HospitalInspections.org

Based on review of the hospital's ED logs and review of the patient electronic medical records for 12 of 20 sampled patients (3, 4, 5, 6, 7, 8, 12, 13, 14, 16, 18, and 19), it was determined the hospital failed to comply with the provider agreement as defined in §489.20 and §489.24 by ensuring:
*Patients with psychiatric diagnoses received a medical screen consistent with their presenting signs and symptoms for 12 of 20 sampled patients (3, 4, 5, 6, 7, 8, 12, 13, 14, 16, 18, and 19) placed on protective mental health holds (PMHH).
*Patients with psychiatric diagnoses were transported to a behavioral healthcare facility consistent with their presenting signs and symptoms for 12 of 12 sampled patients (3, 4, 5, 6, 7, 8, 12, 13, 14, 16, 18, and 19) that were discharged to jail or the juvenile detention in the care of law enforcement officers.
*Patients who had been evaluated by a qualified mental health professional (QMHP) with recommendations for admission to a behavioral health facility for further treatment for 3 of 3 sampled patients (4, 7, and 12) were not discharged to the care of law enforcement to await transport to an inpatient treatment facility.

1. Review of twenty electronic medical records for ED patients revealed they had psychiatric diagnoses, had been medically cleared, however, those patients with:
*Psychiatric signs and symptoms had not been evaluated by a QMHP to determine appropriate transfer/placement to a behavioral healthcare facility for 12 of 12 sampled patients (3, 4, 5, 6, 7, 8, 12, 13, 14, 16, 18, and 19).
*Psychiatric signs and symptoms had not been evaluated by a QMHP to complete their medical screening examination to rule out psychiatric emergency medical conditions and were discharged and transferred in the care of law enforcement officers to jail or the juvenile detention center (JDC) for 12 of 12 sampled patients (3, 4, 5, 6, 7, 8, 12, 13, 14, 16, 18, and 19).
*Recommendations from a QMHP for inpatient admit to a behavioral health facility were discharged in the care of law enforcement to await transport for 3 of 3 sampled patients (4, 7, and 12).
Findings include:

Refer to A2406, findings 1- 14.

Refer to A2407, findings 1- 15.

Based on interview, record review, and policy review, the provider failed to ensure:
*Two of three sampled patients (8 and 13) who were admitted to the emergency department (ED) with recent suicide attempts by hanging had been thoroughly screened and had a mental health (MH) evaluation completed by a qualified mental health professional (QMHP) prior to having been discharged in the care of law enforcement and transferred to jail or the juvenile detention center (JDC).
*Nine of nine sampled patients (3, 5, 6, 7, 12, 14, 16, 18, and 19) who had been admitted to the ED with suicidal ideation had a mental health evaluation completed by a QMHP prior to having been discharged in the care of law enforcement and transferred to jail.
Findings include:

1. Interview on 2/9/16 at 8:15 a.m. in the ED with registered nurse (RN) C in regards to MH patients in the ED revealed:
*Rooms 1 and 2 were used for MH issues.
*All the staff with the exception of the orientating RN were wearing a panic button to use in an emergency situation when law enforcement needed to be notified.
*The patient would have laboratory (lab) values checked such as urine for drug screening and blood chemistry to evaluate any abnormalities.
*If the patient was cleared medically the patient was then transferred by law enforcement to the evaluation center also known as jail. If those mental health patients had been placed on a mental health hold the patient had no choice but to go to jail.
*The staff would have asked the patient to remove all clothing along with belongings and put them into a plastic bag. The staff would have removed the bag from the room. The patient would have been given a patient gown to wear.
*If a patient had refused to go to the evaluation center (jail) then a petition for hold was read to them.
*The patients were cleared medically but their mental health needs were not addressed in the ED.

Interview on 2/9/16 at 8:55 a.m. with ED director H and quality analyst E in regards to mental health patients who were treated in the ED revealed:
*Transporting patients to a behavioral health facility was problematic.
*Social workers were on call until 10:00 p.m. in the evening.
*There was one QMHP on staff.
*The mental health patients were currently transported to the evaluation center after they were medically cleared by a physician.
*Neither the ED director nor the quality analyst had been over to the evaluation center at the jail to see how the patients were handled once they left the ED.

Interview on 2/9/16 at 9:15 a.m. with ED physician A revealed:
*When a patient with mental health issues came into the ED their main concern was making sure the patient did not have a medical threat.
*Any life threatening problem was cleared.
*The multidisciplinary team was involved including the social worker although that person did not usually come in.
*They had a QMHP, but the nighttime (overnite) shift was a problem.
*Their main concern was keeping the MH patient safe.
*The QMHP evaluation was usually done at the evaluation center at the jail.
*He had not been to the jail to see where the MH patients were detained.
*He was unsure what instructions were given at the time of discharge.
*He was unaware of the staffing at the evaluation center/jail and if they had medical staff on duty.
*He thought since the at-risk patients were safe with law enforcement when they went to the evaluation center and had been medically cleared, they were doing all they could for the patient.

2. Review of patient 8's electronic medical record revealed she:
*Had been admitted to the ED on 10/8/15 at 12:40 a.m. by law enforcement. She was twelve years old.
*Had attempted suicide by placing a sheet around her neck and hanging herself.
*Had rated her pain on a pain scale from 1 to 10 (1 the least pain and 10 severe pain) a 7 on admission and then a 5 at discharge. There had been no follow-up on her pain, and there was no documentation her pain had been addressed.
*Had a physician evaluate her.
*Had been medically cleared for transfer to the JDC after lab work had been completed.
*Had no mental health evaluation.
*Was discharged at 1:30 a.m. in the care of law enforcement.

3. Review of patient 13's electronic medical record revealed she:
*Had been admitted to the ED on 1/9/16 at 2:35 p.m. She was thirteen years old.
*Had attempted suicide by placing a string around her neck to hang herself. There had been a one-to-one (1:1) observation sheet completed by staff at 1:50 p.m. and at 2:05 p.m. The patient had not been admitted to ED until 2:35 p.m. The times were incorrect on the observation sheet.
*Was medically cleared by the physician after lab work had been completed.
*Had no mental health evaluation completed prior to discharge.
*Was discharged at 3:21 p.m. to the JDC in the care of law enforcement.

4. Review of patient 7's electronic medical record revealed:
*She was admitted to the ED on 12/21/15 at 11:14 a.m. with aggressive behaviors. She was twenty-eight years old.
*She had a history of attempted suicide a year prior and had depression. She had been acting out aggressively, threatening others, and herself. She had a previous psychiatric admission for suicidal ideation.
*There was a QMHP assessment completed at that time.
*The QMHP recommended inpatient admission to a behavioral health facility.
*The patient was cleared medically and transferred to jail in the care of law enforcement on 12/21/15 at 12:18 p.m.

5. Review of patient 12's electronic medical record revealed:
*She was admitted to the ED on 10/26/15 at 5:30 p.m. with depression and suicidal ideation. She was twelve years old.
*She had a history of three other suicide attempts.
*She had a plan in place to commit suicide. She had no eye contact and was listless.
*She had been placed on a protective hold by law enforcement.
*The QMHP had completed a mental health evaluation, had recommended committal, and a psychiatric evaluation.
*She was medically cleared after her lab work had been completed.
*On 10/26/15 at 7:20 p.m. she was transferred in the care of law enforcement to the JDC to be held overnight until a transfer to a behavior health facility could be arranged.



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6. Review of patient 18's electronic medical record revealed:
*He presented himself to the ED on 1/26/16 at 9:39 a.m.
*His admission diagnosis was schizophrenia.
*He informed the staff he did not feel safe at home due to increased anxiety, hallucinations, and felt he needed his medications adjusted.
*He was offered outpatient counseling, but he did not think that would help him.
*He was placed on a protective custody hold by staff.
*At 10:40 a.m. he was transferred to jail by law enforcement with discharge instructions he should go to jail/detox with "Suicide precautions."
*A QMHP evaluation had not been completed prior to his discharge from the ED.

7. Review of patient 5's electronic medical record revealed:
*He was a fourteen year old boy who was admitted to the ED on 10/26/15 at 11:09 p.m.
*His admission diagnoses were depression, suicidal ideation (thoughts), and had cut himself on the arms.
*While in the ED his arms were bandaged, and he was then cleared medically by the ED physician.
*He was placed on a protective custody hold by staff and was transferred at 12:10 a.m. to the JDC.
*The QMHP evaluation was not done in the hospital and was to have been completed in the morning at the JDC.

8. Review of patient 6's electronic medical record revealed:
*A fifteen year old female was brought to the ED by her parents on 12/6/15 at 9:03 p.m.
*Her admission diagnoses included recurrent major depression and suicidal ideation.
*She was placed on observation in a crisis room.
*At 10:27 p.m. she had been seen by the social worker with no significant recommendations.
*A 24-hour protective custody hold was put in place by staff.
*At 11:55 p.m. she was discharged and transferred to the JDC by law enforcement.
*The QMHP evaluation was not completed in the hospital.

9. Review of patient 14's electronic medical record revealed:
*A fourteen year old girl was brought to the ED by the police on 11/8/15 at 8:17 p.m. following posting on social media her thoughts of suicide.
*Her assessment revealed she had thoughts of self-harm and felt hopeless.
*During her admission in the ED she was seen by the social worker but would not cooperate with a QMHP evaluation.
*She was placed on a protective custody hold by staff.
*At 8:49 p.m. she was discharged from the ED and transferred by law enforcement to the JDC with a plan to be transferred to a mental health facility immediately the next day.

10. Review of patient 16's electronic medical record revealed:
*She voluntarily came to the ED on 1/3/16 at 4:38 a.m. with suicidal thoughts.
*Her assessment revealed she felt hopeless and had thoughts of self-harm.
*She informed the staff she had a knife that she had intended to use on herself, but she decided to come to the ED instead.
*A protective custody hold was put in place by staff.
*At 6:25 a.m. she was discharged and transferred to jail by law enforcement with a plan for a QMHP evaluation to have been completed there instead of at the hospital.



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11. Review of patient 19's electronic medical record revealed:
*She presented to the ED on 1/6/16 at 4:19 a.m.
*Her admission diagnoses was suicidal ideation, anxiety, and depression.
*She was twenty-one years old.
*There was no documentation found for social service involvement prior to the patient's discharge.
*The facility had initiated a protective custody hold and law enforcement had read the mental health hold to her at 4:53 a.m.
*The physician's ED note dated 1/6/16 indicated:
-She had cut her left wrist with a razor. The cuts were not full thickness (deep).
-She had a history of mental health problems, had been hospitalized four times, once for ten months in 2009.
-The physical examination showed no apparent distress.
-She had indicated family stress, reported anxiety, and suicidal ideation.
-The treatment plan was for a QMHP in a few hours "as it is 4:30 a.m."
*Toxicology report revealed her:
-Salicylate (Aspirin) level was less than 4; normal range is 18-30 milligrams (mg) per deciliter (dL).
-Tylenol level was less than 10; normal is 10-20 mg/milliliter (ml).
-Alcohol level was zero.
*The physician's medical clearance form stated "I have examined (patient name) on 1/6/16. I find (patient name) to be medically acceptable for admission to Detox/Jail with the following conditions:"; there were no conditions listed for the patient.
*The patient was escorted by law enforcement to jail.

12. Review of patient 3's electronic medical record revealed:
*She had presented to the ED on 1/29/16 at 1:32 a.m. for an overdose of Motrin.
*She was sixteen years old.
*The facility had initiated a mental health hold and law enforcement had read the mental health hold to her at 1:58 a.m.
*The physician's ED note dated 1/29/16 at 2:07 a.m. indicated the parents would receive a call from the QMHP in the morning.
*Toxicology report revealed her:
-Salicylate (Aspirin) level was less than 4; normal range is 18-30 milligrams (mg) per deciliter (dL).
-Tylenol level was less than 10; normal is 10-20 mg/milliliter (ml).
-Alcohol level was less than one.
*The physician's medical clearance form stated "I have examined (patient name) on 1/29/16. I find (patient name) to be medically acceptable for admission to Detox/Jail with the following conditions:"; there were no conditions listed for the patient.
*There was no documentation found for social service involvement prior to the patient's discharge.
*At 2:07 a.m. the patient was escorted by two officers to detox/jail.

13. Interview on 2/9/16 at 8:55 a.m. with ED director H and quality analyst E in regards to mental health patients who were treated in the ED revealed:
*Transporting of those patients to a behavioral health facility was problematic.
*Social workers were on call until 10:00 p.m. in the evening.
*There was one QMHP on staff.
*The mental health patients were now transported to the evaluation center after they were medically cleared by a physician.
*Neither the ED director nor the quality analyst had been over to the evaluation center at the jail to see how the patients were handled once they left the ED.

Interview on 2/9/16 at 4:20 p.m. with sheriff F per telephone conference in regards to mental health patients transferred from the ED to the jail revealed:
*The patients went to jail.
*Every mental health patient that left the ED to be transferred to jail was handcuffed.
*The evaluation center was an intake area, but it was a jail cell.
*They had a padded cell for those individuals who wanted to hurt themselves.
*The staff at the jail attempted to isolate the mental health patients from the inmate population, but sometimes the jail became overcrowded and those mental health patients were co-mingled with the inmates.
*A mental health hold meant those individuals had their liberties taken away.
*Law enforcement would read the patients their mental health rights.
*Those patients needed to be evaluated by a qualified mental health professional and a plan had to have been put in place for either a transport to another behavioral health facility or plan to have out-patient mental health services within twenty-four hours of having been placed on a protective hold.
*The patients transferred to the jail from the hospital ED had discharge instructions with them.
*If the patient had medications on the discharge instruction sheet, that patient might or might not get their required medication. The jail had a nurse who worked forty hours a week Monday through Friday 8:00 a.m. to 4:00 p.m. There was also a certified nurse practitioner who worked six hours a week. So if the mental health patient was taken to the jail after 4:00 p.m. or on the weekends they might not get their medications, because they did not have the staff available to verify the individuals medications.
*The sheriff's office employed five full time deputies.
*A trip to a behavior health facility could have taken up to eight hours.
*If the mental health patient that was transferred to the jail was on suicide precautions the staff at the jail monitored those individuals every fifteen minutes. That monitoring was electronically documented. Those individuals were also on a camera and were monitored intermittently by staff.
*He had not felt locking them up in jail was an appropriate way to treat mental health patients. He felt that was inhumane.
*He agreed transferring those individuals to a behavioral health facility was problematic.
*He felt the crisis room at the hospital would have been a more humane way to have kept the mental health patients prior to a QMHP mental health evaluation or a transfer to a behavioral health facility.

Interview on 2/9/16 at 4:55 p.m. with vice-president of patient services G regarding mental health patients revealed:
*She had not felt the mental health patients were safe in the ED after the December 2015 visit from the South Dakota Department of Health (SD DOH).
*They had added an extra RN to the ED staffing.
*The hospital felt as though they needed to do something before the revisit occurred from the SD DOH.
*The mental health patients were "a hot topic."
*There was a huge need for mental health services in the community.
*Patient safety had to come first.
*All mental health patients were now being transferred to jail to keep the patients safe.
*Hospital staff and the hospital security staff had no training in CPI (non-violent crisis intervention techniques).

Interview on 2/10/16 at 1:30 p.m. with QMHP D in regards to mental health patients in the ED revealed:
*She worked 7:30 a.m. to 4:30 p.m. Monday through Friday.
*She had a masters degree in social work.
*The social workers would be on call until 10:00 p.m. in the evening. After 10:00 p.m. she would come in if there was an emergency with a child and child protective services, but she would not come in for a QMHP mental health evaluation.
*The QMHPs' responsibility would have been to make the evaluation, give their recommendations for either a safe plan so the patient could return home or for inpatient treatment at a behavioral health facility.
*It was the hospital's responsibility to care for the patient once they were admitted to the hospital.
*The hospital was unable to get timely transportation to a behavioral health facility from the sheriff's office.
*The sheriff's office did not like to transfer mental health patients to a behavioral health facility after 3:00 p.m.
*It was the hospital's responsibility to have a plan for the mental health patient.
*The patient had to have been on a mental health hold in order to have received a QHMP mental health evaluation.
*If the mental health patient had been placed on a twenty-four hour hold that individual would go to jail for a QMHP mental health assessment.
*The process had just changed recently.
*The ED physician or the nurse would implement a mental health hold on a patient that had a plan to harm themselves. They would write out the petition.
*The patients did not stay at the hospital; those mental health patients were either taken to jail or to the JDC.
*She had not been utilized as the QMHP for at least a month, because all QMHP mental health evaluations were conducted at the jail or the JDC.
*She would have preferred the mental health evaluations were performed at the hospital for the mental health patients.
*She did not agreed with the mental health patients going to the jail or to JDC from the ED.

Interview on 2/10/16 at 11:17 a.m. with medical director I in regards to mental health patients in the ED revealed:
*The process had been evaluated for the past twenty years.
*If the patient was medically stable then the QMHP would evaluate the patient. The evaluation process over the years had taken twenty-four to forty-eight hours to complete.
*Obtaining a bed in a behavioral health facility had been problematic.
*The hospital did not have the capability to treat mental health patients.
*If the patients were on a legal hold then it would be law enforcement's responsibility to transport those mental health patients to a behavioral health facility.
*The hospital had been holding mental health patients in the ED if those individuals were manageable and were observed by the hospital staff or a volunteer provided from the county.
*Keeping the patient at the hospital would have taken multiple resources.
*The hospital was looking to the future at other possible alternatives.
*He was unsure how patients transferred to the jail were handled.
*The certified nurse practitioner that worked at the jail had mental health training.
*ED physicians did not have the resources to provide continued behavior health care.
*He would like to have seen a QMHP conduct mental health evaluations in the hospital while the patient was in the ED.
*Bed availability in the behavioral health facilities had become challenging.
*The hospital had been working with other agencies and resources to come up with a solution.

14. Review of the provider's January 2016 Care of Patients with Mental Health Disorders policy revealed:
*"It was the policy of Avera St. Mary's to work cooperatively with other institutions and public officials in the care of the mental health patient, recognizing the hospitals physical limitations and staffing capabilities in treating patients with mental health disorders. Avera St. Mary's is not licensed nor accredited for care of inpatient Behavior Health services. Avera St. Mary's is committed to the safety of our patients and staff.
*Patients presenting to the Emergency Department (ED) by a peace Officer, family member, or other concerned party will be seen by the ED physician and a Medical Screening Examination (MSE) will be conducted. Those patients who are seen for mental health disorders, but are cleared medically will be determined to be a Voluntary Admission or as an Involuntary Admission (under legal state of Protective Custody). Staff will follow the correct procedure for each patient given his or her status."
*"Patients having medical needs in addition to mental health services need to be admitted for care until medical care is stabilized; then patients may be transferred to Behavioral Health inpatient unit as deemed necessary. When patients are being admitted to the hospital for medical care, in addition to mental health needs, these patients will be admitted to the ICU [intensive care unit] or discharged/transferred according to the patients needs.
*Upon completion of MSE by ED physician, it may be determined that the patient has a safe plan to be admitted voluntarily to a Behavioral Health inpatient hospital.
*Patients admitted to ED under Protective Custody or placed in Protective Custody after ED admission will have a Peace Officer Hold Authorization issued.
*If the patient is found to be at risk of harm to self or others, contact security and law enforcement. Hospital security will stay with the patient until law enforcement arrives.
*Law enforcement will stay with the patient during the entire time of the medical evaluation.
*If the patient is medically cleared the patient will be taken at that time to JDC or jail (we do not need to wait for the QMHP evaluation or a plan for them to be taken by law enforcement)."

Review of the provider's May 2015 Crisis Intervention policy revealed:
*"It is the policy of Avera St. Mary's to work cooperatively with other institutions and public officials in the care of the mental health patient, recognizing the hospital's physical limitations and staffing capabilities in treating patients with mental health disorders.
*The purpose of the crisis intervention is to provide temporary short term care in a supportive and safe environment for patients who are experiencing a mental health crisis.
*Patients brought to the Emergency Department (ED) by a Peace Officer, family member or other concerned party will be seen by the E.D. physician or family physician and mental health professional or social services prior to admission with 1:1[one-to-one] observation maintained.
*Patients may be admitted as a Voluntary Admission or as an Involuntary Admission (Under the legal state of Protective Custody). Staff will follow the appropriate procedure for each patient given his or her status.
*Patients admitted under Protective Custody will be held for a period of time to allow for an evaluation by a Qualified Mental Health Professional (QMHP) and development of a discharge/treatment plan (usually up to 24 hours).
*Patients under Protective Custody that become violent, attempt to harm themselves or others or attempt to elope may be transferred to an appropriate facility. Staff should notify law enforcement by calling 9-911 when a patient becomes out of control or attempts to leave.
*Protective Custody patients may be refused admission due to:
1. Inadequate staffing to provide 1:1 observation.
2. Occupied room.
3. Violent behavior.
*If the QMHP (Qualified Mental Health Professional) determines the patient does not meet criteria for involuntary commitment the patient must be discharged. An order for release will be issued by the Chair of the County Mental Health Board. Patients should not be discharged until this order is obtained. Order for discharge is also obtained from the attending physician.
*Unauthorized Absence (Elopement) and Violent or Aggressive Behavior:
-If the patient leaves or attempts to leave without an order for release or discharge order, staff shall:
-Notify law enforcement immediately if the patient is in Protective Custody (Call 9-911)."

Review of the provider's January 2016 Suicide Precautions policy revealed:
*The purpose of the policy was to provide guidelines and procedures designed to create a safe and secure environment for patients identified as potentially suicidal.
*"Nursing staff or physician may determine the need for suicide precautions based on patient assessment. Suicide precautions are initiated for all patients on mental health holds.
*Every 15 minutes close observation by hospital staff.
*Constant supervision may be implemented for patients with strong and persistent preoccupation for self-harm or suicide and who appear intent on harming or killing themselves.
*This policy was developed as a guide for the delivery of health services and is not intended to define the standard of care. This policy should be used as a guide for the delivery of service, although hospital personnel may deviate from this guide to provide appropriate individualized care and treatment for each patient."

Review of the provider's revised April 2015 Emergency Medical Screening and Transfer (EMTALA) revealed:
*"The Hospital will provide an appropriate medical screening examination within the capability of the Hospital's dedicated emergency department, including ancillary services routinely available to the dedicated emergency department, to determine whether an emergency medical condition exists. The examination will be conducted by an individual(s) determined qualified by Hospital Bylaws or rules and regulations; and
*The Hospital will provide an individual with an emergency medical condition such further medical examination and treatment as required to stabilize the emergency medical condition, within the capability and capacity of the Hospital, or to arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below; and ..."
*Emergency medical condition means:
-"A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in either":
-Placing the health of the individual in serious jeopardy.
*To stabilize or stabilize means:
-"With respect to an emergency medical condition, the patient is provided such medical treatment of the condition as is necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the patient; or..."
-"The emergency medical condition has been resolved."
*Stable discharge means:
-"The physician has determined the patient has reached the point where his continued medical treatment could reasonably be performed as an outpatient or later as an inpatient, as long as the patient is given a plan for appropriate follow-up care with discharge instructions; or..."
-"With respect to an individual with a psychiatric condition, the physician has determined the patient is no longer considered to be a threat to himself/herself or others."
*Stable for transfer means:
-"With respect to an individual with a psychiatric condition, a physician or Qualified Medical Person in consultation with a physician determines that the patient is protected and prevented from injuring himself/herself or others."
*"Within the capability of the Hospital means those services which the Hospital is required to have as a condition of its license, as well as on-call physician specialists and Hospital ancillary services routinely available."

Review of the provider's January 2011 Transfer of a Patient to Another Facility policy revealed:
*The purpose of the policy was to have provided appropriate medical screening and stabilizing treatment to any individual who comes to the emergency room. To offer specialized services to a patient by arranging a transfer to another facility that provided those services.
*"Patient transfers are made after instituting essential lifesaving measures and implementing emergency procedures that will minimize further compromise of the condition of any infant, child or adult being transferred. No patient is transported until such time that the patient is considered sufficiently stabilized for such transport by the responsible medical practitioner."
*"Perform and document final assessment of patient's physical stability."

Based on interview, record review, and policy review, the provider failed to ensure:
*Nine of nine sampled patients (3, 5, 6, 8, 13, 14, 16, 18, and 19) with psychiatric diagnoses were discharged to a behavioral healthcare facility consistent with their presenting signs and symptoms, or that a plan had been put in place by a qualified mental health professional (QMHP) to ensure continued care for those mental health (MH) patients.
*Three of three sampled patients (4, 7, and 12) who were admitted to the emergency department (ED) and were evaluated by a QMHP who had recommended a transfer to a behavioral health facility were not transferred to the jail.
Findings include:

1. Interview on 2/9/16 at 8:15 a.m. in the ED with registered nurse ( RN) C in regards to mental health patients seen in the ED revealed:
*Rooms 1 and 2 were used for mental health issues.
*All the staff with the exception of the orientating RN were wearing a panic button to use in an emergency situation when law enforcement needed to be notified.
*The patient would have laboratory (lab) values checked such as urine for drug screening blood chemistry to evaluate any abnormalities.
*If the patient was cleared medically the patient was then transferred by law enforcement to the evaluation center also known as jail. If those mental health patients had been placed on a mental health hold the patient had no choice but to go to jail.
*The staff would have asked the patient to remove all clothing along with belongings and put them into a plastic bag. The staff would have removed the bag from the room. The patient would have been given a patient gown to wear.
*If a patient had refused to go to the evaluation center (jail) then a petition for hold was read to them.
*The patients were cleared medically but their mental health needs were not addressed in the ED.

Interview on 2/9/16 at 8:55 a.m. with ED director H and quality analyst E in regards to mental health patients who were treated in the ED revealed:
*Transporting patients to a behavioral health facility was problematic.
*Social workers were on call until 10:00 p.m. in the evening.
*There was one QMHP on staff.
*The mental health patients were currently transported to the evaluation center after they were medically cleared by a physician.
*Neither the ED director nor the quality analyst had been over to the evaluation center at the jail to see how the patients were handled once they left the ED.

Interview on 2/9/16 at 9:15 a.m. with ED physician A revealed:
*When a patient with mental health issues came into the ED their main concern was making sure the patient did not have a medical threat.
*Any life threatening problem was cleared.
*The multidisciplinary team was involved including the social worker although that person did not usually come in.
*They had a QMHP, but the nighttime (overnite) shift was a problem.
*Their main concern was keeping the MH patient safe.
*He was unsure what instructions were given at the time of discharge.
*The QMHP evaluation was usually done at the evaluation center at the jail.
*He had not been to the jail to see where the MH patients were detained.
*He was unsure what instructions were given at the time of discharge.
*He was unaware of the staffing at the evaluation center/jail and if they had medical staff on duty.
*He thought since the at-risk patients were safe with law enforcement when they went to the evaluation center and had been medically cleared, they were doing all they could for the patient.

2. Review of patient 8's electronic medical record revealed she:
*Had been admitted to the ED on 10/8/15 at 12:40 a.m. by law enforcement. She was twelve years old.
*Had attempted suicide by placing a sheet around her neck and hanging herself.
*Had rated her pain on a pain scale from 1 to 10 (1 the least pain and 10 severe pain) a 7 on admission and then a 5 at discharge. There had been no follow-up on her pain, and there was no documentation her pain had been addressed.
*Had a physician evaluate her.
*Had been medically cleared for transfer to the juvenile detention center (JDC) after lab work had been completed.
*Had no mental health evaluation.
*Was discharged at 1:30 a.m. in the care of law enforcement.

3. Review of patient 13's electronic medical record revealed she:
*Had been admitted to the ED on 1/9/16 at 2:35 p.m. She was thirteen years old.
*Had attempted suicide by placing a string around her neck to hang herself. There had been a one-to-one (1:1) observation sheet completed by staff at 1:50 p.m. and at 2:05 p.m. The patient had not been admitted to the ED until 2:35 p.m. The times were incorrect on the observation sheet.
*Was medically cleared by the physician after lab work had been completed.
*Had no mental health evaluation completed prior to discharge.
*Was discharged at 3:21 p.m. to the JDC in the care of law enforcement.

4. Review of patient 7's electronic medical record revealed:
*She was admitted to the ED on 12/21/15 at 11:14 a.m. with aggressive behaviors. She was twenty-eight years old.
*She had a history of attempted suicide a year prior and had depression. She had been acting out aggressively, threatening others, and herself. She had a previous psychiatric admission for suicidal ideation.
*There was a QMHP assessment completed at that time.
*The QMHP recommended inpatient admission to a behavioral health facility.
*The patient was cleared medically and transferred to jail in the care of law enforcement on 12/21/15 at 12:18 p.m.

5. Review of patient 12's electronic medical record revealed:
*She was admitted to the ED on 10/26/15 at 5:30 p.m. with depression and suicidal ideation. She was twelve years old.
*She had a history of three other suicide attempts.
*She had a plan in place to commit suicide. She had no eye contact and was listless.
*She had been placed on a protective custody hold by law enforcement.
*The QMHP had completed a mental health evaluation, had recommended committal, and a psychiatric evaluation.
*She was medically cleared after lab work had been completed.
*On 10/26/15 at 7:20 p.m. she was transferred in the care of law enforcement to the JDC to be held overnight until a transfer to a behavior health facility could be arranged.



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6. Review of patient 18's electronic medical record revealed:
*He presented himself to the ED on 1/26/16 at 9:39 a.m.
*His admission diagnosis was schizophrenia.
*He informed the staff he did not feel safe at home due to increased anxiety, hallucinations, and felt he needed his medications adjusted.
*He was offered outpatient counseling, but he did not think that would help him.
*He was placed on a protective custody hold by staff.
*At 10:40 a.m. he was transferred to jail by law enforcement with discharge instructions he should go to jail/detox with "Suicide precautions."
*A QMHP evaluation had not been completed prior to his discharge from the ED.

7. Review of patient 4's electronic medical record revealed:
*He was a sixteen year old boy who was brought to the ED by law enforcement on 10/12/15 at 5:53 p.m.
*His admission diagnoses was bipolar disease (manic/depressive), anxiety and Oppositional Defiant Disorder (a pattern of argumentative/defiant mood).
*Prior to coming to the ED he had threatened to kill his dad, and himself, and he had been taken in by his father for drug testing. While he was at the physician's office for the drug testing he ran from the clinic, and the police were called. When law enforcement found him they brought him to the ED.
*A QMHP evaluation was completed in the ED with a recommendation and referral for admission to a mental health facility.
*He was placed on a protective custody hold by staff.
*At 5:06 p.m. law enforcement transferred him to the JDC until placement was found.

8. Review of patient 5's electronic medical record revealed:
*He was a fourteen year old boy who was admitted to the ED on 10/26/15 at 11:09 p.m.
*His admission diagnoses was depression, suicidal ideation (thoughts), and had cut himself on the arms.
*While in the ED his arms were bandaged, and he was then cleared medically by the ED physician.
*He was placed on a protective custody hold by staff and was transferred at 12:10 a.m. to the JDC.
*The QMHP evaluation was not done in the hospital and was to have been completed in the morning at the JDC.

9. Review of patient 6's electronic medical record revealed:
*A fifteen year old female was brought to the ED by her parents on 12/6/15 at 9:03 p.m.
*Her admission diagnoses included recurrent major depression and suicidal ideation.
*She was placed on observation in a crisis room.
*At 10:27 p.m. she had been seen by the social worker with no significant recommendations.
*A protective custody hold was put in place by staff.
*At 11:55 p.m. she was discharged and transferred to the JDC by law enforcement.
*The QMHP evaluation was not completed in the hospital.

10. Review of patient 14's electronic medical record revealed:
*A fourteen year old girl was brought to the ED by law enforcement on 11/8/15 at 8:17 p.m. following posting on social media her thoughts of suicide.
*Her assessment revealed she had thoughts of self harm and felt hopeless.
*During her admission in the ED she was seen by the social worker but would not cooperate with a QMHP evaluation.
*She was placed on a protective custody hold by staff.
*At 8:49 p.m. she was discharged from the ED and transferred by law enforcement to the JDC with a plan to be transferred to a mental health facility immediately the next day.

11. Review of patient 16's electronic medical care record revealed:
*She voluntarily came to the ED on 1/3/16 at 4:38 a.m. with suicidal thoughts.
*Her assessment revealed she felt hopeless and had thoughts of self-harm.
*She informed the staff she had a knife that she had intended to use on herself, but she decided to come to the ED instead.
*A protective custody hold was put in place by the staff.
*At 6:25 a.m. she was discharged and transferred to jail by law enforcement with a plan for a QMHP evaluation to have been completed there instead of the hospital.



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12. Review of patient 19's electronic medical record revealed:
*She presented to the ED on 1/6/16 at 4:19 a.m.
*Her admission diagnoses was suicidal ideation, anxiety, and depression.
*She was twenty-one years old.
*There was no documentation found for social service involvement prior to the patient's discharge.
*The facility had initiated a mental health hold and law enforcement had read the mental health hold to her at 4:53 a.m.
*The physician's ED note dated 1/6/16 indicated:
-She had cut her left wrist with a razor. The cuts were not full thickness (deep).
-She had a history of mental health problems, had been hospitalized four times, once for ten months in 2009.
-The physical examination showed no apparent distress.
-She had indicated family stress, reported anxiety, and suicidal ideation.
-The treatment plan was for a QMHP in a few hours "as it is 4:30 a.m."
*Toxicology report revealed her:
-Salicylate (Aspirin) level was less than 4; normal range is 18-30 milligrams (mg) per deciliter (dL).
-Tylenol level was less than 10; normal is 10-20 mg/milliliter (ml).
-Alcohol level was zero.
*The physician's medical clearance form stated "I have examined (patient name) on 1/6/16. I find (patient name) to be medically acceptable for admission to Detox/Jail with the following conditions:"; there were no conditions listed for the patient.
*The patient was escorted by law enforcement to jail.

13. Review of patient 3's medical record revealed:
*She had presented to the ED on 1/29/16 at 1:32 a.m. for an overdose of Motrin.
*She was sixteen years old.
*The facility had initiated a mental health hold and law enforcement had read the mental health hold to her at 1:58 a.m.
*The physician's ED note dated 1/29/16 at 2:07 a.m. indicated the parents would receive a call from the QMHP in the morning.
*Toxicology report revealed her:
-Salicylate (Aspirin) level was less than 4; normal range is 18-30 milligrams (mg) per deciliter (dL).
-Tylenol level was less than 10; normal is 10-20 mg/milliliter (ml).
-Alcohol level was less than one.
*The physician's medical clearance form stated "I have examined (patient name) on 1/29/16. I find (patient name) to be medically acceptable for admission to Detoxify/jail with the following conditions:"; there were no conditions listed for the patient.
*There was no documentation found for social service involvement prior to the patient's discharge.
*At 2:07 a.m. the patient was escorted by two officers to detox/jail.

14. Interview on 2/9/16 at 8:55 a.m. with ED director H and quality analyst E in regards to mental health patients who were treated in the ED revealed:
*Transporting of those patients to a behavioral health facility was problematic.
*Social workers were on call until 10:00 p.m. in the evening.
*There was one QMHP on staff.
*The mental health patients were now transported to the evaluation center after they were medically cleared by a physician.
*Neither the ED director nor the quality analyst had been over to the evaluation center at the jail to see how the patients were handled once they left the ED.

Interview on 2/9/16 at 4:20 p.m. with sheriff F per telephone conference in regards to mental health patients transferred from the ED to the jail revealed:
*The patients went to jail.
*Every mental health patient that left the ED to be transferred to jail was handcuffed.
*The evaluation center was an intake area, but it was a jail cell.
*They did have a padded cell for those individuals who wanted to hurt themselves.
*The staff at the jail attempted to isolate the mental health patients from the inmate population, but sometimes the jail became overcrowded and those mental health patients were co-mingled with the inmates.
*A mental health hold meant those individuals had their liberties taken away.
*Law enforcement would read the patients their mental health rights.
*Those patients needed to be evaluated by a qualified mental health professional for either a transport to another behavioral health facility or plan to have out-patient mental health services within twenty-four hours of having been placed on a protective hold.
*The patients transferred to the jail from the hospital ED had discharge instructions with them.
*If the patient had medications on the discharge instruction sheet, that patient might or might not get his required medication. The jail had a nurse who worked forty hours a week Monday through Friday 8:00 a.m. to 4:00 p.m. There was also a certified nurse practitioner who worked six hours a week. So if the mental health patient was taken to the jail after 4:00 p.m. or on the weekends they might not get their medications, because they did not have the staff available to verify the individuals medications.
*The sheriff's office employed five full time deputies.
*A trip to a behavior health facility would have taken up to eight hours.
*If the mental health patient that was transferred to the jail was on suicide precautions the staff at the jail monitored those individuals every fifteen minutes. That monitoring was electronically documented. Those individuals were also on a camera and were monitored intermittently by staff.
*He had not felt locking them up in jail was an appropriate way to treat mental health patients. He felt that was inhumane.
*He agreed transferring those individuals to a behavioral health facility was problematic.
*He felt the crisis room at the hospital would have been a more humane way to have kept the mental health patients prior to a QMHP mental health evaluation or a transfer to a behavioral health facility.

Interview on 2/9/16 at 4:55 p.m. with vice-president of patient services G regarding mental health patients revealed:
*She had not felt the mental health patients were safe in the ED after the December 2015 visit from the South Dakota Department of Health (SD DOH).
*They had added an extra RN to the ED staffing.
*The hospital felt as though they needed to do something before the revisit occurred from the SD DOH.
*The mental health patients were a "hot topic."
*There was a huge need for mental health services in the community.
*Patient safety had to come first.
*All mental health patients were now being transferred to jail to keep the patients safe.
*Hospital staff and the hospital security staff had no training in CPI (non-violent crisis intervention techniques).

Interview on 2/10/16 at 1:30 p.m. with QMHP D in regards to mental health patients in the ED revealed:
*She worked 7:30 a.m. to 4:30 p.m. Monday through Friday.
*She had a masters degree in social work.
*The social workers would be on call until 10:00 p.m. in the evening. After 10:00 p.m. she would come in if there was an emergency with a child and child protective services, but she would not come in for a QMHP mental health evaluation.
*The QMHPs' responsibility would have been to make the evaluation, give their recommendations for either a safe plan so the patient could return home or for inpatient treatment at a behavioral health facility.
*It was the hospital's responsibility to care for the patient once they were admitted to the hospital.
*The hospital was unable to get timely transportation to a behavioral health facility from the sheriff's office.
*The sheriff's office did not like to transfer mental health patients after 3:00 p.m.
*It was the hospital's responsibility to have a plan for the mental health patient.
*The patient had to have been on a mental health hold in order to have received a QMHP mental health evaluation.
*If the mental health patient had been placed on a twenty-four hour hold that individual would go to jail for a QMHP mental health assessment.
*The process had just changed recently.
*The ED physician or the nurse would implement a mental health hold on a patient that has a plan to harm themselves. They would write out the petition.
*The patients did not stay at the hospital; those mental health patients were either taken to jail or to the JDC.
*She had not been utilized as the QMHP for at least a month, because all QMHP mental health evaluations were conducted at the jail or the JDC.
*She would prefer the mental health patients evaluations were performed at the hospital for the mental health patients.
*She had not agreed with the mental health patients going to the jail or the JDC from the ED.

Interview on 2/10/16 at 11:17 a.m. with medical director I in regards to mental health patients in the ED revealed:
*The evaluation process had been evaluated for the past twenty years.
*If the patient is medically stable then the QMHP would evaluate the patient. The evaluation process over the years had taken twenty-four to forty-eight hours to complete.
*Obtaining a bed in a behavioral health facility had been problematic.
*The hospital did not have the capability to treat mental health patients.
*If the patients were on a legal hold then it would be law enforcement's responsibility to transport those mental health patients to a behavioral health facility.
*The hospital had been holding mental health patients in the ED if those individuals were manageable and were observed by the hospital staff or a volunteer provided from the county.
*Keeping the patient at the hospital would have taken multiple resources.
*The hospital was looking to the future at other possible alternatives.
*He was unsure how patients transferred to the jail were handled.
*The certified nurse practitioner that worked at the jail had mental health training.
*ED physicians did not have the resources to provide continued behavior health care.
*He would like to have seen a QMHP conduct mental health evaluations in the hospital while the patient was in the ED.
*Bed availability in the behavioral health facilities had become challenging.
*The hospital has been working with other agencies and resources to come up with a solution.

15. Review of the provider's January 2016 Care of Patients with Mental Health Disorders policy revealed:
*"It was the policy of Avera St. Mary's to work cooperatively with other institutions and public officials in the care of the mental health patient, recognizing the hospitals physical limitations and staffing capabilities in treating patients with mental health disorders. Avera St. Mary's is not licensed nor accredited for care of inpatient Behavior Health services. Avera St. Mary's is committed to the safety of our patients and staff.
*Patients presenting to the Emergency Department (ED) by a peace Officer, family member, or other concerned party will be seen by the ED physician and a Medical Screening Examination (MSE) will be conducted. Those patients who are seen for mental health disorders, but are cleared medically will be determined to be a Voluntary Admission or as an Involuntary Admission (under legal state of Protective Custody). Staff will follow the correct procedure for each patient given his or her status."
*"Patients having medical needs in addition to mental health services need to be admitted for care until medical care is stabilized; then patients may be transferred to Behavioral Health inpatient unit as deemed necessary. When patients are being admitted to the hospital for medical care, in addition to mental health needs, these patients will be admitted to the ICU [intensive care unit] or discharged/transferred according to the patients needs.
*Upon completion of MSE by ED physician, it may be determined that the patient has a safe plan to be admitted voluntarily to a Behavioral Health inpatient hospital.
*Patients admitted to ED under Protective Custody or placed in Protective Custody after ED admission will have a Peace Officer Hold Authorization issued.
*If the patient is found to be a at risk of harm to self or others, contact security and law enforcement. Hospital security will stay with the patient until law enforcement arrives.
*Law enforcement will stay with the patient during the entire time of the medical evaluation.
*If the patient is medically cleared the patient will be taken at that time to the JDC or jail (we do not need to wait for the QMHP evaluation or a plan for them to be taken by law enforcement)."

Review of the provider's May 2015 Crisis Intervention policy revealed:
*"It is the policy of Avera St. Mary's to work cooperatively with other institutions and public officials in the care of the mental health patient, recognizing the hospital's physical limitations and staffing capabilities in treating patients with mental health disorders.
*The purpose of the crisis intervention is to provide temporary short term care in a supportive and safe environment for patients who are experiencing a mental health crisis.
*Patients brought to the Emergency Department (ED) by a Peace Officer, family member or other concerned party will be seen by the E.D. physician or family physician and mental health professional or social services prior to admission with 1:1 [one-on-one] observation maintained.
*Patients may be admitted as a Voluntary Admission or as an Involuntary Admission (Under the legal state of Protective Custody). Staff will follow the appropriate procedure for each patient given his or her status.
*Patients admitted under Protective Custody will be held for a period of time to allow for an evaluation by a Qualified Mental Health Professional (QMHP) and development of a discharge/treatment plan (usually up to 24 hours).
*Patients under Protective Custody that become violent, attempt to harm themselves or others or attempt to elope may be transferred to an appropriate facility. Staff should notify law enforcement by calling 9-911 when a patient becomes out of control or attempts to leave.
*Protective Custody patients may be refused admission due to:
1. Inadequate staffing to provide 1:1 observation.
2. Occupied room.
3. Violent behavior.
-If the QMHP (Qualified Mental Health Professional) determines the patient does not meet criteria for involuntary commitment the patient must be discharged. An order for release will be issued by the Chair of the County Mental Health Board. Patients should not be discharged until this order is obtained. Order for discharge is also obtained from the attending physician.
*Unauthorized Absence (Elopement) and Violent or Aggressive Behavior:
-If the patient leaves or attempts to leave without an order for release or discharge order, staff shall:
-Notify law enforcement immediately if the patient is in Protective Custody (Call 9-911)."

Review of the provider's January 2016 Suicide Precautions policy revealed:
*The purpose of the policy was to provide guidelines and procedures designed to create a safe and secure environment for patients identified as potentially suicidal.
*"Nursing staff or physician may determine the need for suicide precautions based on patient assessment. Suicide precautions are initiated for all patients on mental health holds.
*Every 15 minutes close observation by hospital staff.
*Constant supervision may be implemented for patients with strong and persistent preoccupation for self-harm or suicide and who appear intent on harming or killing themselves.
*This policy was developed as a guide for the delivery of health services and is not intended to define the standard of care. This policy should be used as a guide for the delivery of service, although hospital personnel may deviate from this guide to provide appropriate individualized care and treatment for each patient."

Review of the provider's revised April 2015 Emergency Medical Screening and Transfer (EMTALA) revealed:
*"The Hospital will provide an appropriate medical screening examination within the capability of the Hospital's dedicated emergency department, including ancillary services routinely available to the dedicated emergency department, to determine whether an emergency medical condition exists. The examination will be conducted by an individual(s) determined qualified by Hospital Bylaws or rules and regulations; and
*The Hospital will provide an individual with an emergency medical condition such further medical examination and treatment as required to stabilize the emergency medical condition, within the capability and capacity of the Hospital, or to arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below; ..."
*Emergency medical condition means:
*"A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in either":
-Placing the health of the individual in serious jeopardy.
*To stabilize or stabilize means:
-"With respect to an emergency medical condition, the patient is provided such medical treatment of the condition as is necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the patient; or ..."
-"The emergency medical condition has been resolved."
*Stable discharge means:
-"The physician has determined that the patient has reached the point where his continued medical treatment could reasonably be performed as an outpatient or later as an inpatient, as long as the patient is given a plan for appropriate follow-up care with discharge instructions; or..."
-"With respect to an individual with a psychiatric condition, the physician has determined that the patient is no longer considered to be a threat to himself/herself or others."
*Stable for transfer means:
-"With respect to an individual with a psychiatric condition, a physician or Qualified Medical Person in consultation with a physician determines the patient is protected and prevented from injuring himself/herself or others."
*"Within the capability of the Hospital means those services which the Hospital is required to have as a condition of its license, as well as on-call physician specialists and Hospital ancillary services routinely available."

Review of the provider's January 2011 Transfer of a Patient to Another Facility policy revealed:
*The purpose of the policy was to have provided appropriate medical screening and stabilizing treatment to any individual who comes to the emergency room. To offer specialized services to a patient by arranging a transfer to another facility that provided those services.
*"Patient transfers are made after instituting essential lifesaving measures and implementing emergency procedures that will minimize further compromise of the condition of any infant, child or adult being transferred. No patient is transported until such time that the patient is considered sufficiently stabilized for such transport by the responsible medical practitioner."
*"Perform and document final assessment of patient's physical stability."

Based on interview, record review, and policy review, the provider failed to ensure:
*Two of three sampled patients (8 and 13) who were admitted to the emergency department (ED) with recent suicide attempts by hanging had been thoroughly screened and had a mental health (MH) evaluation completed by a qualified mental health professional (QMHP) prior to having been discharged in the care of law enforcement and transferred to jail or the juvenile detention center (JDC).
*Nine of nine sampled patients (3, 5, 6, 7, 12, 14, 16, 18, and 19) who had been admitted to the ED with suicidal ideation had a mental health evaluation completed by a QMHP prior to having been discharged in the care of law enforcement and transferred to jail.
Findings include:

1. Interview on 2/9/16 at 8:15 a.m. in the ED with registered nurse (RN) C in regards to MH patients in the ED revealed:
*Rooms 1 and 2 were used for MH issues.
*All the staff with the exception of the orientating RN were wearing a panic button to use in an emergency situation when law enforcement needed to be notified.
*The patient would have laboratory (lab) values checked such as urine for drug screening and blood chemistry to evaluate any abnormalities.
*If the patient was cleared medically the patient was then transferred by law enforcement to the evaluation center also known as jail. If those mental health patients had been placed on a mental health hold the patient had no choice but to go to jail.
*The staff would have asked the patient to remove all clothing along with belongings and put them into a plastic bag. The staff would have removed the bag from the room. The patient would have been given a patient gown to wear.
*If a patient had refused to go to the evaluation center (jail) then a petition for hold was read to them.
*The patients were cleared medically but their mental health needs were not addressed in the ED.

Interview on 2/9/16 at 8:55 a.m. with ED director H and quality analyst E in regards to mental health patients who were treated in the ED revealed:
*Transporting patients to a behavioral health facility was problematic.
*Social workers were on call until 10:00 p.m. in the evening.
*There was one QMHP on staff.
*The mental health patients were currently transported to the evaluation center after they were medically cleared by a physician.
*Neither the ED director nor the quality analyst had been over to the evaluation center at the jail to see how the patients were handled once they left the ED.

Interview on 2/9/16 at 9:15 a.m. with ED physician A revealed:
*When a patient with mental health issues came into the ED their main concern was making sure the patient did not have a medical threat.
*Any life threatening problem was cleared.
*The multidisciplinary team was involved including the social worker although that person did not usually come in.
*They had a QMHP, but the nighttime (overnite) shift was a problem.
*Their main concern was keeping the MH patient safe.
*The QMHP evaluation was usually done at the evaluation center at the jail.
*He had not been to the jail to see where the MH patients were detained.
*He was unsure what instructions were given at the time of discharge.
*He was unaware of the staffing at the evaluation center/jail and if they had medical staff on duty.
*He thought since the at-risk patients were safe with law enforcement when they went to the evaluation center and had been medically cleared, they were doing all they could for the patient.

2. Review of patient 8's electronic medical record revealed she:
*Had been admitted to the ED on 10/8/15 at 12:40 a.m. by law enforcement. She was twelve years old.
*Had attempted suicide by placing a sheet around her neck and hanging herself.
*Had rated her pain on a pain scale from 1 to 10 (1 the least pain and 10 severe pain) a 7 on admission and then a 5 at discharge. There had been no follow-up on her pain, and there was no documentation her pain had been addressed.
*Had a physician evaluate her.
*Had been medically cleared for transfer to the JDC after lab work had been completed.
*Had no mental health evaluation.
*Was discharged at 1:30 a.m. in the care of law enforcement.

3. Review of patient 13's electronic medical record revealed she:
*Had been admitted to the ED on 1/9/16 at 2:35 p.m. She was thirteen years old.
*Had attempted suicide by placing a string around her neck to hang herself. There had been a one-to-one (1:1) observation sheet completed by staff at 1:50 p.m. and at 2:05 p.m. The patient had not been admitted to ED until 2:35 p.m. The times were incorrect on the observation sheet.
*Was medically cleared by the physician after lab work had been completed.
*Had no mental health evaluation completed prior to discharge.
*Was discharged at 3:21 p.m. to the JDC in the care of law enforcement.

4. Review of patient 7's electronic medical record revealed:
*She was admitted to the ED on 12/21/15 at 11:14 a.m. with aggressive behaviors. She was twenty-eight years old.
*She had a history of attempted suicide a year prior and had depression. She had been acting out aggressively, threatening others, and herself. She had a previous psychiatric admission for suicidal ideation.
*There was a QMHP assessment completed at that time.
*The QMHP recommended inpatient admission to a behavioral health facility.
*The patient was cleared medically and transferred to jail in the care of law enforcement on 12/21/15 at 12:18 p.m.

5. Review of patient 12's electronic medical record revealed:
*She was admitted to the ED on 10/26/15 at 5:30 p.m. with depression and suicidal ideation. She was twelve years old.
*She had a history of three other suicide attempts.
*She had a plan in place to commit suicide. She had no eye contact and was listless.
*She had been placed on a protective hold by law enforcement.
*The QMHP had completed a mental health evaluation, had recommended committal, and a psychiatric evaluation.
*She was medically cleared after her lab work had been completed.
*On 10/26/15 at 7:20 p.m. she was transferred in the care of law enforcement to the JDC to be held overnight until a transfer to a behavior health facility could be arranged.



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6. Review of patient 18's electronic medical record revealed:
*He presented himself to the ED on 1/26/16 at 9:39 a.m.
*His admission diagnosis was schizophrenia.
*He informed the staff he did not feel safe at home due to increased anxiety, hallucinations, and felt he needed his medications adjusted.
*He was offered outpatient counseling, but he did not think that would help him.
*He was placed on a protective custody hold by staff.
*At 10:40 a.m. he was transferred to jail by law enforcement with discharge instructions he should go to jail/detox with "Suicide precautions."
*A QMHP evaluation had not been completed prior to his discharge from the ED.

7. Review of patient 5's electronic medical record revealed:
*He was a fourteen year old boy who was admitted to the ED on 10/26/15 at 11:09 p.m.
*His admission diagnoses were depression, suicidal ideation (thoughts), and had cut himself on the arms.
*While in the ED his arms were bandaged, and he was then cleared medically by the ED physician.
*He was placed on a protective custody hold by staff and was transferred at 12:10 a.m. to the JDC.
*The QMHP evaluation was not done in the hospital and was to have been completed in the morning at the JDC.

8. Review of patient 6's electronic medical record revealed:
*A fifteen year old female was brought to the ED by her parents on 12/6/15 at 9:03 p.m.
*Her admission diagnoses included recurrent major depression and suicidal ideation.
*She was placed on observation in a crisis room.
*At 10:27 p.m. she had been seen by the social worker with no significant recommendations.
*A 24-hour protective custody hold was put in place by staff.
*At 11:55 p.m. she was discharged and transferred to the JDC by law enforcement.
*The QMHP evaluation was not completed in the hospital.

9. Review of patient 14's electronic medical record revealed:
*A fourteen year old girl was brought to the ED by the police on 11/8/15 at 8:17 p.m. following posting on social media her thoughts of sui

Based on interview, record review, and policy review, the provider failed to ensure:
*Nine of nine sampled patients (3, 5, 6, 8, 13, 14, 16, 18, and 19) with psychiatric diagnoses were discharged to a behavioral healthcare facility consistent with their presenting signs and symptoms, or that a plan had been put in place by a qualified mental health professional (QMHP) to ensure continued care for those mental health (MH) patients.
*Three of three sampled patients (4, 7, and 12) who were admitted to the emergency department (ED) and were evaluated by a QMHP who had recommended a transfer to a behavioral health facility were not transferred to the jail.
Findings include:

1. Interview on 2/9/16 at 8:15 a.m. in the ED with registered nurse ( RN) C in regards to mental health patients seen in the ED revealed:
*Rooms 1 and 2 were used for mental health issues.
*All the staff with the exception of the orientating RN were wearing a panic button to use in an emergency situation when law enforcement needed to be notified.
*The patient would have laboratory (lab) values checked such as urine for drug screening blood chemistry to evaluate any abnormalities.
*If the patient was cleared medically the patient was then transferred by law enforcement to the evaluation center also known as jail. If those mental health patients had been placed on a mental health hold the patient had no choice but to go to jail.
*The staff would have asked the patient to remove all clothing along with belongings and put them into a plastic bag. The staff would have removed the bag from the room. The patient would have been given a patient gown to wear.
*If a patient had refused to go to the evaluation center (jail) then a petition for hold was read to them.
*The patients were cleared medically but their mental health needs were not addressed in the ED.

Interview on 2/9/16 at 8:55 a.m. with ED director H and quality analyst E in regards to mental health patients who were treated in the ED revealed:
*Transporting patients to a behavioral health facility was problematic.
*Social workers were on call until 10:00 p.m. in the evening.
*There was one QMHP on staff.
*The mental health patients were currently transported to the evaluation center after they were medically cleared by a physician.
*Neither the ED director nor the quality analyst had been over to the evaluation center at the jail to see how the patients were handled once they left the ED.

Interview on 2/9/16 at 9:15 a.m. with ED physician A revealed:
*When a patient with mental health issues came into the ED their main concern was making sure the patient did not have a medical threat.
*Any life threatening problem was cleared.
*The multidisciplinary team was involved including the social worker although that person did not usually come in.
*They had a QMHP, but the nighttime (overnite) shift was a problem.
*Their main concern was keeping the MH patient safe.
*He was unsure what instructions were given at the time of discharge.
*The QMHP evaluation was usually done at the evaluation center at the jail.
*He had not been to the jail to see where the MH patients were detained.
*He was unsure what instructions were given at the time of discharge.
*He was unaware of the staffing at the evaluation center/jail and if they had medical staff on duty.
*He thought since the at-risk patients were safe with law enforcement when they went to the evaluation center and had been medically cleared, they were doing all they could for the patient.

2. Review of patient 8's electronic medical record revealed she:
*Had been admitted to the ED on 10/8/15 at 12:40 a.m. by law enforcement. She was twelve years old.
*Had attempted suicide by placing a sheet around her neck and hanging herself.
*Had rated her pain on a pain scale from 1 to 10 (1 the least pain and 10 severe pain) a 7 on admission and then a 5 at discharge. There had been no follow-up on her pain, and there was no documentation her pain had been addressed.
*Had a physician evaluate her.
*Had been medically cleared for transfer to the juvenile detention center (JDC) after lab work had been completed.
*Had no mental health evaluation.
*Was discharged at 1:30 a.m. in the care of law enforcement.

3. Review of patient 13's electronic medical record revealed she:
*Had been admitted to the ED on 1/9/16 at 2:35 p.m. She was thirteen years old.
*Had attempted suicide by placing a string around her neck to hang herself. There had been a one-to-one (1:1) observation sheet completed by staff at 1:50 p.m. and at 2:05 p.m. The patient had not been admitted to the ED until 2:35 p.m. The times were incorrect on the observation sheet.
*Was medically cleared by the physician after lab work had been completed.
*Had no mental health evaluation completed prior to discharge.
*Was discharged at 3:21 p.m. to the JDC in the care of law enforcement.

4. Review of patient 7's electronic medical record revealed:
*She was admitted to the ED on 12/21/15 at 11:14 a.m. with aggressive behaviors. She was twenty-eight years old.
*She had a history of attempted suicide a year prior and had depression. She had been acting out aggressively, threatening others, and herself. She had a previous psychiatric admission for suicidal ideation.
*There was a QMHP assessment completed at that time.
*The QMHP recommended inpatient admission to a behavioral health facility.
*The patient was cleared medically and transferred to jail in the care of law enforcement on 12/21/15 at 12:18 p.m.

5. Review of patient 12's electronic medical record revealed:
*She was admitted to the ED on 10/26/15 at 5:30 p.m. with depression and suicidal ideation. She was twelve years old.
*She had a history of three other suicide attempts.
*She had a plan in place to commit suicide. She had no eye contact and was listless.
*She had been placed on a protective custody hold by law enforcement.
*The QMHP had completed a mental health evaluation, had recommended committal, and a psychiatric evaluation.
*She was medically cleared after lab work had been completed.
*On 10/26/15 at 7:20 p.m. she was transferred in the care of law enforcement to the JDC to be held overnight until a transfer to a behavior health facility could be arranged.



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6. Review of patient 18's electronic medical record revealed:
*He presented himself to the ED on 1/26/16 at 9:39 a.m.
*His admission diagnosis was schizophrenia.
*He informed the staff he did not feel safe at home due to increased anxiety, hallucinations, and felt he needed his medications adjusted.
*He was offered outpatient counseling, but he did not think that would help him.
*He was placed on a protective custody hold by staff.
*At 10:40 a.m. he was transferred to jail by law enforcement with discharge instructions he should go to jail/detox with "Suicide precautions."
*A QMHP evaluation had not been completed prior to his discharge from the ED.

7. Review of patient 4's electronic medical record revealed:
*He was a sixteen year old boy who was brought to the ED by law enforcement on 10/12/15 at 5:53 p.m.
*His admission diagnoses was bipolar disease (manic/depressive), anxiety and Oppositional Defiant Disorder (a pattern of argumentative/defiant mood).
*Prior to coming to the ED he had threatened to kill his dad, and himself, and he had been taken in by his father for drug testing. While he was at the physician's office for the drug testing he ran from the clinic, and the police were called. When law enforcement found him they brought him to the ED.
*A QMHP evaluation was completed in the ED with a recommendation and referral for admission to a mental health facility.
*He was placed on a protective custody hold by staff.
*At 5:06 p.m. law enforcement transferred him to the JDC until placement was found.

8. Review of patient 5's electronic medical record revealed:
*He was a fourteen year old boy who was admitted to the ED on 10/26/15 at 11:09 p.m.
*His admission diagnoses was depression, suicidal ideation (thoughts), and had cut himself on the arms.
*While in the ED his arms were bandaged, and he was then cleared medically by the ED physician.
*He was placed on a protective custody hold by staf