HospitalInspections.org

1100

Based on observation, policy review, medical record review, document review, and interview, in 12 of 12 medical records reviewed, the hospital failed to meet the emergency needs of patients in accordance with acceptable standards of care. (Patient #1 to Patient #12).

Reference:
482.55 (a)(3): Emergency Services Policies

1104

Based on observation, policy review, medical record review, document review, and interview, in 12 of 12 medical records reviewed, the hospital failed to ensure clinical staff implemented established policies and procedures, and the medical staff did not conduct ongoing assessment of the medical care in the emergency department (ED). Specifically, patients presenting to the emergency department (ED) for a mental health evaluation, are not screened for violence/homicidal ideation; do not receive a coordinated psychiatric consultation assessment by qualified professional staff communicated between services; the ED provider, the psychiatrist, and the behavioral health navigator do not hold a conference to discuss patient information to determine treatment and/or disposition; the ED provider and on-call psychiatrist do not review 9.41/9.45 paperwork (the Director of Community Services/designee authorizes the involuntary transport of a patient with mental illness for emergency assessment for immediate observation, care, and treatment, who is likely harm themselves or others), collateral information, and mental health assessments by the behavioral health navigator, leaving the responsibility on the Behavioral Health Navigator (non-licensed practitioner) to report out to them and make recommendations; and the psychiatrist does not document a consultation and/or made treatment/disposition recommendations in the medical record after being consulted.(Patient #1 to Patient #12).

Findings include:

Review of the policy " Medical Staff Bylaws, Policies, and Rules and Regulations," dated 04/01/24 revealed consulting staff members may evaluate and treat patients in conjunction with other members of the medical staff. When providing a consultation, the consulting practitioner will review the patient's medical record, brief the patient on the consulting practitioner's role, and examine the patient in a manner consistent with the requested consultation. Any plan for ongoing involvement by the consulting practitioner will be directly communicated to the requesting practitioner through a note in the electronic medical record, by phone call, or by secure text message. Once the consulting practitioner is involved in the care of the patient, the requesting practitioner and consulting practitioner are expected to review each other's notes in the patient's medical record on a regular basis to assure continuity of care until the consulting practitioner has signed off on the case or the patient is discharged. Consultation reports will be completed in a timely manner and documented in the electronic medical record or dictated/legible written notes. The consultation report will contain the date and time of the consultation, opinions based on relevant findings and reasons, and recommendations by the consulting practitioner.

Review of the policy "Emergency Department Mental Health Unit Coverage," dated 03/08/24 revealed counselors (behavioral health navigators or designated Registered Nurses-RN) are scheduled to provide behavioral health evaluations in the ED. The on-call psychiatrist works with ED counselors/RNs in their case-by-case interactions to develop the counselor's assessment and communications skills.

Review of the policy "Psychiatric Evaluation of Patients in the Emergency Department," dated 03/22/24, revealed a person in need of a mental health evaluation may come to the ED. An ED provider will write an order for a psychiatric evaluation to be initiated. The ED counselor (Mental Health Counselor /Behavioral Health Navigator) will assess the patient upon arrival and with ED staff determine level of security required to manage the patient (the need for seclusion, where to interview patient, appropriate room). The ED counselor will interview the patient, family, significant others, custodians and complete an evaluation. A conference will occur between the ED provider, ED counselor, and psychiatrist to review care. The ED counselor will call the unit charge nurse to discuss evaluation and disposition options. The ED counselor will discuss evaluation findings and psychiatrist recommendations with the ED physician and charge nurse. The ED physician/Physician Assistant will medically clear the patient. The ED physician will note agreement with the evaluation disposition on ED record. If ED physician does not agree with the disposition, the physician may discuss the disposition with the on-call psychiatrist or request the psychiatrist to come to the ED for a face-to-face evaluation. If after evaluation, the counselor, charge nurse, ED physician and on-call psychiatrist determine a patient may be discharged with referrals to outpatient mental health/chemical dependency program, or to the patient's present linkage, the ED counselor will give the patient discharge instructions and make appointments for outpatient services. The ED counselor will complete a behavioral health evaluation and document the evaluation findings/disposition in the ED record. (This policy does not address the need for a licensed healthcare professional to review the ED counselor's assessments and/or the need for the ED provider or on-call psychiatrist to document their recommendations for the treatment and/or disposition of mental health patients).

Review of the policy "Assessing Patient Risk for Suicide," dated 01/27/25 revealed patients who are being evaluated or treated for behavioral health conditions as their primary reason for care, will be screened for suicidal ideation using the Columbia-Suicide Severity Rating Scale (C-SSRS). If a patient screens positive for suicide after a completed C-SSRS, a SAFE-T Suicide Risk Assessment form will be completed by trained staff in order to determine the suicide risk level of the patient. (This policy does not address violence/homicidal patient screening. No policy was found for violence/homicidal screening).

Review of ED medical record for Patient #1, dated 09/11/25, revealed the following:
At 10:30 AM, the 9.45 Mental Hygiene Law paperwork revealed Patient #1's case manager contacted the Director of Community Services, who contacted the local police department to have Patient #1 transported to the facility for an emergency admission under the Mental Hygiene Law (the Director of Community Services/designee authorizes the involuntary transport of a patient with mental illness for emergency assessment for immediate observation, care, and treatment, who is likely harm themselves or others).
The 9.45 Mental Hygiene Law paperwork addendum (not timed) revealed Patient #1 was a danger to themself and others, specifically their roommate and other residents in the building. Patient #1 had a plan to use a machete. Patient #1 was potentially violent due to their paranoia and belief that they needed to defend themself. Patient #1 had several knives and a machete available to them as a weapon. Patient #1 reported that they had not been home due to the fear that others were plotting against them. Patient #1 was fearful that when they arrived home, they would attempt to protect themselves with a machete or end their own life by overdosing.
At 10:59 AM, Patient #1 presented to the ED for a mental health examination on a 9.45 Mental Hygiene Law request for examination. Patient #1 signed the consent for treatment.
At 11:39 AM, Staff (K), Registered Nurse, performed a triage assessment that indicated Patient #1 presented for a 9:41 mental health exam from home. Patient #1' s complained of occasional paranoia especially when using methamphetamine (meth) and stated they were worried about hurting others when they used. Patient #1 stated they had a history of a home invasion, had PTSD, and had possible paranoid schizophrenia (persistent delusions and auditory hallucinations). Patient #1 denied suicidal ideation. Patient #1 was assigned an ESI Level Two- urgent (triage patient conditions based on severity. One is most urgent, five is least urgent). Patient #1 scored low risk for suicide on the C-SSRS and denied suicidal thoughts in the past month. Patient #1 was a current substance user of cocaine/crack and crystal meth, three to five times a week and experienced withdrawals. Vital signs were within normal limits, Patient #1 denied pain. (No violence or homicidal screening was performed).
At 11:40 AM, Staff (L), Physician, performed a medical screening exam that indicated Patient #1 presented to the ED for a mental health evaluation and admitted to methamphetamine use that made them paranoid. Patient #1 stated they currently did not have any suicidal or homicidal thoughts. Patient #1 had rapid speech, but was in no acute distress and did not look acutely intoxicated. Patient #1 had a normal physical examination and was alert and oriented in no acute distress. Patient #1 was cooperative and had an appropriate mood and affect. Patient #1 had a negative suicide risk screen and had no thoughts of death, no plan, intent, or behavior. Patient #1 was seen by the Behavior Health Navigator (an unlicensed mental health counselor) who saw and cleared Patient #1 for discharge (Patient #1's mental health assessment was not performed until 05:50 PM by the behavioral health navigator or BHN). Patient #1's symptoms were clearly from using methamphetamine. Patient #1 was not acutely intoxicated and was encouraged to stop using. Given their outside resources, Patient #1 was discharged in stable condition. The discharge diagnosis was listed as methamphetamine use disorder. At 01:00 PM, 03:00PM, and 05:00 PM, the medical record indicated "re-evaluation" that was "unchanged" was documented.
At 05:40 PM, Staff (L), Physician, ordered Patient #1 to be discharged. The "Discharge Clinical Summary" and "Discharge Instructions "indicated a discharge diagnosis of methamphetamine use disorder. Vital signs were listed, no new prescriptions were given, and no laboratory data had resulted. Information for substance abuse disorder with specific instructions were given to Patient #1 and they were to follow-up with their primary care provider within three to five days. The crisis services phone number was provided. (Staff (L) discharged Patient #1 home prior to the mental health evaluation, the violence screening, and recommendation for discharge by the psychiatrist).
At 05:43 PM, by Staff (P), Registered Nurse, reviewed and signed off the discharge order.
At 05:50 PM, Staff (M), Behavior Health Navigator, documented a mental health evaluation that indicated Patient #1 presented at the ED on a 9.45 mental health evaluation request from the mobile crisis team after their probation officer (PO) initiated and called the request in. The PO was concerned Patient #1 was suicidal last month, using meth recently, and had increased paranoia from it. The PO was concerned Patient #1 would harm someone else. Staff (M) documented Patient #1 had history of psychiatric hospitalization (most recent hospitalization was 08/08/25 to 08/27/25 at this hospital), no history of violence, no history of suicide attempts, and was a heavy/frequency user of amphetamine for seven years. Patient #1's risk factors for suicide and homicide include current /symptomatic psychiatric illness, and inadequate or overwhelmed coping. Patient #1 had internal protective factors of future planning, identified reasons for living, and had positive coping skills. Patient #1 was willing to access treatment and support. Patient #1 has an unknown primary care physician. An outpatient clinic for chemical dependency, and an outpatient clinic for mental health are documented with contact information. Patient #1 completed a 28-day rehab program. Patient #1 lives alone in permanent housing. Patient #1 stated they know the paranoia is from meth use but they are struggling to reality test at this point. Patient #1 had pressured speech and is tangential (erratic) with repeated stories from previous evaluations they had done. Patient #1 thinks there is a group of people spying on them, videoing them in their apartment, and posting to social media. There is no outside evidence this happened. Patient #1 admitted to using meth yesterday and prior to their arrival to the ED. This appeared to be the "typical baseline when they use meth and present to the ED." Patient #1 denied suicidal and homicidal ideations but said they are fearful when they use. Staff (M) documented the medical provider and Staff (L), Psychiatrist, were consulted and agreed to discharge Patient #1 to current outpatient services at this time. (This assessment does not include information from the 9.45 paperwork indicating Patient #1 was a danger to self and others, specifically mentioning their roommate; had a plan for homicide to defend self; had access to knives and a machete; and had not been home for fear of committing homicide and/or suicide by overdose upon arrival at their home. The ED physician and the on-call psychiatrist did not review this assessment. Staff (M) did not receive the psychiatrist's recommendation for discharge until 07:00 PM. Patient #1 was discharged at 06:26 PM).
At 06:26 PM, Staff (K), Registered Nurse, documented Patient #1 was discharged unaccompanied to home or self-care, ambulatory, in stable condition.
At 07:43 PM, Staff (M), Behavior Health Navigator, documented the following violence risk assessment: Patient #1 answered "yes" to owning or having access to firearms or other weapons. Patient #1 stated they have knives and a machete. Patient #1 has poor impulse control and a legal history. Patient #1 has a psychiatric history that included PTSD, suicide/self-injury, psychotic disorder and prescribed psychiatric medications.
Patient #1 answered "NO" to they and others who know Patient #1 report that Patient #1 has been having thoughts of harming others. Patient #1 denied making a statement of the intent to kill or harm others. Patient #1 denied focused threats on a specific person. Patient #1 denied attempting or inflicting serious or intentional harm to a person. Patient #1 denied recent loss or significant changes in life. Patient #1 answered "YES" to they or others who know the Patient #1 report that Patient #1 is in danger because of disturbed thinking. Patient #1 has a psychiatric diagnosis consistent with the development of psychotic process. Patient #1 exhibited, or others reported impairment in capacity to reality test. Patient #1 answered "NO" to reporting expressions of hallucinations specific to harming self or others. Patient #1 denied exhibiting or others report impairment in ability to make rational, life preserving judgements. (The ED physician or the on-call psychiatrist did not review this assessment).

Review of the TEAMS (unsecure, online messaging system) message on 09/11/25 at 05:49 PM by Staff (M), Behavior Health Navigator (BHT) to Staff (N), Psychiatrist revealed the message contained Patient #1's name and they presented to the ED on a 9.45 from mobile crisis after their probation officer (PO) called in. Collateral information from the PO (PO left a voice message, Staff (M) did not speak to them) was they were concerned since Patient #1 was suicidal last month, as well as using meth recently, and had increased paranoia from it. The PO stated they were concerned Patient #1 will harm someone else. Patient #1 stated they know the paranoia is from meth and are struggling to reality test at this point. Patient #1 had pressured speech with tangential and repeated stories from previous evaluations they had completed on them. Patient #1 stated they think there is a group of people spying on them, videoing them in their apartment, and posting it on social media. There is no evidence this is happening. Patient #1 admitted to using meth yesterday and today, prior arriving to the ED. Staff (M) documented "think we are at the typical baseline when they use meth and presents here." Patient #1 denied suicidal ideations/homicidal ideations currently, but did say they are fearful when they use. Patient #1 stated they are now friends with Patient #10 (homicide victim) since they spent time together on the inpatient unit recently. Patient #10 has been staying with them. "Can we discharge?"
At 06:21 PM, Staff (M), BHN, sent an additional message to Staff (N), Psychiatrist, with Patient #2's name with history and "Can we discharge?" At 06:21 PM, Staff (L), Psychiatrist, replied "OK to discharge." At 06:22 PM, Staff (M), BHT, replied "OK to discharge both?" At 07:00 PM, Staff (L), Psychiatrist, replied "Yes please."

Interview on 09/24/25 at 02:30 PM with Staff (O), Hospital Administrator, revealed that a violence risk screen is done by the behavioral health navigators (an unlicensed mental health counselor). The screening will be documented on paper and scanned into the electronic medical record. Staff (O) verified that Patient #1 ' s violence risk screen assessment was timed and dated after Patient #1 was discharged from the hospital. Staff (O) stated the registered nurses complete the C-SSRS to assess suicide risk but there is no current process in place for assessing homicidal ideation.

Interview on 09/24/25 at 02:35 PM and 03:04 PM with Staff (J), Hospital Administrator, revealed there was no formal process or procedure for nursing staff to ask a patient about homicide or if they intend to harm others during triage. Nursing staff use the ED Triage assessment that does not have homicidal questions.

Interview on 09/24/25 at 03:25 PM and 09/25/25 at 02:44 PM with Staff (N), Psychiatrist, revealed methamphetamine use caused Patient #1 to be paranoid. Patient #1 was familiar to them. On 09/11/25, Patient #1 did not present psychotic that day, but it is possible they could have been psychotic upon discharge. The plan for Patient #1 was to follow/continue the previously set up outpatient services after the 08/27/25 inpatient psychiatric unit discharge. Staff (N) did not evaluate Patient #1 in person but reviewed the "TEAMS" message chat from Staff (M), Behavioral Health Navigator (BHN), who recommended the discharge disposition. Staff (N) gave the okay to discharge Patient #1 via "TEAMS" message to Staff (M), BHN. Staff (N), has access to the electronic medical record but did not review Patient #1's 9.45 paperwork or the violence risk assessment, indicating that is the responsibility of the BHN to review and report the findings. The BHN makes a discharge recommendation to the psychiatrist via " TEAMS," and the psychiatrist makes a discharge recommendation to the ED physician via the BHN. The ED physician has the ultimate decision regarding the discharge disposition of the patient from the ED. It is not common for the psychiatrist to speak to the ED physician unless a patient was a "complicated case" where the ED physician disagreed with the psychiatry recommendation. Staff (N) was aware the BHN are not licensed, are only able to complete data collection, and cannot perform assessments. There is no requirement for psychiatrist documentation of the discharge recommendation. Staff (N) makes that recommendation to the BHN who will document it. A patient brought to the ED for a 9.45 must be evaluated by a provider. If a BHN is unavailable, the ED physician would be responsible for the evaluation. It is very uncommon for the psychiatrist to present to the ED for an evaluation. The only time that would occur is if the ED physician requested the psychiatrist to do an in-person evaluation.

Interview on 09/24/25 at 04:11 PM and 09/25/25 at 04:16 PM with Staff (L), Physician, revealed that the initial evaluation of Patient #1 was completed while Patient #1 sat in a hallway chair across from the nursing station. Patient #1 was calm, and directable. Patient #1 stated they had an increase in paranoia when they used methamphetamine and confirmed meth use that morning. Patient #1 was not "high" and did not show signs of methamphetamine psychosis, which varies. Patient #1 was cooperative, had capacity (answered all questions) despite their methamphetamine use, and was easily cleared medically. Staff (L) was aware of Patient #1 ' s presenting complaint to harm others, however, Patient #1 never expressed suicidal or homicidal ideations upon their assessment. Staff (M), Behavioral Health Navigator (BHN), completed their evaluation and informed Staff (L) that Patient #1 was able to be discharged. After that conversation, Staff (L) ordered the discharge of Patient #1. Once the BHN/mental health counselor is involved, the ED provider waits for the psychiatric disposition. Staff (L) did not re view the 9.45 paperwork for Patient #1. There was no conversation between Staff (M), BHN, Staff (N), Psychiatrist, and Staff (L). Staff (L) does not review the BHN' s documentation and does not obtain collateral information. It is rare for the ED physician to speak directly to the psychiatrist; the conversation is always held with the BHN. This process has been in place for at least six years. Patient #1 was previously set up with outpatient community services when they were discharged from the inpatient setting in August 2025. Patient #1 was previously provided chemical dependency rehab and was set up for outpatient substance abuse rehab in the community. Discharge education was provided to Patient #1 for substance use disorders and to follow up with their mental health providers in the community. Further mental health discharge instructions regarding appointment times would be provided by the BHN. Patient #1 was cleared by psychiatry and not intoxicated by methamphetamines. Staff (L) felt comfortable with the discharge of Patient #1.

Interview on 09/25/25 at 08:10 AM with Staff (K), Registered Nurse, revealed that Patient #1 presented on a 9.41 with police. Patient #1 was triaged across from the nursing station with a complaint of feeling confused and paranoid. Patient #1 had PTSD, and their paranoia worsened when they used methamphetamine. Patient #1 heard voices and stated they "didn't want to hurt anyone" by listening to the voices. Patient #1 was calm, not twitchy or nervous, and directly answered questions. Patient #1 did not have the desire to hurt themselves or anyone else. Staff (K) does not remember reviewing the 9.41/9.45 paperwork for Patient #1 but usually does. During triage, the police officer mentioned they were familiar with Patient #1 and when Patient #1 wanted help, they would reach out to the police department or their counselor. Staff (K) did not recall Patient #1 mentioning anything about a machete, but they stated they wanting to harm others when they used methamphetamine. Patient #1 was non-committal to when they last used methamphetamine, eventually stating it was "days ago." Staff (K) stated there are no homicidal questions that are a part of the triage process. Staff (K) discharged Patient #1 and provided substance use education.

Interview on 09/25/25 at 11:19 AM with Staff (R), Hospital Administrator, revealed that the hospital does not have any policies in place to assess homicidal risk.

Interview on 09/25/25 at 11:31 AM with Staff (O), Hospital Administrator, revealed that behavioral health navigators (BHN) are not licensed staff. They can collect data and gather information for the psychiatrist. The psychiatrist does not sign-off on the BHN notes and does not provide a consultation note. The ED physician, BHN, and the psychiatrist will have a three-way conversation in rare, specific patient circumstances.

Interview on 09/25/25 at 12:26 PM with Staff (M), Behavioral Health Navigator (BHN), revealed they are not licensed in New York State. Patient #1 was brought into the hospital by the police for a mental health evaluation. Patient #1 was calm and cooperative. Patient #1 stated walking in the streets all night after using methamphetamine, which caused them to see shadows. Patient #1 called their probation officer and was concerned they would go to go to jail for the prohibited drug use. Staff (M) was familiar with Patient #1 from past evaluations. Patient #1 appeared to be at their baseline. Patient #1 had no current homicidal or suicidal ideations, but stated they were afraid when they were high on methamphetamine that they would hurt someone. Patient #1 admitted to having access to knives and a machete. Patient #1 had carried a large hunting knife in the past but self-surrendered the knife to security when they came to the hospital because of the fear others were going to harm them. The mental health evaluation process includes a review of previous admission or evaluations, asking the patient questions from the evaluation form, obtaining collateral information, messaging the on-call psychiatrist via "TEAMS" chat messaging, and speaking to the ED physician in person. If the psychiatrist did not reply in the "TEAMS" chat, they would attempt to call them. Staff (M) updated Staff (N), Psychiatrist, through "TEAMS" chat for Patient #1. The message included the evaluation, collateral information collected, and Staff (M)'s recommendation for discharge. Staff (N), Psychiatrist agreed with the recommendation and responded it was okay to discharge. If the psychiatrist disagreed with the recommendation, they would provide their recommendations to be communicated to the ED physician by the BHN. The violence risk assessment questions are completed during the patient evaluation; however, Staff (M) documents and signs the form when they have time during their shift. Patient #1 ' s violence risk assessment documentation was signed after Patient #1 left the ED. Patient #1 stated they lived alone with a dog. Staff (M) was unaware that Patient #1 had a roommate. Patient #1 stated they should not use methamphetamines anymore but was not interested in substance abuse rehab. Staff (M) stated a conference call between the BHN, the ED physician, and the psychiatrist does not occur. The only time the ED physician would speak directly to the psychiatrist would be if they disagreed with each other. On discharge from the hospital, Patient #1 appeared to be at their baseline mentation. Staff (M) obtained collateral information from a voicemail left by Patient #1 ' s probation officer, and did not recall speaking directly to the probation officer.