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Based on DED (Dedicated Emergency Department) medical record reviews, and physician and staff interviews, the hospital failed to provide an appropriate medical screening examination and necessary stabilizing treatment, within the capability of the hospital's DED, for 1 of 20 sampled patients (Patient #9) presenting to the hospital's DED.

The findings include:

1. Based on DED medical record reviews, and physician and staff interviews, the hospital failed to provide for an appropriate medical screening examination, within the capability of the hospital's DED for an individual who presented for psychiatric evaluation in 1 of 20 sampled patients (Patient #9).

~cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

2. Based on hospital policy review, DED medical record reviews, and staff interviews, the hospital failed to provide necessary stabilizing treatment, within the capability of the hospital's DED for an individual who presented for psychiatric evaluation in 1 of 20 sampled patients (Patient #9).

~cross refer to 489.24(d) (1-3), Stabilizing Treatment - Tag A2407.

Based on medical record reviews, and physician and staff interviews, the hospital failed to provide for an appropriate medical screening examination, within the capability of the hospital's Dedicated Emergency Department for an individual who presented for psychiatric evaluation in 1 of 20 sampled patients, (Patient #9).

Findings included:

Closed medical record review conducted on 04/07/2020 revealed Patient #9 was a 32-year-old male who presented voluntarily to Hospital A by law enforcement on 11/28/2019 at 0528 complaining of Psychiatric Evaluation. Patient #9's vital signs at 0534 were: blood pressure (BP) 130/91, pulse (P) 102, respirations (R) 18, pulse oximetry (SPO2) 100 %, and temperature (T) 98.7. Review of an ED (Emergency Department) Provider Note written by DO (Doctor of Osteopathic Medicine) #1 on 11/28/2019 at 0636 revealed, "Chief Complaint Patient presents with Psychiatric Evaluation brought (sic) in voluntarily by (Named Town) PD (Police Department), cousin told PD that pt (patient) is having a mental breakdown. Pt said, 'I need to talk to someone.' 32-year-old male with a history of traumatic brain injury and depression presents to the emergency department with police for evaluation. The patient was having an argument with his parents prior to arrival. He lives with his mother and father. He states that he got into an argument with them today. The called the police, because he was angry and throwing things around the room. The patient states that he was angry at them because they were very stressed about preparing the house for Thanksgiving. The patient states that please (sic) were called because he was throwing things around the room. When police arrived, he stated that he was very upset and 'needed to talk to someone.' On arrival, the patient is calm and pleasant. States that he has not had these for many years, only had these back in 2005 after his traumatic brain injury. Today, the patient states that he is just upset and needed some time away from the house. He states that he harbors no feelings of homicidal ideation toward his parents, nor any intentions to hurt himself. He patient states that he just wanted to talk it over, but states that he is planning to go back home. Police state that the patient has been cooperative. States that he is here voluntarily. Has not demonstrated any signs or symptoms of concern for his own safety or others. History provided by: Patient and police ... Presenting symptoms: agitation Associated symptoms: anxiety ... Past Medical History: Diagnosis - Depression - Traumatic brain injury Past Surgical History: Procedure - Brain surgery - Eye surgery - Tonsillectomy ... Home Medications FISH OIL ... MELATONIN ... Physical Exam ... Constitutional: Vital signs normalHe (sic) does not appear distressed and no respiratory distress. Not diaphoretic. HENT: Head: Negative Racoon sign. No right periorbital ecchymosis and no left periorbital ecchymosis. Mouth/Throat: Voice normal. Eyes: EOM are intact. Pupils are equal, round, and reactive to light. Neck: Normal range of motion and voice normal. Neck supple. Cardiovascular: Normal rate and regular rhythm. Pulmonary/Chest: No respiratory distress. Respiratory effort normal. Abdominal: Soft. There is no abdominal tenderness. Musculoskeletal: Normal range of motion. Right knee: He exhibits no deformity. Left knee: He exhibits no deformity. Neurological: He is alert. He exhibits normal muscle tone. Skin: Not diaphoretic. No petechiae. Psychiatric: He has a normal mood and affect. His behavior is normal. He is not agitated. Judgement and thought content normal. Thought content is not delusional ... MDM (Medical Decision Making) ... Anxiety: new and requires workup Diagnosis management comments: (Patient #9 Named) presents for evaluation of an episode of an argument with him and his parents. States that he is only here to talk it over. I spent over 20 minutes in the patient's room speaking to him about this situation. We spoke about the issue while playing a game of cards in the room. Patient appears very pleasant and cooperative. Oriented to person, place, and time. The patient states no suicidal or homicidal ideations. States that he was just upset about his argument with his parents and just wanted to talk it over with someone. I offered behavioral health resources here, but the patient states that he would rather just go home now and go back to his room before Thanksgiving dinner tonight. States that he will call his parents to pick him up. At this time, the patient's (sic) appears oriented to person, place, and time. Does not display any intoxication. Blood work is unremarkable. The patient appears competent to make his own decisions. I cannot keep the patient here against as well (sic). The patient states that he would like to be discharged. I will discharge the patient home, but advised him to call 9110 (sic) return to the emergency department if he has any further concerns or symptoms ... Follow-up Information Schedule an appointment as soon as possible for a visit with (Named Local Psychiatric Service with Address and Phone Number) ..." The laboratory and diagnostic studies performed on the patient during this admission included a Complete Blood Count and Differential, Salicylate, Acetaminophen, and Ethanol Levels, a Comprehensive Metabolic Panel, and Urine Drug Screen. All studies were unremarkable. Review of an ED Note written by Registered Nurse (RN) #1 on 11/28/2019 at 0635 revealed, "Patient refused to wait for discharge instructions, patient states that he is voluntary. Patient states that he doesn't need discharge vital signs. (Named DO #1) is aware and states that patient may safely leave the emergency department." Patient #9 left the DED on 11/28/2019 at 0635, 1 hour and 7 minutes after arrival.

Patient #9 returned to Hospital A's DED by private vehicle accompanied by his parents on 11/28/2019 at 1830 (12 hours and 5 minutes after he left). Patient #9's vital signs at 1841 were: BP 146/89, P 109, R 16, SPO2 100 %, and T 98.6. Review of an ED Provider Note written by DO #2 on 11/28/2019 at 1842 revealed, " ...Chief Complaint Patient presents with -Psychiatric Evaluation was (sic) brought in this am for the same evuated (sic) and d/c (discharged) this afternoon had another episode of 'mania' per parents, kicked in 2 doors, grabbed mother physically. Patient present to the emergency department with his parents and brother at bedside, per patient's family, patient does have a history of traumatic brain injury as well as manic depression, for which he is on multiple medications including lithium, parents state that he has been taking his medications regularly however over the last few days he has been undergoing a manic episode, mom states that he has been aggressive at home, he reportedly destroyed his wooden bed at home and was slamming and destroying doors, and he also was verbally aggressive towards his mom and grabbed her, they state that they had the police bring him to the emergency department earlier today but he was discharged, and he was then trying to walk home to (Named Town) when he was again picked up by police, his family states that they do live with him however they do not feel that he is safe to be at home at this time. Mom states patient has also had sleep difficulties and did not sleep at all last night. At this time, patient is awake and alert. He does answer questions appropriately and he is calm and cooperative, he denies SI (Suicidal Ideation) or HI (Homicidal Ideation), denies any alcohol or drug use, denies any audio or visual hallucinations, and states he does not know why he is here today. He denies any somatic complaints ... Home Medications DOCUSATE SODIUM ... FISH OIL ... LAMOTRIGINE ... LITHIUM ... LORATADINE ... MELATONIN ... SEROUEL ... Physical Exam ... Psychiatric: His speech is normal. He has poor eye contact. He is withdrawn. His affect is angry. He exhibits a depressed mood. He expresses no homicidal and no suicidal ideation. He expresses no suicidal plans and no homicidal plans ... Lab results ... LITHIUM LEVEL - Abnormal ... 0.45 ... MDM ... Upon presentation to the emergency department, he is calm and cooperative although he appears angry, he is somewhat withdrawn, his physical examination is otherwise unremarkable and he is denying SI or HI at this time, therefore, we will begin with basic psychiatric screening labs including alcohol, Tylenol, salicylate, and UDS (Urine Drug Screen), and as long as these are unremarkable I do feel that he will be able to be safely medically cleared for behavioral health consultation ... 820 p.m.: Patient's labs have result and are unremarkable, other than a lithium level which is slightly low, however he did not yet have his home dose of lithium that he is due for tonight, therefore I do feel that he is safe to be medically cleared for behavioral health consultation at this time ... 10:30 PM: Spoke with (Named Employee) from behavioral health, she states that she assessed the patient but he was not cooperative with her exam however family states they do feel that he may be a danger to himself or others at home, so she is recommending placement or for psych to see in the morning, he is calm and cooperative at this time, but given the fact that he would not be safe to be discharged home, we will begin IVC (Involuntary Commitment) papers at this time. He will also be given his home dose of Lamictal at this time. His family is in agreement with this plan ..." Patient #9 was ultimately IVC'ed, and on 11/30/2019 the patient received an inpatient room and was transferred to Hospital B on 11/30/2019 at 1805.

Review of a History and Physical written at Hospital B by Medical Doctor (MD) #1 on 12/01/2019 at 0827 revealed, " ...Principal Problem: Bipolar 1 disorder, current or most recent episode manic, with psychotic features Active problems: TBI (traumatic brain injury) Nonadherence to medication ... Reason for Admission: current assaultive threats or behavior, resulting from a psychiatric disorder, with a clear risk of escalation or future repetition and disorientation or memory impairment which is due to a psychiatric disorder (not a neurodevelopmental disorder, not a TBI or other organic brain diseases) AND endangers the welfare of self and others ... Patient transferred to (Hospital B) from (Hospital A) due to lack of inpatient psychiatry. Family reported that patient had been behaving more aggressively at home, where he broke furniture. Patient assessed at (Hospital A) ED initially on 11/29/19, however he was discharged home. Patient's mother filed IVC on him, police picked him up, where he was found walking. He was assessed again by ED, however due to IVC he was held in ED. He was discharge focused, however he was counseled that he was being admitted to inpatient psychiatry. Patient was observed pacing and attempting to elope from ED ... Mother was contacted by writer and she gave collateral information. Mother stated, 'His Lamictal, Lithium and melatonin have been stable, and we have been adjusting Seroquel.' Seroquel added one month ago to aid with dyssomnia. Mother stated that Zoloft had previously been added to his regimen to, 'increase focus and inattention,' by (Named Nurse Practitioner). Mother reports that (Patient #9) did not sleep well two nights prior to coming to the ED, even though, 'I gave him 150 mg, plus another 50 mg,' of Seroquel with hope that he would rest. Mother recalls (Patient #9) received a cortisol injection on 11/1/19. Mother counseled that cortisol has been known to have psychoactive effects ..." Patient #9 remained at Hospital B until he was discharged on 12/06/2019.

Telephone interview was conducted on 04/08/2020 at 1000 with RN #1, who did not recall Patient #9. Interview revealed typically if a patient is alert and oriented, their own guardian, and answering questions appropriately facility staff would not typically attempt to contact their family for more information regarding their condition, medications, or history.

Interview was conducted with DO #1 on 04/08/2020 at 1020, who recalled Patient #9. Interview revealed Patient #9 presented as pleasant and not in an acute emergent state. Interview revealed Patient #9's blood work was unremarkable and DO #1 felt Patient #9 was safe for discharge. Interview revealed DO #1 recalled giving Patient #9 verbal discharge instructions. Interview revealed DO #1 recalled facility staff asking Patient #9 if he wanted them to contact his family for a ride home, but not for any other information. Patient #9 stated he would contact his family regarding discharge. DO #1 felt the information Patient #9 was providing was adequate for his medical screening examination.

Based on hospital policy review, medical record reviews, and staff interviews, the hospital failed to provide necessary stabilizing treatment, within the capability of the hospital's DED for an individual who presented for psychiatric evaluation in 1 of 20 sampled patients, (Patient #9).

Findings included:

Closed medical record review conducted on 04/07/2020 revealed Patient #9 was a 32-year-old male who presented voluntarily to Hospital A by law enforcement on 11/28/2019 at 0528 complaining of Psychiatric Evaluation. Patient #9's vital signs at 0534 were: blood pressure (BP) 130/91, pulse (P) 102, respirations (R) 18, pulse oximetry (SPO2) 100 %, and temperature (T) 98.7. Review of an ED (Emergency Department) Provider Note written by DO (Doctor of Osteopathic Medicine) #1 on 11/28/2019 at 0636 revealed, "Chief Complaint Patient presents with Psychiatric Evaluation brought (sic) in voluntarily by (Named Town) PD (Police Department), cousin told PD that pt (patient) is having a mental breakdown. Pt said, 'I need to talk to someone.' 32-year-old male with a history of traumatic brain injury and depression presents to the emergency department with police for evaluation. The patient was having an argument with his parents prior to arrival. He lives with his mother and father. He states that he got into an argument with them today. The called the police, because he was angry and throwing things around the room. The patient states that he was angry at them because they were very stressed about preparing the house for Thanksgiving. The patient states that please (sic) were called because he was throwing things around the room. When police arrived, he stated that he was very upset and 'needed to talk to someone.' On arrival, the patient is calm and pleasant. States that he has not had these for many years, only had these back in 2005 after his traumatic brain injury. Today, the patient states that he is just upset and needed some time away from the house. He states that he harbors no feelings of homicidal ideation toward his parents, nor any intentions to hurt himself. He patient states that he just wanted to talk it over, but states that he is planning to go back home. Police state that the patient has been cooperative. States that he is here voluntarily. Has not demonstrated any signs or symptoms of concern for his own safety or others. History provided by: Patient and police ... Presenting symptoms: agitation Associated symptoms: anxiety ... Past Medical History: Diagnosis - Depression - Traumatic brain injury Past Surgical History: Procedure - Brain surgery - Eye surgery - Tonsillectomy ... Home Medications FISH OIL ... MELATONIN ... Physical Exam ... Constitutional: Vital signs normalHe (sic) does not appear distressed and no respiratory distress. Not diaphoretic. HENT: Head: Negative Racoon sign. No right periorbital ecchymosis and no left periorbital ecchymosis. Mouth/Throat: Voice normal. Eyes: EOM are intact. Pupils are equal, round, and reactive to light. Neck: Normal range of motion and voice normal. Neck supple. Cardiovascular: Normal rate and regular rhythm. Pulmonary/Chest: No respiratory distress. Respiratory effort normal. Abdominal: Soft. There is no abdominal tenderness. Musculoskeletal: Normal range of motion. Right knee: He exhibits no deformity. Left knee: He exhibits no deformity. Neurological: He is alert. He exhibits normal muscle tone. Skin: Not diaphoretic. No petechiae. Psychiatric: He has a normal mood and affect. His behavior is normal. He is not agitated. Judgement and thought content normal. Thought content is not delusional ... MDM (Medical Decision Making) ... Anxiety: new and requires workup Diagnosis management comments: (Patient #9 Named) presents for evaluation of an episode of an argument with him and his parents. States that he is only here to talk it over. I spent over 20 minutes in the patient's room speaking to him about this situation. We spoke about the issue while playing a game of cards in the room. Patient appears very pleasant and cooperative. Oriented to person, place, and time. The patient states no suicidal or homicidal ideations. States that he was just upset about his argument with his parents and just wanted to talk it over with someone. I offered behavioral health resources here, but the patient states that he would rather just go home now and go back to his room before Thanksgiving dinner tonight. States that he will call his parents to pick him up. At this time, the patient's (sic) appears oriented to person, place, and time. Does not display any intoxication. Blood work is unremarkable. The patient appears competent to make his own decisions. I cannot keep the patient here against as well (sic). The patient states that he would like to be discharged. I will discharge the patient home, but advised him to call 9110 (sic) return to the emergency department if he has any further concerns or symptoms ... Follow-up Information Schedule an appointment as soon as possible for a visit with (Named Local Psychiatric Service with Address and Phone Number) ..." The laboratory and diagnostic studies performed on the patient during this admission included a Complete Blood Count and Differential, Salicylate, Acetaminophen, and Ethanol Levels, a Comprehensive Metabolic Panel, and Urine Drug Screen. All studies were unremarkable. Review of an ED Note written by Registered Nurse (RN) #1 on 11/28/2019 at 0635 revealed, "Patient refused to wait for discharge instructions, patient states that he is voluntary. Patient states that he doesn't need discharge vital signs. (Named DO #1) is aware and states that patient may safely leave the emergency department." Patient #9 left the DED on 11/28/2019 at 0635, 1 hour and 7 minutes after arrival.

Patient #9 returned to Hospital A's DED by private vehicle accompanied by his parents on 11/28/2019 at 1830 (12 hours and 5 minutes after he left). Patient #9's vital signs at 1841 were: BP 146/89, P 109, R 16, SPO2 100 %, and T 98.6. Review of an ED Provider Note written by DO #2 on 11/28/2019 at 1842 revealed, " ...Chief Complaint Patient presents with -Psychiatric Evaluation was (sic) brought in this am for the same evuated (sic) and d/c (discharged) this afternoon had another episode of 'mania' per parents, kicked in 2 doors, grabbed mother physically. Patient present to the emergency department with his parents and brother at bedside, per patient's family, patient does have a history of traumatic brain injury as well as manic depression, for which he is on multiple medications including lithium, parents state that he has been taking his medications regularly however over the last few days he has been undergoing a manic episode, mom states that he has been aggressive at home, he reportedly destroyed his wooden bed at home and was slamming and destroying doors, and he also was verbally aggressive towards his mom and grabbed her, they state that they had the police bring him to the emergency department earlier today but he was discharged, and he was then trying to walk home to (Named Town) when he was again picked up by police, his family states that they do live with him however they do not feel that he is safe to be at home at this time. Mom states patient has also had sleep difficulties and did not sleep at all last night. At this time, patient is awake and alert. He does answer questions appropriately and he is calm and cooperative, he denies SI (Suicidal Ideation) or HI (Homicidal Ideation), denies any alcohol or drug use, denies any audio or visual hallucinations, and states he does not know why he is here today. He denies any somatic complaints ... Home Medications DOCUSATE SODIUM ... FISH OIL ... LAMOTRIGINE ... LITHIUM ... LORATADINE ... MELATONIN ... SEROUEL ... Physical Exam ... Psychiatric: His speech is normal. He has poor eye contact. He is withdrawn. His affect is angry. He exhibits a depressed mood. He expresses no homicidal and no suicidal ideation. He expresses no suicidal plans and no homicidal plans ... Lab results ... LITHIUM LEVEL - Abnormal ... 0.45 ... MDM ... Upon presentation to the emergency department, he is calm and cooperative although he appears angry, he is somewhat withdrawn, his physical examination is otherwise unremarkable and he is denying SI or HI at this time, therefore, we will begin with basic psychiatric screening labs including alcohol, Tylenol, salicylate, and UDS (Urine Drug Screen), and as long as these are unremarkable I do feel that he will be able to be safely medically cleared for behavioral health consultation ... 820 p.m.: Patient's labs have result and are unremarkable, other than a lithium level which is slightly low, however he did not yet have his home dose of lithium that he is due for tonight, therefore I do feel that he is safe to be medically cleared for behavioral health consultation at this time ... 10:30 PM: Spoke with (Named Employee) from behavioral health, she states that she assessed the patient but he was not cooperative with her exam however family states they do feel that he may be a danger to himself or others at home, so she is recommending placement or for psych to see in the morning, he is calm and cooperative at this time, but given the fact that he would not be safe to be discharged home, we will begin IVC (Involuntary Commitment) papers at this time. He will also be given his home dose of Lamictal at this time. His family is in agreement with this plan ..." Patient #9 was ultimately IVC'ed, and on 11/30/2019 the patient received an inpatient room and was transferred to Hospital B on 11/30/2019 at 1805.

Review of a History and Physical written at Hospital B by Medical Doctor (MD) #1 on 12/01/2019 at 0827 revealed, " ...Principal Problem: Bipolar 1 disorder, current or most recent episode manic, with psychotic features Active problems: TBI (traumatic brain injury) Nonadherence to medication ... Reason for Admission: current assaultive threats or behavior, resulting from a psychiatric disorder, with a clear risk of escalation or future repetition and disorientation or memory impairment which is due to a psychiatric disorder (not a neurodevelopmental disorder, not a TBI or other organic brain diseases) AND endangers the welfare of self and others ... Patient transferred to (Hospital B) from (Hospital A) due to lack of inpatient psychiatry. Family reported that patient had been behaving more aggressively at home, where he broke furniture. Patient assessed at (Hospital A) ED initially on 11/29/19, however he was discharged home. Patient's mother filed IVC on him, police picked him up, where he was found walking. He was assessed again by ED, however due to IVC he was held in ED. He was discharge focused, however he was counseled that he was being admitted to inpatient psychiatry. Patient was observed pacing and attempting to elope from ED ... Mother was contacted by writer and she gave collateral information. Mother stated, 'His Lamictal, Lithium and melatonin have been stable, and we have been adjusting Seroquel.' Seroquel added one month ago to aid with dyssomnia. Mother stated that Zoloft had previously been added to his regimen to, 'increase focus and inattention,' by (Named Nurse Practitioner). Mother reports that (Patient #9) did not sleep well two nights prior to coming to the ED, even though, 'I gave him 150 mg, plus another 50 mg,' of Seroquel with hope that he would rest. Mother recalls (Patient #9) received a cortisol injection on 11/1/19. Mother counseled that cortisol has been known to have psychoactive effects ..." Patient #9 remained at Hospital B until he was discharged on 12/06/2019.

Telephone interview was conducted on 04/08/2020 at 1000 with RN #1, who did not recall Patient #9. Interview revealed typically if a patient is alert and oriented, their own guardian, and answering questions appropriately facility staff would not typically attempt to contact their family for more information regarding their condition, medications, or history.

Interview was conducted with DO #1 on 04/08/2020 at 1020, who recalled Patient #9. Interview revealed Patient #9 presented as pleasant and not in an acute emergent state. Interview revealed Patient #9's blood work was unremarkable and DO #1 felt Patient #9 was safe for discharge. Interview revealed DO #1 recalled giving Patient #9 verbal discharge instructions. Interview revealed DO #1 recalled facility staff asking Patient #9 if he wanted them to contact his family for a ride home, but not for any other information. Patient #9 stated he would contact his family regarding discharge. DO #1 felt the information Patient #9 was providing was adequate for his medical screening examination.

NC00161541