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Based on observation, interview, record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for three patients (#3, #7 and #8) and failed to ensure stabilization for three patients (#3, #7 and #8) of 23 Emergency Department (ED) records reviewed from 02/15/24 through 07/15/24. The hospital failed to conspicuously post signs in the ED and Labor and Delivery Unit specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMC), and information indicating whether or not the hospital participated in the Medicaid program. These failed practices had the potential to cause harm to all patients who presented to the ED and Labor and Delivery Unit seeking care for an EMC. The hospital's average monthly ED census over the past six months was 716. The hospital's Labor and Delivery average monthly triage (process of determining the priority of a patient's treatment based on the severity of their condition) census over the past six months was 31.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) Requirements Policy," dated 12/20/23, showed:
- Qualified Medical Personnel provide a MSE to each person who comes to the ED. If the individual has an EMC, the ED either provides any necessary stabilizing treatment, provides an appropriate transfer to another hospital or admits the individual as an inpatient.
- An EMC is any condition that is a danger to the health and safety of the patient if not treated in the foreseeable future.
- An EMC consists of a range of conditions including but not limited to undiagnosed, acute (sudden onset) pain which impairs normal functioning, symptoms of alcohol abuse, psychiatric disturbances (e.g., severe depression [extreme sadness that doesn't go away], insomnia [difficulty falling asleep or staying asleep], suicide attempt [to cause one's own death], suicidal ideation [SI, thoughts of causing one's own death] dissociative state [feeling disconnected from yourself and the world around you or the inability to comprehend danger or care for oneself]).
- An MSE is a process required in determining within reasonable clinical confidence whether an EMC exists.
- The screening must be completed within the capabilities of the hospital, must determine what if any further medical examinations and/or treatments may be required to stabilize the patient, or to determine that the patient needs to be transferred to a different facility once the patient is stabilized per the capabilities of the transferring facility.
- Stabilized means that within reasonable clinical confidence, the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, 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 a psychiatric condition, the patient is stabilized when he/she is no longer considered to be a threat to himself/ herself or to others.
- The ED shall not discharge a person without having completed a MSE unless the person or his/her legal representative refuses to consent to the MSE, and the refusal is documented on an approved Patient Consent/Refusal of Treatment Form. If a Person (or legally responsible person) chooses to withdraw his or her request for examination or treatment, and if the staff is aware that the patient intends to leave prior to completion of the MSE or stabilizing treatment, they are to offer the person a MSE and treatment as may be required to identify and stabilize an EMC; inform the person of the benefits of a MSE and and/or stabilizing treatment, and of the risks of leaving prior to receiving a MSE and stabilizing treatment, and take all reasonable steps to obtain the person's written informed refusal of the MSE and stabilizing treatment on an approved Patient Consent/Refusal of Treatment Form. Include documentation of the risks and benefits discussed with the patient in the patient's medical record.
- When the MSE indicates that a patient has an EMC, the ED must provide stabilizing treatment within its capacity and capability or, if the ED does not have the capacity or capability to provide stabilizing treatment, the ED must provide a transfer to another hospital having such capabilities. Until a Person is transferred, the ED must provide treatment to the person within the ED's capacity and capability to minimize the risks to the person's health.
- The ED may not discharge a patient with an EMC until the patient is stabilized or when the patient or his/her legal representative refuses to consent to stabilizing treatment, and the refusal is documented on a the-approved Patient Consent/Refusal of Treatment Form.

Review of the hospital's document titled, "Perry County Health System Emergency Services Rules and Regulations," revised 05/2023, showed:
- The services provided to patients in the ED are collaboratively planned and organized with other clinical service departments.
- All patients will receive an appropriate MSE and stabilization treatment for medical conditions within the hospital's capability and capacity by a physician upon arrival to the ED.
- Any unstable patient in need of an appropriate transfer to another consenting medical facility possessing additional capability and capacity will be coordinated, in a timely manner, using qualified personnel and transportation after known risks/benefits are communicated and documented by the physician.
- Physician consultations regarding risks and benefits of treatment and transfers related to the care of the patient with an EMC should be recorded in the medical record.
- After an MSE and stabilization, the ED physician may arrange for immediate transfer of a patient requiring specialty care not offered or not available at the time of the transfer or by the patient's request.
- The ED was to properly post dedicated ED signage explaining the rights of individuals with EMCs and women in labor and acknowledging the hospital's participation in the Medicaid Program.

Review of the hospital's policy titled, "Clinical Hold for Patients Who Lack Decisional Capacity Guidelines," date 01/2019, showed:
- A clinical hold is ordered by a licensed practitioner (LP) who has assessed the patient and determines that the patient lacks decisional capacity, and that the patient is at imminent risk of serious harm to self or others if the patient leaves the hospital. The patient's LP is required to thoroughly document the patient's condition and reason for clinical hold in the patient Electronic Medical Record (EMR).
- If a LP is not available to issue an order, a clinical hold maybe initiated temporarily, in an emergency situation, by a RN based on appropriate assessment of the patient.
- Clinical coworkers shall monitor the patient and take precautionary steps for the safety of the patient and coworkers.
- Any coworker with knowledge that the patient is on a clinical hold or on a temporary clinical hold is authorized to use measures to prevent the patient from leaving the hospital for the patient's safety.
- When a patient is on a clinical hold, the clinical coworkers must also work to support the patient's rights. Patients are to be included in care decisions and coworkers are expected to perform capacity assessments and seek consent for clinical interventions.
- If a psychiatrist (physician who specializes in mental health disorders) determines that a patient needs ongoing inpatient psychiatric care beyond what the hospital can provide, the hospital pursues an appropriate transfer in accordance with its transfer policy to an inpatient psychiatric facility.


Please refer to 2402, 2406 and 2407 for further details.




50151

Based on observations and interview, the hospital failed to conspicuously post signs in the the Emergency Department (ED) and Labor and Delivery unit specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMCs), and information indicating whether or not the hospital participated in the Medicaid program. These failures had the potential to affect all patients that presented to the ED and the Labor and Delivery unit for emergency medical treatment. The hospital's average monthly ED census over the past six months was 716. The hospital's average monthly Labor and Delivery triage (process of determining the priority of a patient's treatment based on the severity of their condition) census over the past six months was 31.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC)," dated 12/20/23, showed:
- Each Mercy ED shall have appropriate signage notifying individuals of the right to a medical screening exam (MSE) and stabilization treatment as specified under EMTALA as well as information indicating whether the hospital participates in the Medicaid program.
- The sign must be posted in a place easily noticed by all individuals entering the facility.
- The sign must also be posted in a place where it will be noticed by individuals waiting for treatment.

Review of the hospital's document titled, "Perry County Health System Emergency Services Rules and Regulations," revised 05/2023, directed the hospital to properly post dedicated ED signage explaining the rights of individuals with EMCs and women in labor, and acknowledging the hospital's participation in the Medicaid program.

Observation on 07/16/24 at 1:15 PM, in the Labor and Delivery unit, showed no EMTALA signage at the nurses' desk, family waiting room or patient rooms. Two triage rooms each had one EMTALA sign.

During an interview on 07/16/24 at 1:15 PM, Staff B, Obstetrics (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) Manager, stated that patients may be scheduled for procedures and then receive triage treatment in patient rooms without EMTALA signs. She agreed there was no EMTALA signage at the nurses' desk, family waiting room or patient rooms.

Observation on 07/16/24 at 1:20 PM, in the ED, showed no EMTALA signage in the ambulance bay.
During an interview on 07/18/24 at 1:16 PM, Staff C, ED Manager, stated that patients entered the ED through the ambulance bay. She agreed there was no EMTALA signage in the ambulance bay.



50151

Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for three patients (#3, #7 and #8) of 23 Emergency Department (ED) records reviewed from 02/15/24 through 07/15/24. This failed practice had the potential to cause harm to all patients who presented to Mercy Hospital Perry seeking care for an EMC.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) Requirements," dated 12/20/23, showed:
- All patients that come to the ED, will be provided a MSE to determine, with reasonable clinical confidence, if an EMC exists.
- The MSE must determine if any further medical examinations and/or treatments are needed to stabilize the patient or determine if the patient needs to be transferred to a different hospital with the capabilities to provide the needed stabilizing treatment.
- The hospital should not discharge a patient without having completed a MSE and providing stabilizing treatment for their EMC.

Review of the hospital's document titled, "Perry County Health System Emergency Services Rules and Regulations," revised 05/2023, showed:
- The ED physician is responsible for the provision of a MSE to all patients seeking medical aid that have presented to the ED.
- The services provided to patients in the ED are collaboratively planned and organized with other clinical service departments.
- All patients will receive an appropriate MSE and be provided with stabilizing treatment for medical conditions, within the capability and capacity of the hospital, by an ED physician upon arrival to the ED.

Review of the hospital's policy titled, "Clinical Hold (allows a hospital to prevent a patient from leaving when a patient lacks the capacity for decision making) for Patients Who Lack Decisional Capacity Guidelines," date 01/2019, showed:
- A clinical hold is ordered by a licensed practitioner (LP) who has assessed the patient and determines that the patient lacks decisional capacity, and that the patient is at imminent risk of serious harm to self or others if the patient leaves the hospital. The patient's LP is required to thoroughly document the patient's condition and reason for the clinical hold in the patient Electronic Medical Record (EMR).
- If a LP is not available to issue an order, a clinical hold may be initiated temporarily, in an emergency situation, by a RN based on an appropriate assessment of the patient.
- Clinical coworkers shall monitor the patient and take precautionary steps for the safety of the patient and coworkers.
- Any coworker with knowledge that the patient is on a clinical hold or on a temporary clinical hold is authorized to use measures to prevent the patient from leaving the hospital for the patient's safety.
- When a patient is on a clinical hold, the clinical coworkers must also work to support the patient's rights. Patients are to be included in care decisions and coworkers are expected to perform capacity assessments and seek consent for clinical interventions.
- If a psychiatrist (physician who specializes in mental health disorders) determines that a patient needs ongoing inpatient psychiatric care beyond what the hospital can provide, the hospital pursues an appropriate transfer in accordance with its transfer policy to an inpatient psychiatric facility.

Review of the Police Department (PD) E Incident Report Complaint #2024-0469, dated 06/30/24 showed:
- At approximately 8:49 PM, officers were dispatched to a hotel in reference to a male subject having a mental health crisis.
- At approximately 8:52 PM, Staff RR, Police Sergeant, made contact with Patient #8.
- Patient #8 stated that he was not doing very well and was confused about a lot of things. Patient #8 made several strange claims about "bad things he had done" and seemed out of sorts.
- Staff RR spoke with Patient #8's roommate and was told Patient #8 was hitting his head against the wall and she was afraid he would do something worse. Patient #8 was not violent towards the roommate.
- Staff RR informed Staff QQ, Police Officer (PO) and the EMS staff that Patient #8 admitted to suicidal ideations (SI) and he was voluntarily being transported to the Emergency Department (ED) for evaluation and treatment.
- Staff QQ and RR followed the ambulance to the ED due to Patient #8's state of mind. Upon arrival to the ED Patient #8 became noncompliant with ED staff and the Counselor.
- Due to Patient #8's noncompliance, the ED staff requested affidavits from Staff QQ and the EMS staff. Patient #8's status was changed to involuntary due to his statements of a desire to self-harm.
- The ED staff were advised if Patient #8 woke up and became combative to call for assistance and Staff QQ and Staff RR would return to the ED.
- On 07/01/24 at approximately 4:35 AM, officers were dispatched for a report of a male heard screaming as if in pain.
- At approximately 4:40 AM, officers arrived on the scene and Patient #8 was on the side of the road. Patient #8 appeared to have been struck by a vehicle. EMS was requested and Patient #8 was air evacuated for treatment.
- Follow up with the ED staff showed Patient #8 did not cooperate during his Behavioral Health (BH) evaluation and was released from the hospital.
- Staff RR asked the ED staff if the Judge refused to sign the order for a 96-hour hold for BH evaluation and treatment. The ED staff responded the affidavits were not submitted for consideration.
- The ED staff were advised Patient #8's injuries were consistent with contact with the side of a vehicle in transport. It was believed Patient #8 attempted to throw himself in front of a vehicle or into the side of a vehicle to harm himself.

Review of Patient #8's ambulance report #1484, dated 06/30/24, showed:
- Dispatch was for a 32-year-old male having a mental health crisis.
- Upon arrival the patient was talking with a PO. He stated he struggled with mental illness and was not feeling right. The patient stated he thought of hurting himself but did not have a plan. The patient stated he was not taking his medication and had not seen his doctor. The patient stated he was homeless and "wanted it all to end."
- He was agitated and antsy.
- His chief complaint was SI.
- Halfway to the hospital the patient refused to answer any questions or cooperate.
- The patient continued to be uncooperative for the ED staff and the PO. Affidavits were completed by EMS and the PO.

Review of Patient #8's ambulance report #1487, dated 07/01/24, showed:
- Upon arrival on the scene there was a male subject lying face down on the left side of the roadway with a male PO standing over him.
- The patient was alert but unsure of what happened.
- There was blood on his face, swelling on his forehead and his nose was bleeding.
- There was a large hematoma (collection of blood below the surface of the skin) to his forehead with a laceration (a deep cut or tear in skin).
- There was a large area of road rash to the right side of his chest.
- He was unable to answer questions, he would say "I don't know" or would not answer.
- He stated, "he was walking and then everything changed." He did not know if he was struck by a vehicle.
- He complained of pain "everywhere."

Review of Patient #8's air evacuation transport report #91085620, dated 07/01/24, showed:
- The team was called for a major trauma to respond to a 32-year-old male found down on the side of the road.
- The patient was seen at the local ED the day before for SI and was discharged.
- He was found down on the shoulder of the road, noted to have lacerations to his forehead and abrasions (areas of skin damaged by scraping) to his chest, back, arms and legs. He had an altered mental status (mental functioning ranging from slight confusion to coma), was able to answer his name and state he did not know the time of day and did not recall the event prior to EMS arrival or how he was injured. Given his road rash like abrasions and head injury with a change in his mental status EMS was concerned he may have been struck by a vehicle and had a high risk for additional internal injuries.
- He was transported to a trauma center for a higher level of care.

Review of Patient #8's medical record, dated 06/30/24, showed:
- At 9:22 PM, he was a 32-year-old male who arrived at the ED accompanied by a PO with an arrival complaint of SI.
- His past medical history included depression and SI.
- At 9:25 PM, he would not verbalize anything, and his chief complaint was updated to agitation and routine psychiatric/medical clearance. His blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) was 143/100.
- At 9:29 PM, The Columbia-Suicide Severity Rating Scale (C-SSRS, a suicide risk assessment tool) showed information was provided by a PO, the patient would not speak to the hospital staff, he called EMS and reported SI and he was uncooperative.
- At 9:31 PM, a one-to-one (1:1, continuous visual contact with close physical proximity) suicide observation order was placed. The patient was awake in the room, quiet and withdrawn.
- At 9:33 PM, the encounter was related to suicidal behavior/attempt, he would not speak to the staff and per EMS and the PO he indicated he was suicidal.
- At 9:35 PM, a BH intake evaluation was ordered.
- At 9:52 PM, the VBH consult was at his bedside.
- At 9:58 PM, he was on a telemedicine (telemed, remote delivery of healthcare services while the health care provider is at a separate location, including exams and consultations, through video and telephone communication) call for evaluation, was agitated and withdrawn.
- At 10:00 PM through 07/01/24 at 2:45 AM, he was asleep.
- At 10:43 PM, his disposition was set to a voluntary admission to inpatient BH.
- At 10:52 PM, the BH intake coordinator was unable to complete the virtual assessment. He was alert and uncooperative. His speech was regular rate, normal volume, tone and amount. He only responded to questions. His thought process was logical. He was agitated and anxious. His insight (to understand a specific cause and effect) and judgement were fair. Per a medical record review, he was brought to the ED by the police for SI.
- At 11:22 PM, he had potential for insight and few/no coping skills. His emotional state was uncooperative.
- At 2:00 AM, a transfer request was initiated.
- At 2:40 AM, the transfer request was accepted by Hospital D.
- At 2:46 AM, nursing report was given.
- At 3:23 AM, his ED disposition was set to discharge.
- At 3:29 AM, PD E was notified the patient was discharged from the ED.
- At 3:31 AM, an addendum was written and showed when EMS arrived, the patient decided he did not want to go to Hospital D. After speaking with BH, "they stated the patient was offered a voluntary admission and would be discharged if not voluntary as he had made no binding statements to staff or BH that he was a danger to himself of anyone else." The patient stated he could not leave his stuff at the hotel and did not have a ride back to Perryville. BH stated they spoke with Hospital D; they could arrange transport back when he was discharged. The patient was again offered the admission bed at Hospital D. The patient stated the nurse could make the decision. The patient was again told he needed to make a choice, he could go voluntarily, or the physician would discharge him from the ED. The patient chose to discharge from the ED. The patient refused to sign the acknowledgement of paperwork given for discharge. Staff K, RN witnessed the discharge paperwork given and the education material provided.
- At 3:42 AM, he was discharged home and discharge instructions were reviewed. He walked out of the ED.
- The history of present illness showed his history was provided by the PO; the patient was not cooperative/verbally interactive with the ED provider. He was "apparently" staying at a local hotel, police were called for "some kind of mental health crisis," and EMS was summoned. "Apparently, he made some form of statements about SI and hallucinations." According to EMS while enroute to the ED he completely stopped speaking and refused to answer any further questions. On arrival to the ED, he would not speak to the provider or answer questions. Review of his history in the EMR indicated multiple prior psychiatric diagnoses. He did not seem to be taking any of his medications or undergoing any current therapy. EMS and the PO were going to write affidavits regarding their verbal interactions with the patient prior to his arrival at the ED. His orientation status could not be assessed. He did not consent to blood draws, diagnostic testing or other medical interventions. He did not voice suicidality to the provider or in the ED. At 11:05 PM, BH recommended offering admission on a voluntary basis, the patient agreed. He had numerous prior visits to outside hospitals for various forms of substance abuse disorders (characterized by a misuse of alcohol and/or other drugs) alcohol use and psychiatric considerations. At 3:26 AM, he was offered admission, arrangements were made for transfer. The patient determined at the time of transfer that he no longer wanted to be admitted psychiatrically. He was a voluntary admission, there was no hold or judgement against him, in light of that fact, he did not want to be transferred and could be discharged.
- The BH intake assessment showed it was determined the patient was to be admitted to a BH facility. He was an imminent danger to self. His legal status was voluntary.
- Staff QQ, PO, affidavit showed he responded to the hotel in Perryville, MO for a male subject with SI. Upon arrival, Patient #8 stated that he was a "bottom feeder." EMS asked Patient #8 if he was suicidal. The patient was "back and forth." He stated his "head was telling him to do things to himself." Patient #8 went back and forth about wanting to go to the hospital. He became uncooperative and his roommate stated Patient #8 was self-harming by "banging his head on the wall." Patient #8 was transported to the hospital and became uncooperative and silent with the staff.
- An EMS affidavit showed EMS was called for a mental health crisis. Patient #8 was antsy and told the PO to arrest him for his crimes. He told EMS he was not well; he was supposed to be on medication for several mental health problems but did not take them for "a while." When asked if he was suicidal, he responded, "yes, I want it all to end. I want to be brain dead." He had no plan at that time.
- His BH provisional diagnosis was major depressive disorder (an individual with a persistently low or depressed mood) single episode, severe without psychotic features (characterized by defective or lost contact with reality).
- He was combative and uncooperative with the BH intake provider. He refused to answer questions.

Review of the hospital's document titled "Group Conversation" dated 06/30/24, showed:
- At 9:58 PM, Staff Z, BH Intake Specialist, stated that the patient refused to participate in the BH Assessment. She planned to review the medical record and obtain collateral information from a friend or family member.
- At 10:34 PM, Staff Z, stated that the psychiatrist said they could offer inpatient admission, but there were no criteria to admit him involuntarily. If he refused admission he would be discharged.
- At 10:42 PM, Staff U, CNA, placed the virtual cart in Patient #8's room and stated that Patient #8 did not want to talk.
- At 10:44 PM, Staff Z stated that "he talked to me" and she was done with the virtual assessment. The patient gave verbal consent to admission.
- At 10:54 PM, Staff U asked Staff Z if she was able to assess Patient #8. Staff Z responded "no."
- On 07/01/24 at 2:34 AM, the patient was to transfer to Hospital D.
- At 3:13 AM, Staff Y, RN, notified Staff KK, Referral Counselor, the patient refused to go and asked if he could be admitted involuntarily with a judge's warrant.
- At 3:24 AM, Staff Y informed Staff KK the patient was discharged. "He did not want to go." Staff KK responded "alright, thanks for letting me know."

Review of Patient #8's Hospital B medical record dated 07/01/24 showed:
- At 6:26 AM, he arrived via helicopter. He was struck by a vehicle.
- The RN presumed the patient walked in front of a vehicle. She was unsure if he fell or was hit, no person stayed from the vehicle or saw him fall.
- The patient was unable to recall the event.
- The mechanism of the trauma was unknown; the patient was unwilling to provide a history.
- It was suspected the patient caused self-injury due to SI.
- He had road rash abrasions all over his body, both arms and legs. He complained of left elbow and head pain.
- At 6:35 AM his BP was 155/86 and his pulse (normal pulse/heartbeats for adults range from 60 to 100 per minute) was 164.
- His review of systems was positive for joint stiffness, muscle aches/pain and wounds.
- At 6:51 AM, a 1:1 sitter was in place.
- He had abrasions on his right leg, right thigh, right foot, left knee, and right chest wall. He had scattered abrasions to his forehead. He had a four-centimeter (cm) laceration on his forehead and a five cm laceration on his scalp. The lacerations were repaired with stitches and staples.
- His urine drug screen (UDS, a test that analyzes urine for the presence of certain illegal drugs and prescription medications) was positive for amphetamines (stimulant drug), marijuana and fentanyl (an addictive drug).
- At 7:22 AM, his complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) and comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) showed a white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood, normal is 4.5-11) was 23.8. His blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person's health, normal are between 70 and 100) was 133. His aspartate aminotransferase (AST, an enzyme that is found mostly in the liver, normal is 14-20) was 76. His alanine transaminase (ALT, an enzyme that is found mostly in the liver, normal is 4-36) was 91.
- At 7:31 AM, a computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) of his facial bones showed foreign bodies (something that is stuck inside you but is not supposed to be there) in his upper lip.
- Head, cervical spine (neck region of the back), chest, abdominal and pelvis (area of the body below the abdomen) CTs showed no acute (sudden onset) injuries.
- Pelvis and chest x-rays showed no acute injuries.
- At 3:34 PM, a BH intake evaluation was ordered.
- At 3:55 PM, the BH assessment showed he was brought to the ED by EMS after being discharged against medical advice (AMA) from Mercy Hospital Perry. Mercy Hospital Perry, "ED provider let the patient go AMA, even though BH stated he had involuntary criteria."
- At 4:18 PM, the ED disposition was set to involuntary inpatient BH.
- At 4:19 PM, the CSSR's showed he was a high suicide risk.
- At 4:28 PM, he was medically cleared for a BH admission.
- At 11:06 PM, he was transferred to Hospital C.

During an interview on 07/18/24 at 10:30 AM, Staff V, ED Medical Director, stated that the root cause of the event with Patient #8 was a miscommunication with the BH services. The ED provider believed he was speaking with the BH counselor when he was speaking with the bed placement coordinator. The patient refused to talk. He was unaware the patient was hearing voices. The safety planning was completed by the BH counselor, and she was not notified of the discharge. There were no discharge instructions for follow up and no BH resources were provided.

During a telephone interview on 07/23/24 at 10:48 AM, Staff EE, MD, stated that he communicated with the BH intake specialist. "Psychiatry said to admit him to a BHU inpatient, but he did not meet criteria for an involuntary admission." The patient would not talk, he thought the patient was "tweaking" (slang term that means to be under the influence of methamphetamine). Initially Patient #8 consented to admission, a bed was found, transfer was arranged, and the patient refused transfer. The lesson learned was to always ask for a reassessment. If the patient was no longer suicidal per the reassessment, then it was safe to discharge. If the plan was for discharge the intake specialist developed a safety plan with the patient. He did not think of developing a safety plan for Patient #8, it was an oversight. The only communication he had with the intake specialist was via secure chat. When the patient refused to transfer, he called the "BH line" and was told to make him involuntary. He was not aware that he was speaking with bed placement. He "sensed" Patient #8 responded to internal stimuli, he was disorganized. He may have been on Methamphetamine (an illegal stimulant). The patient slept for four hours; he did not need medication. After he slept, he no longer "tweaked" and was not disruptive. He did not know if his awareness of hallucinations would have changed the plan of care. There were "clearly gaps, this event changed his practice." The decision for discharge was based on the information he received that Patient #8 was not a candidate for an involuntary admission.

During an interview on 07/17/24 at 2:30 PM and 07/18/24 at 2:25 PM, Staff C, ED Manager, stated that the police were called because the patient made SI statements. EMS was called and the patient stopped talking. A BH assessment was ordered, he was placed on 1:1 observation and affidavits were completed by EMS and a PO. The patient was initially willing to go to Hospital D voluntarily. When EMS arrived to transport him to Hospital D, he refused the transfer. Bed placement was called, and the hospital was told to "get an involuntary." The affidavits from EMS and the PO were there and he should have been placed on a clinical hold. Hospital D was to get the 96-hour hold. The ED provider decided to discharge Patient #8 because the affidavits were "not weighted enough." It was not the ED's decision to make. If the patient refused to transfer, a safety plan should have been developed. The BH provider was not involved in the RCA.

During a telephone interview on 07/18/24 at 1:55 PM, Staff AA, BH NP, stated that the process was for the intake specialist to evaluate the patient. His/her findings were discussed with the BH provider and recommendations were made. He recommended Patient #8 be admitted involuntarily because he was uncooperative with the BH assessment. The patient should not have been allowed to leave because he was uncooperative. If the decision for discharge was made the intake specialist developed a safety plan with the patient. The intake specialist was to be notified before discharge to create the safety plan. The intake specialist was not notified prior to Patient #8's discharge, no safety plan was developed. There was no documentation in the EMR regarding a voluntary versus involuntary admission. The intake specialist "wrote admit," she did not document "involuntary." The BH provider only talked to the ED provider if there was a difference in opinion with the patient's disposition. The intake specialist is the communicator between the ED provider and the BH provider. Patient #8 was a "straight forward" case. His recommended disposition was involuntary because he would not provide any information.

During a telephone interview on 07/18/24 at 11:45 AM, Staff PP, BH Intake Specialist, stated that Patient #8 came to the ED with a PO and was noncompliant with a virtual assessment. He refused to participate during the assessment. He would not verify his identity. She was told the PO and EMS wrote affidavits. She spoke with Staff AA, BH NP and it was determined the patient would be offered admission based on the medical record notes and affidavits if he was willing to give consent to treatment, he agreed. She was not notified he was discharged. There was no attempt for a BH reassessment. The nurse messaged her at 7:00 AM to say he was discharged and "got hit." The process was the ED provider or nurse should have notified her the patient refused transfer and a reassessment would be completed to determine if the patient was safe for discharge or an involuntary admission needed to be pursued. The bed placement team did not perform assessments and should not make recommendations. Patient #8's affidavits only said he had suicidal thoughts, there was not a plan or intent to self-harm. He needed a full assessment and connection to resources if he was not at an imminent risk of harm to self or others. She was unable to assess him before he was discharged. If discharge was the plan of care, she would have entered resources into the EMR and created a safety plan with Patient #8. She was not involved in the RCA.

During a telephone interview on 07/18/24 at 11:15 AM, Staff X, RN, stated that she was the primary nurse for Patient #8. He was brought to the ED by EMS and escorted by a PO. The ED was "super busy." He walked to room three and changed into psychiatric safe clothing. He sat in a chair and looked towards the wall with his arms crossed. He refused to talk and was barefoot. She thought he was drunk. She attempted multiple times to assess him, he seemed "mad." She asked three times to takes is blood pressure, the PO said, "they are not going to hurt you," he "flung" his arm out and his blood pressure was taken. He refused to talk; she could not assess him. The PO said, "he was just going through some stuff and needed help." A psychiatric consult was ordered. He refused to answer questions about SI and homicidal ideation (HI, thoughts or attempts to cause another's death). The PO said, he was feeling suicidal. The patient initially agreed to the transfer to Hospital D and wanted a copy of the transfer paperwork. When EMS came to transport him, she was not in the room. She was told he said he could not go. She notified Staff EE, MD, and called bed placement to see if he could go involuntarily. Bed placement confirmed Hospital D could take him involuntarily. She was told Hospital D needed "warrants" signed by the judge. Bed placement called her and asked if she had started the involuntary process. Staff EE stated Hospital D needed to initiate the involuntary placement and he was told the patient was a voluntary admission or discharge. The patient did not want to leave his belongings and did not have transportation back to Perryville. Bed placement stated that Hospital D would arrange for transportation back. The patient was told if he agreed to a voluntary admission he would be transported then, and a ride back was available. The patient told Staff X she could decide. She told him he needed to decide. He said "discharge." She informed Staff EE and gave the patient information on psychosis (a serious mental illness characterized by defective or lost contact with reality). The ED was unable to give a diagnosis, he would not talk, he would only say "go" and "no go" regarding the transfer. She asked if he had any questions, he did not respond. She reviewed the discharge paperwork with him, he refused to sign the discharge paperwork. Staff K, RN, witnessed the discharge paperwork and the patient walked out of the ED. She was unsure who she secure chatted with about a voluntary versus involuntary admission. She was unsure if the individual who gave her the bed placement assignment was different than the person who performed his BH evaluation. She was "surprised" he was allowed to discharge because he did not say anything except that he would go. He never responded to her questions regarding SI or HI. He was not violent, he looked angry. Affidavits were present. She was told the BH provider said the affidavits were not "weighted enough" to be "binding." Staff EE told her the BH provider told him the patient was either a voluntary admission or he was discharged because the affidavits were not "binding." She was not aware he heard voices. She was unsure if her awareness of the hallucinations would have changed his plan of care. She assumed the police were called when he was discharged because he initially came to the PO asking to be arrested. After the event she was informed that a nurse could initiate a clinical hold if he/she felt the patient was at risk and the police could be called if an at-risk patient attempted to leave the ED. She was involved in the RCA, and it was determined that there were too many steps for miscommunication with tele-health and the ED staff. Secure chat messages where not a part of the medical record and needed to be added to the documentation.

During an interview on 07/18/24 at 9:23 AM, Staff K, RN, stated that he was the charge nurse during the night of Patient #8's ED visit. There was a high "influx of patients, more than normal." He was responsible to assign the primary nurse and ensure safety precautions were in place. Upon arrival EMS and the PO reported a "vague in nature SI," not specific. The patient refused to speak, SI precautions and a BH consult were ordered. When Patient #8 began to talk he agreed to a voluntary admission and signed the transfer form. When EMS arrived, he refused the transfer. Education was provided to include there was a long wait for a BH bed. He spoke with the ED provider who spoke with "psychiatric services." The provider was told the only "grounds for admission were voluntary." He believed psychiatric services said, "voluntary only." Patient #8 denied SI and HI to him, he did not document this in the medical record. When a patient refused transfer, it was customary to create a safety plan. Resources were provided for all discharges to include hot-line numbers. If a patient had a positive BH assessment a reassessment was performed if the patient refused admission to determine if the patient needed an involuntary admission. He did not feel that Patient #8 was a risk of harm to himself, he did not observe hallucinations. The patient did not want to wait any longer and did not want to leave Perryville. The patient was aware Hospital D would arrange for his transport back to Perryville after his discharge, but the patient did not believe that. The patient was not discharged AMA, the ED provider agreed to his discharge. Patient #8 walked out of the ED.

During an interview on 07/26/24 at 8:25 AM Staff RR, Police Sergeant, stated that he was called out late in the evening for a "mental health crisis." When he arrived on the scene Patient #8 stated that he "wasn't doing well and had done bad things." Patient #8 "was all over the place." When Staff QQ, PO and an EMS crew arrived he went into the hotel room to check on Patient #8's roommate, at that time Patient #8 told Staff QQ and the EMS crew that he intended to inflict self-harm. Patient #8's roommate stated that Patient #8 was "banging his head on the wall." Patient #8 was voluntarily transferred to the ED for treatment. Because of the unpredictability of mental health patients Staff RR and Staff QQ escorted the ambulance to the ED. Upon arrival to the ED Patient #8 decided not to talk, was uncooperative and noncompliant. Because he had made statements of SI, the ED staff asked Staff QQ and the EMS crew to complete affidavits. Later he received a call, Patient #8 was to transfer but refused the transfer. He was released from the ED. Approximately 45 minutes after he was discharged a call came in, "someone was screaming," and he was found injured and air lifted out. He appeared to be "struck", maybe he "threw himself" in front of a vehicle. Staff RR "wasn't really happy." He went to the ED and asked "why in the hell did we fill out affidavits if he was not going to be committed. If a person was not in their right state of mind, we had to make decisions for them, he was not capable." Staff RR stayed into the next shift to speak with his Captain and created a report. The report was not required because Patient #8 was never involuntarily confined. He wanted to make sure there was a written record of what happened. He believed Patient #8 was suicidal. He was shocked and disappointed. "We had procedures and protocols as first r

Based on interview, record review, and policy review, the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for three patients (#3, #7 and #8) out of 23 Emergency Department (ED) records reviewed from 02/15/24 through 07/15/24, when they were discharged with unstable medical conditions. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC.

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition [EMC]) Requirements Policy," dated 12/20/23, showed:
- If an individual has an EMC, the hospital will either provide any necessary stabilizing treatment, provide an appropriate transfer to another hospital or admit the individual as a patient.
- An EMC is any condition that is a danger to the health and safety of the patient if not treated in the foreseeable future.
- A range of conditions including but not limited to psychiatric disturbances (e.g., severe depression, insomnia [difficulty falling asleep or staying asleep], suicide attempt [to cause one's own death], SI, dissociative state (feeling disconnected from yourself and the world around you) or the inability to comprehend danger or care for oneself.
- In the case of a patient who is suffering from a psychiatric condition, the patient is stabilized when he/she is no longer considered to be a threat to himself/herself or to others.
- The hospital may not discharge a patient with an EMC until the patient is stabilized.

Review of the hospital's policy titled, "Clinical Hold (allows a hospital to prevent a patient from leaving when a patient lacks the capacity for decision making) for Patients Who Lack Decisional Capacity Guidelines," date 01/2019, showed:
- A clinical hold is ordered by a licensed practitioner (LP) who has assessed the patient and determines that the patient lacks decisional capacity, and that the patient is at imminent risk of serious harm to self or others if the patient leaves the hospital. The patient's LP is required to thoroughly document the patient's condition and reason for the clinical hold in the patient Electronic Medical Record (EMR).
- If a LP is not available to issue an order, a clinical hold may be initiated temporarily, in an emergency situation, by a RN based on an appropriate assessment of the patient.
- Clinical coworkers shall monitor the patient and take precautionary steps for the safety of the patient and coworkers.
- Any coworker with knowledge that the patient is on a clinical hold or on a temporary clinical hold is authorized to use measures to prevent the patient from leaving the hospital for the patient's safety.
- When a patient is on a clinical hold, the clinical coworkers must also work to support the patient's rights. Patients are to be included in care decisions and coworkers are expected to perform capacity assessments and seek consent for clinical interventions.
- If a psychiatrist (physician who specializes in mental health disorders) determines that a patient needs ongoing inpatient psychiatric care beyond what the hospital can provide, the hospital pursues an appropriate transfer in accordance with its transfer policy to an inpatient psychiatric facility.

Review of the hospital's document titled, "Perry County Health System Emergency Services Rules and Regulations," revised 05/2023 showed:
- The services provided to patients in the ED are collaborative planned and organized with other clinical service departments.
- All patients will receive stabilization treatment for medical conditions within the hospital's capability and capacity by a physician upon arrival to the ED.
- If necessary, any unstable patient in need of an appropriate transfer to another consenting medical facility possessing additional capability and capacity will be coordinated, in a timely manner, using qualified personnel and transportation after known risks/benefits are communicated and documented by the physician.
- Properly record physician consultations regarding risks and benefits of treatment and transfers related to the care of the patient with an EMC.
- After medical screening and stabilization, the ED physician may arrange for immediate transfer of a patient requiring specialty care not offered or not available at the time of the transfer or by the patient's request.

Review of the Police Department (PD) E Incident Report Complaint #2024-0469, dated 06/30/24 showed:
- At approximately 8:49 PM, officers were dispatched to a hotel in reference to a male subject having a mental health crisis.
- At approximately 8:52 PM, Staff RR, Police Sergeant, made contact with Patient #8.
- Patient #8 stated that he was not doing very well and was confused about a lot of things. Patient #8 made several strange claims about "bad things he had done" and seemed out of sorts.
- Staff RR spoke with Patient #8's roommate and was told Patient #8 was hitting his head against the wall and she was afraid he would do something worse. Patient #8 was not violent towards the roommate.
- Staff RR informed Staff QQ, Police Officer (PO) and the EMS staff that Patient #8 admitted to suicidal ideations (SI) and he was voluntarily being transported to the Emergency Department (ED) for evaluation and treatment.
- Staff QQ and RR followed the ambulance to the ED due to Patient #8's state of mind. Upon arrival to the ED Patient #8 became noncompliant with ED staff and the Counselor.
- Due to Patient #8's noncompliance, the ED staff requested affidavits from Staff QQ and the EMS staff. Patient #8's status was changed to involuntary due to his statements of a desire to self-harm.
- The ED staff were advised if Patient #8 woke up and became combative to call for assistance and Staff QQ and Staff RR would return to the ED.
- On 07/01/24 at approximately 4:35 AM, officers were dispatched for a report of a male heard screaming as if in pain.
- At approximately 4:40 AM, officers arrived on the scene and Patient #8 was on the side of the road. Patient #8 appeared to have been struck by a vehicle. EMS was requested and Patient #8 was air evacuated for treatment.
- Follow up with the ED staff showed Patient #8 did not cooperate during his Behavioral Health (BH) evaluation and was released from the hospital.
- Staff RR asked the ED staff if the Judge refused to sign the order for a 96-hour hold for BH evaluation and treatment. The ED staff responded the affidavits were not submitted for consideration.
- The ED staff were advised Patient #8's injuries were consistent with contact with the side of a vehicle in transport. It was believed Patient #8 attempted to throw himself in front of a vehicle or into the side of a vehicle to harm himself.

Review of Patient #8's ambulance report #1484, dated 06/30/24, showed:
- Dispatch was for a 32-year-old male having a mental health crisis.
- Upon arrival the patient was talking with a PO. He stated he struggled with mental illness and was not feeling right. The patient stated he thought of hurting himself but did not have a plan. The patient stated he was not taking his medication and had not seen his doctor. The patient stated he was homeless and "wanted it all to end."
- He was agitated and antsy.
- His chief complaint was SI.
- Halfway to the hospital the patient refused to answer any questions or cooperate.
- The patient continued to be uncooperative for the ED staff and the PO. Affidavits were completed by EMS and the PO.

Review of Patient #8's ambulance report #1487, dated 07/01/24, showed:
- Upon arrival on the scene there was a male subject lying face down on the left side of the roadway with a male PO standing over him.
- The patient was alert but unsure of what happened.
- There was blood on his face, swelling on his forehead and his nose was bleeding.
- There was a large hematoma (collection of blood below the surface of the skin) to his forehead with a laceration (a deep cut or tear in skin).
- There was a large area of road rash to the right side of his chest.
- He was unable to answer questions, he would say "I don't know" or would not answer.
- He stated, "he was walking and then everything changed." He did not know if he was struck by a vehicle.
- He complained of pain "everywhere."

Review of Patient #8's air evacuation transport report #91085620, dated 07/01/24, showed:
- The team was called for a major trauma to respond to a 32-year-old male found down on the side of the road.
- The patient was seen at the local ED the day before for SI and was discharged.
- He was found down on the shoulder of the road, noted to have lacerations to his forehead and abrasions (areas of skin damaged by scraping) to his chest, back, arms and legs. He had an altered mental status (mental functioning ranging from slight confusion to coma), was able to answer his name and state he did not know the time of day and did not recall the event prior to EMS arrival or how he was injured. Given his road rash like abrasions and head injury with a change in his mental status EMS was concerned he may have been struck by a vehicle and had a high risk for additional internal injuries.
- He was transported to a trauma center for a higher level of care.

Review of Patient #8's medical record, dated 06/30/24, showed:
- At 9:22 PM, he was a 32-year-old male who arrived at the ED accompanied by a PO with an arrival complaint of SI.
- His past medical history included depression and SI.
- At 9:25 PM, he would not verbalize anything, and his chief complaint was updated to agitation and routine psychiatric/medical clearance. His blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) was 143/100.
- At 9:29 PM, The Columbia-Suicide Severity Rating Scale (C-SSRS, a suicide risk assessment tool) showed information was provided by a PO, the patient would not speak to the hospital staff, he called EMS and reported SI and he was uncooperative.
- At 9:31 PM, a one-to-one (1:1, continuous visual contact with close physical proximity) suicide observation order was placed. The patient was awake in the room, quiet and withdrawn.
- At 9:33 PM, the encounter was related to suicidal behavior/attempt, he would not speak to the staff and per EMS and the PO he indicated he was suicidal.
- At 9:35 PM, a BH intake evaluation was ordered.
- At 9:52 PM, the VBH consult was at his bedside.
- At 9:58 PM, he was on a telemedicine (telemed, remote delivery of healthcare services while the health care provider is at a separate location, including exams and consultations, through video and telephone communication) call for evaluation, was agitated and withdrawn.
- At 10:00 PM through 07/01/24 at 2:45 AM, he was asleep.
- At 10:43 PM, his disposition was set to a voluntary admission to inpatient BH.
- At 10:52 PM, the BH intake coordinator was unable to complete the virtual assessment. He was alert and uncooperative. His speech was regular rate, normal volume, tone and amount. He only responded to questions. His thought process was logical. He was agitated and anxious. His insight (to understand a specific cause and effect) and judgement were fair. Per a medical record review, he was brought to the ED by the police for SI.
- At 11:22 PM, he had potential for insight and few/no coping skills. His emotional state was uncooperative.
- At 2:00 AM, a transfer request was initiated.
- At 2:40 AM, the transfer request was accepted by Hospital D.
- At 2:46 AM, nursing report was given.
- At 3:23 AM, his ED disposition was set to discharge.
- At 3:29 AM, PD E was notified the patient was discharged from the ED.
- At 3:31 AM, an addendum was written and showed when EMS arrived, the patient decided he did not want to go to Hospital D. After speaking with BH, "they stated the patient was offered a voluntary admission and would be discharged if not voluntary as he had made no binding statements to staff or BH that he was a danger to himself of anyone else." The patient stated he could not leave his stuff at the hotel and did not have a ride back to Perryville. BH stated they spoke with Hospital D; they could arrange transport back when he was discharged. The patient was again offered the admission bed at Hospital D. The patient stated the nurse could make the decision. The patient was again told he needed to make a choice, he could go voluntarily, or the physician would discharge him from the ED. The patient chose to discharge from the ED. The patient refused to sign the acknowledgement of paperwork given for discharge. Staff K, RN witnessed the discharge paperwork given and the education material provided.
- At 3:42 AM, he was discharged home and discharge instructions were reviewed. He walked out of the ED.
- The history of present illness showed his history was provided by the PO; the patient was not cooperative/verbally interactive with the ED provider. He was "apparently" staying at a local hotel, police were called for "some kind of mental health crisis," and EMS was summoned. "Apparently, he made some form of statements about SI and hallucinations." According to EMS while enroute to the ED he completely stopped speaking and refused to answer any further questions. On arrival to the ED, he would not speak to the provider or answer questions. Review of his history in the EMR indicated multiple prior psychiatric diagnoses. He did not seem to be taking any of his medications or undergoing any current therapy. EMS and the PO were going to write affidavits regarding their verbal interactions with the patient prior to his arrival at the ED. His orientation status could not be assessed. He did not consent to blood draws, diagnostic testing or other medical interventions. He did not voice suicidality to the provider or in the ED. At 11:05 PM, BH recommended offering admission on a voluntary basis, the patient agreed. He had numerous prior visits to outside hospitals for various forms of substance abuse disorders (characterized by a misuse of alcohol and/or other drugs) alcohol use and psychiatric considerations. At 3:26 AM, he was offered admission, arrangements were made for transfer. The patient determined at the time of transfer that he no longer wanted to be admitted psychiatrically. He was a voluntary admission, there was no hold or judgement against him, in light of that fact, he did not want to be transferred and could be discharged.
- The BH intake assessment showed it was determined the patient was to be admitted to a BH facility. He was an imminent danger to self. His legal status was voluntary.
- Staff QQ, PO, affidavit showed he responded to the hotel in Perryville, MO for a male subject with SI. Upon arrival, Patient #8 stated that he was a "bottom feeder." EMS asked Patient #8 if he was suicidal. The patient was "back and forth." He stated his "head was telling him to do things to himself." Patient #8 went back and forth about wanting to go to the hospital. He became uncooperative and his roommate stated Patient #8 was self-harming by "banging his head on the wall." Patient #8 was transported to the hospital and became uncooperative and silent with the staff.
- An EMS affidavit showed EMS was called for a mental health crisis. Patient #8 was antsy and told the PO to arrest him for his crimes. He told EMS he was not well; he was supposed to be on medication for several mental health problems but did not take them for "a while." When asked if he was suicidal, he responded, "yes, I want it all to end. I want to be brain dead." He had no plan at that time.
- His BH provisional diagnosis was major depressive disorder (an individual with a persistently low or depressed mood) single episode, severe without psychotic features (characterized by defective or lost contact with reality).
- He was combative and uncooperative with the BH intake provider. He refused to answer questions.

Review of the hospital's document titled "Group Conversation" dated 06/30/24, showed:
- At 9:58 PM, Staff Z, BH Intake Specialist, stated that the patient refused to participate in the BH Assessment. She planned to review the medical record and obtain collateral information from a friend or family member.
- At 10:34 PM, Staff Z, stated that the psychiatrist said they could offer inpatient admission, but there were no criteria to admit him involuntarily. If he refused admission he would be discharged.
- At 10:42 PM, Staff U, CNA, placed the virtual cart in Patient #8's room and stated that Patient #8 did not want to talk.
- At 10:44 PM, Staff Z stated that "he talked to me" and she was done with the virtual assessment. The patient gave verbal consent to admission.
- At 10:54 PM, Staff U asked Staff Z if she was able to assess Patient #8. Staff Z responded "no."
- On 07/01/24 at 2:34 AM, the patient was to transfer to Hospital D.
- At 3:13 AM, Staff Y, RN, notified Staff KK, Referral Counselor, the patient refused to go and asked if he could be admitted involuntarily with a judge's warrant.
- At 3:24 AM, Staff Y informed Staff KK the patient was discharged. "He did not want to go." Staff KK responded "alright, thanks for letting me know."

Review of Patient #8's Hospital B medical record dated 07/01/24 showed:
- At 6:26 AM, he arrived via helicopter. He was struck by a vehicle.
- The RN presumed the patient walked in front of a vehicle. She was unsure if he fell or was hit, no person stayed from the vehicle or saw him fall.
- The patient was unable to recall the event.
- The mechanism of the trauma was unknown; the patient was unwilling to provide a history.
- It was suspected the patient caused self-injury due to SI.
- He had road rash abrasions all over his body, both arms and legs. He complained of left elbow and head pain.
- At 6:35 AM his BP was 155/86 and his pulse (normal pulse/heartbeats for adults range from 60 to 100 per minute) was 164.
- His review of systems was positive for joint stiffness, muscle aches/pain and wounds.
- At 6:51 AM, a 1:1 sitter was in place.
- He had abrasions on his right leg, right thigh, right foot, left knee, and right chest wall. He had scattered abrasions to his forehead. He had a four-centimeter (cm) laceration on his forehead and a five cm laceration on his scalp. The lacerations were repaired with stitches and staples.
- His urine drug screen (UDS, a test that analyzes urine for the presence of certain illegal drugs and prescription medications) was positive for amphetamines (stimulant drug), marijuana and fentanyl (an addictive drug).
- At 7:22 AM, his complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) and comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) showed a white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood, normal is 4.5-11) was 23.8. His blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person's health, normal are between 70 and 100) was 133. His aspartate aminotransferase (AST, an enzyme that is found mostly in the liver, normal is 14-20) was 76. His alanine transaminase (ALT, an enzyme that is found mostly in the liver, normal is 4-36) was 91.
- At 7:31 AM, a computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) of his facial bones showed foreign bodies (something that is stuck inside you but is not supposed to be there) in his upper lip.
- Head, cervical spine (neck region of the back), chest, abdominal and pelvis (area of the body below the abdomen) CTs showed no acute (sudden onset) injuries.
- Pelvis and chest x-rays showed no acute injuries.
- At 3:34 PM, a BH intake evaluation was ordered.
- At 3:55 PM, the BH assessment showed he was brought to the ED by EMS after being discharged against medical advice (AMA) from Mercy Hospital Perry. Mercy Hospital Perry, "ED provider let the patient go AMA, even though BH stated he had involuntary criteria."
- At 4:18 PM, the ED disposition was set to involuntary inpatient BH.
- At 4:19 PM, the CSSR's showed he was a high suicide risk.
- At 4:28 PM, he was medically cleared for a BH admission.
- At 11:06 PM, he was transferred to Hospital C.

During an interview on 07/18/24 at 10:30 AM, Staff V, ED Medical Director, stated that the root cause of the event with Patient #8 was a miscommunication with the BH services. The ED provider believed he was speaking with the BH counselor when he was speaking with the bed placement coordinator. The patient refused to talk. He was unaware the patient was hearing voices. The safety planning was completed by the BH counselor, and she was not notified of the discharge. There were no discharge instructions for follow up and no BH resources were provided.

During a telephone interview on 07/23/24 at 10:48 AM, Staff EE, MD, stated that he communicated with the BH intake specialist. "Psychiatry said to admit him to a BHU inpatient, but he did not meet criteria for an involuntary admission." The patient would not talk, he thought the patient was "tweaking" (slang term that means to be under the influence of methamphetamine). Initially Patient #8 consented to admission, a bed was found, transfer was arranged, and the patient refused transfer. The lesson learned was to always ask for a reassessment. If the patient was no longer suicidal per the reassessment, then it was safe to discharge. If the plan was for discharge the intake specialist developed a safety plan with the patient. He did not think of developing a safety plan for Patient #8, it was an oversight. The only communication he had with the intake specialist was via secure chat. When the patient refused to transfer, he called the "BH line" and was told to make him involuntary. He was not aware that he was speaking with bed placement. He "sensed" Patient #8 responded to internal stimuli, he was disorganized. He may have been on Methamphetamine (an illegal stimulant). The patient slept for four hours; he did not need medication. After he slept, he no longer "tweaked" and was not disruptive. He did not know if his awareness of hallucinations would have changed the plan of care. There were "clearly gaps, this event changed his practice." The decision for discharge was based on the information he received that Patient #8 was not a candidate for an involuntary admission.

During an interview on 07/17/24 at 2:30 PM and 07/18/24 at 2:25 PM, Staff C, ED Manager, stated that the police were called because the patient made SI statements. EMS was called and the patient stopped talking. A BH assessment was ordered, he was placed on 1:1 observation and affidavits were completed by EMS and a PO. The patient was initially willing to go to Hospital D voluntarily. When EMS arrived to transport him to Hospital D, he refused the transfer. Bed placement was called, and the hospital was told to "get an involuntary." The affidavits from EMS and the PO were there and he should have been placed on a clinical hold. Hospital D was to get the 96-hour hold. The ED provider decided to discharge Patient #8 because the affidavits were "not weighted enough." It was not the ED's decision to make. If the patient refused to transfer, a safety plan should have been developed. The BH provider was not involved in the RCA.

During a telephone interview on 07/18/24 at 1:55 PM, Staff AA, BH NP, stated that the process was for the intake specialist to evaluate the patient. His/her findings were discussed with the BH provider and recommendations were made. He recommended Patient #8 be admitted involuntarily because he was uncooperative with the BH assessment. The patient should not have been allowed to leave because he was uncooperative. If the decision for discharge was made the intake specialist developed a safety plan with the patient. The intake specialist was to be notified before discharge to create the safety plan. The intake specialist was not notified prior to Patient #8's discharge, no safety plan was developed. There was no documentation in the EMR regarding a voluntary versus involuntary admission. The intake specialist "wrote admit," she did not document "involuntary." The BH provider only talked to the ED provider if there was a difference in opinion with the patient's disposition. The intake specialist is the communicator between the ED provider and the BH provider. Patient #8 was a "straight forward" case. His recommended disposition was involuntary because he would not provide any information.

During a telephone interview on 07/18/24 at 11:45 AM, Staff PP, BH Intake Specialist, stated that Patient #8 came to the ED with a PO and was noncompliant with a virtual assessment. He refused to participate during the assessment. He would not verify his identity. She was told the PO and EMS wrote affidavits. She spoke with Staff AA, BH NP and it was determined the patient would be offered admission based on the medical record notes and affidavits if he was willing to give consent to treatment, he agreed. She was not notified he was discharged. There was no attempt for a BH reassessment. The nurse messaged her at 7:00 AM to say he was discharged and "got hit." The process was the ED provider or nurse should have notified her the patient refused transfer and a reassessment would be completed to determine if the patient was safe for discharge or an involuntary admission needed to be pursued. The bed placement team did not perform assessments and should not make recommendations. Patient #8's affidavits only said he had suicidal thoughts, there was not a plan or intent to self-harm. He needed a full assessment and connection to resources if he was not at an imminent risk of harm to self or others. She was unable to assess him before he was discharged. If discharge was the plan of care, she would have entered resources into the EMR and created a safety plan with Patient #8. She was not involved in the RCA.

During a telephone interview on 07/18/24 at 11:15 AM, Staff X, RN, stated that she was the primary nurse for Patient #8. He was brought to the ED by EMS and escorted by a PO. The ED was "super busy." He walked to room three and changed into psychiatric safe clothing. He sat in a chair and looked towards the wall with his arms crossed. He refused to talk and was barefoot. She thought he was drunk. She attempted multiple times to assess him, he seemed "mad." She asked three times to takes is blood pressure, the PO said, "they are not going to hurt you," he "flung" his arm out and his blood pressure was taken. He refused to talk; she could not assess him. The PO said, "he was just going through some stuff and needed help." A psychiatric consult was ordered. He refused to answer questions about SI and homicidal ideation (HI, thoughts or attempts to cause another's death). The PO said, he was feeling suicidal. The patient initially agreed to the transfer to Hospital D and wanted a copy of the transfer paperwork. When EMS came to transport him, she was not in the room. She was told he said he could not go. She notified Staff EE, MD, and called bed placement to see if he could go involuntarily. Bed placement confirmed Hospital D could take him involuntarily. She was told Hospital D needed "warrants" signed by the judge. Bed placement called her and asked if she had started the involuntary process. Staff EE stated Hospital D needed to initiate the involuntary placement and he was told the patient was a voluntary admission or discharge. The patient did not want to leave his belongings and did not have transportation back to Perryville. Bed placement stated that Hospital D would arrange for transportation back. The patient was told if he agreed to a voluntary admission he would be transported then, and a ride back was available. The patient told Staff X she could decide. She told him he needed to decide. He said "discharge." She informed Staff EE and gave the patient information on psychosis (a serious mental illness characterized by defective or lost contact with reality). The ED was unable to give a diagnosis, he would not talk, he would only say "go" and "no go" regarding the transfer. She asked if he had any questions, he did not respond. She reviewed the discharge paperwork with him, he refused to sign the discharge paperwork. Staff K, RN, witnessed the discharge paperwork and the patient walked out of the ED. She was unsure who she secure chatted with about a voluntary versus involuntary admission. She was unsure if the individual who gave her the bed placement assignment was different than the person who performed his BH evaluation. She was "surprised" he was allowed to discharge because he did not say anything except that he would go. He never responded to her questions regarding SI or HI. He was not violent, he looked angry. Affidavits were present. She was told the BH provider said the affidavits were not "weighted enough" to be "binding." Staff EE told her the BH provider told him the patient was either a voluntary admission or he was discharged because the affidavits were not "binding." She was not aware he heard voices. She was unsure if her awareness of the hallucinations would have changed his plan of care. She assumed the police were called when he was discharged because he initially came to the PO asking to be arrested. After the event she was informed that a nurse could initiate a clinical hold if he/she felt the patient was at risk and the police could be called if an at-risk patient attempted to leave the ED. She was involved in the RCA, and it was determined that there were too many steps for miscommunication with tele-health and the ED staff. Secure chat messages where not a part of the medical record and needed to be added to the documentation.

During an interview on 07/18/24 at 9:23 AM, Staff K, RN, stated that he was the charge nurse during the night of Patient #8's ED visit. There was a high "influx of patient, more than normal." He was responsible to assign the primary nurse and ensure safety precautions were in place. Upon arrival EMS and the PO reported a "vague in nature SI," not specific. The patient refused to speak, SI precautions and a BH consult were ordered. When Patient #8 began to talk he agreed to a voluntary admission and signed the transfer form. When EMS arrived, he refused the transfer. Education was provided to include there was a long wait for a BH bed. He spoke with the ED provider who spoke with "psychiatric services." The provider was told the only "grounds for admission were voluntary." He believed psychiatric services said, "voluntary only." Patient #8 denied SI and HI to him, he did not document this in the medical record. When a patient refused transfer, it was customary to create a safety plan. Resources were provided for all discharges to include hot-line numbers. If a patient had a positive BH assessment a reassessment was performed if the patient refused admission to determine if the patient needed an involuntary admission. He did not feel that Patient #8 was a risk of harm to himself, he did not observe hallucinations. The patient did not want to wait any longer and did not want to leave Perryville. The patient was aware Hospital D would arrange for his transport back to Perryville after his discharge, but the patient did not believe that. The patient was not discharged AMA, the ED provider agreed to his discharge. Patient #8 walked out of the ED.

During an interview on 07/26/24 at 8:25 AM Staff RR, Police Sergeant, stated that he was called out late in the evening for a "mental health crisis." When he arrived on the scene Patient #8 stated that he "wasn't doing well and had done bad things." Patient #8 "was all over the place." When Staff QQ, PO and an EMS crew arrived he went into the hotel room to check on Patient #8's roommate, at that time Patient #8 told Staff QQ and the EMS crew that he intended to inflict self-harm. Patient #8's roommate stated that Patient #8 was "banging his head on the wall." Patient #8 was voluntarily transferred to the ED for treatment. Because of the unpredictability of mental health patients Staff RR and Staff QQ escorted the ambulance to the ED. Upon arrival to the ED Patient #8 decided not to talk, was uncooperative and noncompliant. Because he had made statements of SI, the ED staff asked Staff QQ and the EMS crew to complete affidavits. Later he received a call, Patient #8 was to tra