5/30/23 at 4:45 PM, RN S documented a safety visual check was completed on Patient #11, and noted Patient #11's behavioral and emotional observation was calm, cooperative, and restless. From 4:45 PM on 5/30/23 until 6:30 AM on 5/31/23, safety visual checks were completed routinely every 15 minutes.

z. On 5/30/23 at 5:15 PM, RN S documented Patient #11 was "out to nurse's station frequently asking if [Patient #11] can leave yet; goes back to room without difficulty when told no."

aa. On 5/31/23 at 8:21, 9:28, 9:58, 10:32, and 11:15 AM, RN O documented a safety visual check were completed on Patient #11, and noted Patient #11's behavioral and emotional observation was calm. RN O noted Patient #11 was one to one observation and was lying down and/or sleeping.

bb. On 5/31/23 at 9:26 AM, RN O documented that ITP staff call to check on Patient #11 and that there was still no acceptance for an inpatient BH facility.

cc. On 5/31/23 at 9:56 AM, RN O documented that court paperwork for Patient #11 was faxed to inpatient BH, they were contacted with a bed assignment for Patient #11, and the accepting provider's information was obtained.

dd. On 5/31/23 at 11:11 AM RN O documented they contacted the inpatient BH's transfer center for an update on Patient #11, and was informed they were waiting on the charge nurse and nurse practitioner at the inpatient BH facility to assign a bed to Patient #11, and to receive the official acceptance of Patient #11.

ee. On 5/31/23 at approximately 12:06 PM, MD A documented in their progress note for Patient #11 that during Patient #11's two days in the ED, Patient #11 eloped three times, and was brought back by law enforcement. MD A also noted Patient #11 to be easily redirected, and was cooperative with staff.

ff. On 5/31/23 at 12:07 PM, RN O documented calling report to the nurse at the receiving inpatient BH facility.

gg. On 5/31/23 at 12:35 PM, order risperidone tablet stat once, 1 occurrence

hh. On 5/31/23 at 1:10 PM, risperidone 1mg tablet given to patient.

ii. On 5/31/23 at 1:11 PM, Patient #11 was transferred to an inpatient BH facility by ground ambulance.
2. During an interview on 8/17/23 at 10:00 AM, RN E recalled caring for Patient # 11 when they were brought into the ED by law enforcement. RN E reported when caring for Patient #11, they were cooperative, not violent, was not making any sense, and was wanting to go home. RN E denied that Patient #11 eloped from the ED during the time they cared for Patient #11, reporting Patient #11 was present in the ED the whole time.

3. During an interview on 8/17/23 at 11:30AM, MD A did not recalled Patient #11.

4. During an interview on 8/28/23 at 3:45 PM, RN O recalled caring for Patient #11 during his ED stay, and during that time Patient #11 walked out of the ED one time. RN O reported Patient #11 was not able to be redirected by staff and he left the property. RN O reported one nurse followed Patient #11 as long as possible, while RN O called to report Patient #11's elopement to law enforcement. RN O was unable to recall if Patient #11 eloped from the ED more than once during their shift. RN O denied putting additional interventions in place after Patient #11 was brought back to the ED by law enforcement after eloping.

5. During an interview on 8/28/23 at 2:00 PM, RN Q recalled Patient #11 eloping from the ED in the middle of the night. RN Q reported Patient #11 was not suicidal, or a danger to them self or others, but recalled they wanted to go home. RN Q reported following Patient #11 out of the hospital, watched him walk into the woods, and called law enforcement to make sure Patient #11 was safe.

6. During an interview on 8/28/23 at 2:30 PM, CNA P recalled Patient #11 being in the ED, and the nurses would try to talk to Patient #11 when they were trying to walk out of the ED, but they would not listen to anyone. CNA P reported Patient #11 eloped from the ED one night, and one nurse and a paramedic followed Patient #11 as long as they could, then contacted law enforcement. CNA was unable to recall additional intervention for Patient #11 after their elopement from the ED.

7. During an interview on 8/28/23 at 4:45 PM, ED Manager recalled Patient #11 was brought to the ED by law enforcement after going into an elderly woman's home thinking they were going to buy it. ED Manager reported Patient #11 was in the ED for a few days until placement was found for them, and Patient #11 would come out of their room frequently, "like every three seconds to fifteen minutes" asking if he could leave. ED Manager recalled Patient #11 getting out of the hospital, but was not completely off the property when law enforcement picked them up, and brought Patient #11 back into the ED. ED Manager reported nursing staff trying numerous distractions for Patient #11, but nothing worked. ED Manager reported Patient #11 had been off his psychiatric medication for approximately two or three years. ED Manager was not able to recall Patient #11 eloping from the ED three times. ED Manager reported they used redirection, distractions, and contacting law enforcement as interventions to decrease Patient #11's risk for elopement, and when Patient #11 was returned to the ED after they eloped, staff continued redirection and tried to occupy Patient #11's time by offering a variety of activities.

8. During a follow up interview on 8/29/23 at 10:25 AM, ED Manager reported they were unable to find any nursing documentation regarding Patient #11 eloping from the ED or any assessment of Patient #11's elopement risk or psychosocial assessment on admission to the ED. The ED nursing staff failed to document Patient #11's elopement risk and psychosocial assessment until the morning after Patient #11 was admitted to the ED (approximately 12 hours after their admission).

9. During a follow up interview on 8/29/23 at 12:00 PM, ED Manager reported they were only able to ascertain the date and time on two of Patient #11's three elopements from the ED. ED Manager reported talking with MD A, who was unable to recall anything about Patient #11's elopements. ED Manager also reported there were no incident reports completed on Patient #11 eloping from the ED. ED Manager reported on 5/30/23 at 8:05 AM Patient #11 left the ED, but did not get off hospital property, law enforcement arrived immediately, and assisted getting Patient #11 back into the ED. ED Manager also reported they contacted dispatch for the local law enforcement and they were able to provide information on one of Patient #11's elopements from the ED, and reported on 5/30/23 at 10:05 PM law enforcement was dispatched for Patient #11 eloping from the ED, 10:06 PM Patient #11 was located, 10:07 PM Patient #11 was convinced by law enforcement to return to the hospital, and at 10:16 PM Patient #11 was back in the hospital and law enforcement left.

10. During an interview on 8/17/23 at 10:45 AM, MD B was unable to recall Patient #11, and reported they see many patients in the ED for mental health and behavioral health issues. MD B reported that patients that come to the ED can just walk out if they do not want to stay.

11. Review of Patient #11's Law Enforcement "Call For Service Record" revealed:

a. On 5/29/23 at 6:51 PM, law enforcement was called out for Patient #11 entering the home of another individual without permission. Patient #11 was located by law enforcement and transported to the CAH ED.

b. On 5/30/23 at 7:45 AM, CAH staff called to report they could not get Patient #11 back inside and they were roaming the parking lot.

c. On 5/30/23 at 7:52 AM, law enforcement had Patient #11 in their truck.

d. On 5/30/23 at 7:54 AM, Patient #11 was back in the hospital.

e. On 5/30/23 at 8:36 AM, law enforcement was notified that Patient #11 kept leaving the ED, they were going to give them medication, and asked that law enforcement send a deputy.

f. On 5/30/23 at 8:43 AM, law enforcement noted they were taking Patient #11 back to the hospital.

g. On 5/30 at 10:05 PM, law enforcement was notified that Patient #11 was leaving the ED again on foot.

h. On 5/30 at 10:06 PM, Patient #11 was located.

i. On 5/30 at 10:07 PM, Patient #11 was convinced to return to the ED.

j. On 5/30 at 10:16 PM, Patient #11 was returned to the ED by law enforcement.

12. Review of Patient # 11's medical record, law enforcements "Call For Service Record," and staff interviews showed that Patient #11 had severe mental illness and was a safety risk to them self and others due to their illness. The CAH failed to provide Patient #11 with all available and appropriate stabilizing treatment including providing treatment for Patient #11's severe mental illness while being held in the ED waiting for a bed in an inpatient BH facility. The CAH failed to provide interventions to assure Patient #11's safety while in their ED, allowing Patient #11 to elope from the CAH on 3 different occasions putting them self and others at risk for injury or harm.

Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the Emergency Department (ED) staff provided 1 of 20 emergency patients reviewed (Patient #6) with an appropriate transfer after presenting to their ED and requested to go to another hospital. Failure to provide an appropriate transfer from the ED resulted in Patient #6, a patient with psychosis (mental illness with disconnection from reality), schizoaffective disorder (mental illness affecting mood and behavior), and hypertension (high blood pressure), having a delay in receiving an appropriate medical screening exam (MSE) to stabilize their emergency medical condition (EMC), and required hospitalization at another hospital for stabilizing treatment until placement in an inpatient behavioral health (BH) facility was found, and could have could have potentially resulted in Patient #6 causing injury to them self or others. The CAH's administrative staff identified an average of 141 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #6's medical record revealed:

a. On 6/24/23 at 7:07 AM, Patient #6 presented to the ED by law enforcement for behavior issues, and was assigned to see MD A. RN D documented in Patient #6's medical record that "patient is obviously under the influence of some substance, officer got patient to sit in patient room to get assessed."

b. On 6/24/23 at 7:15 AM, RN D documented that Patient #6 "became extremely agitated and aggressive, screaming that [Patient #6] 'wasn't going to see a foreign Asian doctor and have [them] tell [Patient #6] what [Patient #6] was going to do,' and slamming the room door, slamming a bedside table into walls, charging at staff, and threatening to throw a chair, staff were unable to calm [Patient #6] and [Patient #6] became more aggressive." Law enforcement was notified that staff needed assistance. Patient #6 was at the nurse's station sitting on the floor when law enforcement returned.

c. On 6/24/23 at 7:18 AM, RN D noted in Patient #6's medical records they left without being seen, before triage.

d. On 6/24/23 at 7:20 AM, RN D documented that Patient #6 was "refusing care here and requesting to leave this facility." Patient #6 was removed from the CAH by law enforcement per their request. A "Departure Prior to Dismissal" form was completed by RN D, which also noted Patient #6 was screaming they did not want to be seen at the CAH, they wanted to go to Hospital B, and was picked up by law enforcement per their request.

e. On 6/24/23, documentation in Patient #6's medical records failed to address that Patient #6 was given the option for an appropriate transfer after verbalizing to staff that they wanted to go to Hospital B. The documentation also failed to address that staff attempted to explain the risks and benefits to Patient #6 regarding a transfer to another facility.

2. During an interview on 8/22/23 at 9:00 AM, Sheriff K recalled transporting Patient #6 to the ED after being called out for Patient #6 causing damage at their mother's home. Sheriff K reported Patient #6 became combative while in the ED, verbalizing they did not want to be seen at that ED, and wanted to be taken to Hospital B because they had a doctor there.

3. During an interview on 8/17/23 at 3:00 PM, RN D recalled Patient #6 was brought into the ED by law enforcement. RN D reported Patient #6 became agitated, and was screaming at staff that they did not want to be there. Patient #6 was charging at staff, pushing a bedside table into the walls, and slamming doors. RN D reported they called law enforcement back to the ED to get Patient #6, as Patient #6 did not want to be seen at their ED, and was reporting Patient #6 wanted to go to Hospital B, because their BH provider was there.

4. During a follow-up interview on 8/21/23 at 9:42 AM, RN D reported they did not offer to have Patient #6 transferred to Hospital B, or explain the risks and benefits of a transfer to another facility due to Hospital B being a "lateral transfer" (between hospitals with comparable resources). RN D also reported that because Hospital B did not have a BH provider, and that Patient #6's BH provider was at another location in the same town as Hospital B, RN D again said this would be a "lateral transfer," so they couldn ' t do it.

5. During an interview on 8/23/23 at 10:00 AM, Paramedic I recalled Patient #6 was brought into the ED by law enforcement, placed in an exam room, and law enforcement left. Paramedic I reported telling RN D they would obtain Patient #6 ' s vital signs, but when Paramedic I attempted to do this, Patient #6 verbalized they did not want to be touched. Paramedic I recalled Patient #6 pushing the bedside table into the bed and toward Paramedic I, repeating they did not want to be touched. Paramedic I recalled Patient #6 slamming the exam room door. Paramedic I could not recall if Patient #6 verbalized they were not wanting to been seen in the ED, but did recall Patient #6 verbalizing they wanted to be taken to Hospital B. Law enforcement was called to come back to the ED to assist staff with Patient #6. Paramedic I recalled Patient #6 was calmer when law enforcement was present.

6. During an interview on 8/17/23 at 11:30 AM, MD A recalled they were sleeping when Patient #6 came into the ED, it was early on a Sunday around 6:30 or 7:00 AM, and MD A heard someone yelling, then a loud bang. MD A recalled hearing a patient saying things like "get out," and "get away from me," then they slammed the door, and was swearing. The nurse was trying to get Patient #6's vital signs, but they were saying "get off of me." MD A recalled the nurse trying to explain what they were doing, and that staff were trying to help Patient #6, but they kept yelling and not listening. MD A reported Patient #6 calling them a foreigner, and saying they could not understand their English. MD A also recalled Patient #6 saying they were not going to stay, and staff telling Patient #6 that they could leave. MD A failed to document their encounter with Patient #6 in the medical record.

7. During a follow-up interview on 8/23/23 at 11:17 AM, MD A reported that ED staff told Patient #6 they could transfer to Hospital B, but told Patient #6 to let them ask a few questions, but Patient #6 was swinging their hands, and that is when Patient #6 told MD A their English was bad. MD A recalled Patient #6 went outside and that ED staff did not follow Patient #6 outside. Reporting that law enforcement returned at that time, but did not come back into the ED, and took Patient #6 from the parking lot. MD A recalled watching Patient #6 and law enforcement talking outside on the video monitor in the ED, but MD A did not go outside. MD A denied offering Patient #6 any screening or treatment after law enforcement returned to the ED. MD A failed to document that a transfer was offered to Patient #6 or that they attempted to educate Patient #6 on the risks and benefits of being transferred to another ED.

8. During an interview on 8/17/23 at 12:45 PM, LPN G recalled they were at the nurse's station when Patient #6 was brought into the ED by law enforcement. Reporting that when the paramedic went to get Patient #6's vital signs, they became violent, was throwing the bedside table around, and yelling at staff. LPN G reported Patient #6 wanted to be taken to Hospital B.

9. During an interview on 8/22/23 at 9:00 AM, Sheriff K recalled returning to the ED to pick up Patient #6, transporting them to the Sheriff 's office, and then having Deputy J transport Patient #6 to Hospital B.

10. During an interview on 8/18/23 at 11:07 AM, Deputy J recalled transporting Patient #6 to Hospital B's ED. Deputy J reported Patient # 6 was initially taken from the ED to the Sheriff's office to decide what the best option was for Patient #6, either taking them to jail or to another hospital for mental health help. It was decided to take Patient #6 to Hospital B, because Patient #6 was verbalizing that was where they wanted to go, and that all their doctors were there, including their therapist. Deputy J also reported they contacted Hospital B to inform them that Patient #6 was being brought to their hospital, and provided them with Patient #6's name, date of birth, and reason for bringing them.

11. Review of Patient #6's medical record from Hospital B revealed:

a. . On 6/27/23 at 8:15 AM, Patient #6 presented to Hospital B's ED (55 minutes after leaving CHI Health - Mercy Corning ED) by law enforcement for a psychiatric Evaluation and received an approprate MSE.

b. On 6/24/23 at 9:48 AM, CRNA N documented that Patient #6 was confused about place and time, was talking about random facts, and was unable to complete a thought. CRNA N noted Patient #6 had moments of verbal outbursts and was verbally aggressive, but had not been physically aggressive. CRNA N also noted that Patient #6 had sent a text message to their mother the day before being in the ED threatening to end Patient #6's life, and when asked about feeling suicidal or if they had a plan, Patient #6 did not answer. CRNA N documented that Patient #6 was disoriented, inattentive, anxious with blunt affect, their speech was rapid and pressured, behavior was agitated, they were paranoid and delusional, cognition was impaired, and judgment was impulsive. Patient #6 was noted to be medically stable for a psychiatric evaluation and treatment. Patient #6 was diagnosed with psychosis, schizoaffective disorder, and hypertension.

c. On 6/24/23 at 2:37 PM, documentation from the ITP psychiatric evaluation noted that Patient #6 presented to the ED paranoid, was unable to finish a thought, was disorganized, had flight of ideas, was tangential, and was unable to participate in an assessment. It was also noted in the evaluation that Patient # 6 was given their outpatient medications in the ED earlier in the day, and had been resting after being initially agitated and verbally aggressive on admission to the ED.

d. Patient #6 remained at Hospital B's ED until he was transferred to an inpatient BH facility on 6/28/23 at 10:19 AM.

12. During an interview on 8/21/23 at 2:40 PM, RN M recalled caring for Patient #6 while in the ED at Hospital B, and that Patient #6 would only talk to law enforcement when they first arrived. RN M reported Patient #6 was in the hallway during his ED stay yelling and screaming at RN M, threw a pen and paper at RN M, and law enforcement was contacted to come back to assist with Patient #6.

13. During an interview on 8/22/23 at 10:35 AM, CRNA N recalled Patient #6 was brought to Hospital B's ED in handcuffs, by law enforcement, and was talking incoherently. Reporting Patient #6's was delusional, theatrical with his movements, was all over the place, and was not able to answer questions and would just keep talking. CRNA N reported Patient #6 would be tolerant with staff one minute and the next minute, they would elevate their voice, being verbally aggressive toward staff. CRNA N reported they did not receive a report from staff at the initial ED for Patient #6, and that an RN from Hospital B contacted the initial ED to inquire about Patient #6.

14. Patient #6's medical record review, and staff interviews showed the CAH failed to provide Patient #6 an appropriate transfer to Hospital B after verbalizing several times they wanted to go to Hospital B where their provider was located. The CAH staff failed to show that an attempt was made to explain the risks and benefits of Patient #6 being transferred to another hospital. The CAH staff also failed to attempt any screening or treatment to Patient #6 after law enforcement returned to the ED to assist with Patient #6. This resulted in delaying Patient #6 receiving an appropriate MSE, and could have potentially resulted in Patient #6 causing injury to them self or others.