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Based on a review of policies, review of medical record documentation, and staff interviews, the hospital failed to enforce EMTALA policies requiring staff to provide a proper medical screening exams for 3 of 28 sampled patients requesting care in the Emergency Department (ED) of the hospital between January of 2015 through March 17, 2015 (Patients #9, 16, and 17). Patients #9, 16, and 17 presented to the ED for care for an emergency psychiatric conditions.

Failure by the ED staff to follow the the hospital's EMTALA policies and provide a complete an appropriate medical screening exam for each patient requesting emergency care in the ED may result in harm for patients.

Findings include:

The hospital's "EMTALA" policy, dated 04/14, revealed the following in part, ..."any patient who comes to the Hospital's dedicated emergency department and requests or has a request made on his or her behalf for emergency examination and treatment, or who a prudent layperson would believe, on the basis of the individual's appearance or behavior, requires examination or treatment for a medical condition, will be provided an appropriate medical screening examination within the capabilities of the dedicated emergency department including ancillary services routinely available to the emergency department...The Medical Screening Examination extends until the point that the Qualified Medical Person or Physician determines that an emergency medical condition does not exist..."

The same policy revealed in part..."If the Hospital is unable to provide the treatment necessary to stabilize the patient according to EMTALA guidelines and its EMTALA: Patient Transfer to another Acute Care Facility policy. The hospital will continue to provide treatment to minimize the risk of transfer." Transfer is defined as "the movement of a patient, including discharge outside of the Hospital's facilities at the direction of any Hospital's facilities at the direction of any hospital employee or person affiliated with the hospital."

Refer to A 2406 for additional information concerning the medical screening examination of Patients #9,16, and 17.

Based on review of medical records, video footage, hospital documents, and interview with staff members, the hospital emergency department (ED) staff failed to provide an appropriate medical screening examination for 3 of 28 sampled patients presenting to the ED for an emergency medical condition in January of 2015 through March 17 of 2015. The medical records for Patient's #16, 9, and 17 revealed the patients presented to the hospital with psychiatric conditions and the patients were in need of a medical screening exam. The emergency department nurse manager identified an average of 6 psychiatric patients presenting to the ED daily.

Failure to provide an appropriate medical screening exam and allowing Patient #16 to elope from the ED while barefoot and dressed only in paper scrubs without appropriate clothing for the weather contributed to the patient's death. The patient's body was found 17 days later near the hospital campus wearing the paper scrubs worn when walking out of the hospital. Failure to provide an appropriate medical screening exam for Patients #9 and #17 could potentially result result in harm to themselves or to others.

Findings include:

A. The information in this section relates to the care Patient #16 received in the ED.

1. Patient #16's medical record revealed the following information.

The patient arrived at the ED on 2/22/15 at 6:03 AM. Practitioner C, Physician Assistant (PA) documentation at 7:53 AM, "Clinical History of Present Illness" summary stated in part, "...The patient presents today for a psychiatric exam. The patient moved to the area about a month earlier from another country. The patient stated his mind has been "disturbed" and he "has been forgetting things". Symptoms started one week ago..."Slight language barrier exists during history - patient speaks English but accent difficult to understand, therefore difficult to obtain a good history..." In addition, at 7:53 AM, Practitioner C completed the patient's physical exam, assessment, and documentation stated in part, "... the Psychiatric evaluation was "Mood and affect normal. No evidence of psychotic ideation - denies any hallucinations, SI or HI." (suicidal ideation or homicidal ideation)..."

A progress note documented at 8:47 AM by Practitioner C, stated in part, "...the patient wanted to go home, refused discharge papers, and eloped..." Prior to the patient leaving Practitioner C documented the patient denied suicidal, homicidal thoughts, or hallucinations. and that Practitioner C felt the patient was free to leave the ED. Practitioner C documented the patient walked out into single degree weather wearing only the paper scrubs and that behavior demonstrated concern for the patient's safety. Practitioner C documentation stated in part, "...any attempts made by staff to stop the patient from eloping were unsuccessful and the patient ran. Police were notified...contacted the magistrate's court to obtain an order for committal..." At 9:08 AM, Practitioner C documented "Delusional Disorder" as the patient's primary diagnosis.

Patient #16's ED record lacked evidence that the patient was seen by the ED Physician working in the ED at the time Patient #16 was present. Along with, no evidence that showed Practitioner C consulted with the ED Physician concerning the patient's medical screening examination. At the time of Patient #16's ED visit, a psychiatrist was on call, the Access Call Center and the Behavioral Health Unit staff were available for consultation. However, the ED record lacked evidence that showed any of the ED staff contacted the on call psychiatrist, the Access Call Center, or the Hospital Behavioral Unit staff for a consultation about Patient #16.

Review of the ED log dated 2/22/15 revealed 8 patients presented requesting treatment from the time Patient #16 arrived to the ED on 2/22/15 at 6:03 AM to the time he eloped from the hospital at 8:35 AM. On 3/23/15, Staff Z, Chief Nursing Officer, reported there were no other patients requesting emergency treatment for psychiatric services during the time Patient #16 was in their ED. At the time Patient #16 was present in the ED, staffing consisted of one Physician, one Physician Assistant, and three Registered Nurses. Additionally, two security officers were available for the ED.

2. The following interviews were obtained during the on-site investigation. They were consistent with the events related to the arrival and elopement of Patient #16 from the hospital and the failure of the hospital staff's to comply with the EMTALA requirements as directed by hospital policy.

a. During an interview on 3/17/15 at 1:35 PM, Staff J, ED RN, verified he triaged Patient #16. According to the ED record for Patient #16, the triage occurred almost an hour after the patient arrived. Two family members were waiting with the patient in the waiting area of the ED. Staff J reported taking the patient and two family members (an aunt and uncle) to a regular exam room in the ED. Staff J reported, the patient's uncle said that they were very concerned with the recent changes in the patient's behavior. Staff J reported the patient's chief complaint sounded like anxiety but after Staff J had spent some time with the patient Staff J felt there may of been something else going on with Patient #16. Staff J went on to report, it was the change of shift and Staff J had given report to Staff H, ED RN. Staff J reported Patient #16 was still wearing street clothes and shoes when Staff J left the ED.

During a follow up interview on 3/18/15 at 11:00 AM, Staff J acknowledged he failed to document a complete triage assessment, the patient's anxiety level, or the concerns expressed by the patient's family members in the patient's medical record. Staff J acknowledged he failed to inform Practitioner C of the patient's status prior to leaving that morning. Staff J admitted he should have documented more information in the patient's medical record stating "I dropped the ball."

b. During an interview on 3/17/15 at 2:10 PM, Staff H, ED RN verified she took charge of Patient #16 from Staff J, RN on 2/22/15. Staff H confirmed the patient and the two family members were in a regular exam room in the ED. Staff H said she was informed by the patient's aunt that Patient #16 wasn't sleeping, was stating people were watching him, was hiding from the family, and peeking out windows.

Staff H acknowledged she failed to document this information in the patient's medical record but remembered thinking there was obviously something out of the ordinary going on with Patient #16. She said the patient was quiet and she got a "funny feeling" from what she was observing and hearing from the family. She decided to move the patient to one of the behavior rooms in the ED and as they made their way to the room she gave the patient paper scrubs to change into. She had instructed the patient to go into the bathroom to remove his coat, clothes, and shoes. After the patient put the paper scrubs on, the patient's belongings were put in a clear plastic bag that she placed in a file cabinet in the ED's central core.

Staff H acknowledged she failed to document this information in the patient's medical record at the time it occurred. Staff H said at that point she viewed the patient as a psychiatric patient although he was cooperative and did not appear to be a threat to himself or others.

Staff H said after arriving to the behavior room, the patient reported he felt confused in his head. She said the patient's affect was flat (a severe reduction in emotional expressiveness) and the patient responded to questions but did not initiate conversation. Staff H said her first thought as a nurse showed the patient was exhibiting schizophrenic behaviors and the direction would be admitting him to the hospital's behavior health unit for psychiatric evaluation and observation. She said she based her opinion of the situation on an instinct and her "gut" feelings.

Staff H acknowledged she failed to document this information in the patient's medical record at the time it occurred and she failed to communicate any of this information to Practitioner C.

Staff H said she had contact with Patient #16 and his family three times while they were in the behavior room but she failed to document this in the patient's medical record. She said at some point she realized the family was gone and the patient was alone. She said she was under the impression Patient #16 was going to be admitted and thought this was why the family members left.

Staff H reported she saw the patient approach Practitioner C in the inner core and heard the patient say, "I want to go home" at approximately 8:30 AM. She said she watched the patient walk down the inner core toward the lobby exit doors. Staff H said she called out to the patient; the patient turned to look at her but continued walking. She saw the patient walk across the lobby to the visitors exit doors and go outside. Staff H said she opened the lobby exit doors and called out the patient's name again; the patient turned to look at her but continued walking. She said Staff F, security officer, joined her at the door and he went outside to watch the patient.

Staff H denied attempting to intervene or to redirect the patient while she observed the patient eloping. When asked why she didn't follow the patient outside, her response was because it was "bitterly cold" weather and Staff F was watching the patient anyway. She added that ultimately the patient was "free to go" even if he was barefoot and only dressed in paper scrubs.

During a follow up interview on 3/18/15 at 9:30 AM, Staff H acknowledged Patient #16's medical record failed to give a clear picture of what happened. She admitted if they had searched his belongings and found the wooden handled utility (type) knife with a 5 inch serrated and curved blade in his winter coat pocket, things may have gone differently but she did not feel this would have changed the "course of events".

Staff H acknowledged critical information should have been documented in the patient's medical record prior to Practitioner C's medical assessment, in order for them to provide an appropriate medical screening exam to determine appropriate care and services for Patient #16.

c. During an interview on 3/17/15 at 12:30 PM, Practitioner C, PA, stated he assessed Patient #16 on 2/22/15 at 7:53 AM. He did not recall speaking with Staff H prior to seeing the patient but confirmed he reviewed the patient's medical record (which lacked information regarding the patient's status as reported during interview with Staff J and Staff H). Practitioner C said the patient's demeanor was calm and his face expressionless. He said although the patient's accent was thick the patient insisted on speaking to him in English.

Practitioner C verified the patient arrived to the ED for psychiatric evaluation and screening to determine if the patient was an immediate harm to himself or others. He said the plan was to discharge the patient with a referral for outpatient psychiatric services. Practitioner C reported asking Patient #16' s aunt if she had any concerns and she told him "no." Practitioner C said when the patient stated he wanted to go home, Practitioner C advised the patient to wait for discharge instructions. The patient started walking down the inner core of the ED towards the lobby. Practitioner C said he did not attempt to intervene or redirect Patient #16 physically, because the patient was "free to go" and they were not able to physically hold the patient.

Practitioner C said Patient #16 did not demonstrate psychotic indicators or impaired judgement up until when he walked away from the hospital. Practitioner C said when the patient decided to leave and go outside; exposing himself to winter weather conditions and 1 degree temperature; dressed only in paper scrubs and barefoot, the patient demonstrated impaired judgement. Practitioner C said when the patient eloped, he asked Staff H to call the police and he contacted the magistrate to obtain a legal hold to admit the patient when he returned to their hospital. Practitioner C admitted, in hindsight, when the family left around 8:30 AM this very well could have been the precipitating factor for Patient #16 leaving.

During a follow up phone interview on 3/18/15 at 12:30 PM, Practitioner C stated if Staff H had informed him of the patient's behaviors reported to her by the family or any other concerns, this information would have been critical for the patient's psychiatric medical screening examination. Practitioner C said if hospital staff had searched Patient #16's belongings and found a knife, he would have consulted a psychiatrist to seek their opinion for possible admission to the hospital. Practitioner C, said the patient may have met the criteria for admission to their behavior health unit for further psychiatric evaluation and treatment at that point.

d. During an interview on 3/17/15 at 8:05 AM, Staff F, Security Officer, reported he went to the ED at 8:45 AM. Upon arrival in the ED, Staff H, RN told him a patient had just left. At that time, he noticed Patient #16 dressed in paper scrubs and barefoot exiting the hospital. Staff H said the patient was "free to go". Staff F said he called out to the patient, the patient paused and looked at him but continued walking. Staff F said because it was so bitter cold outside and there was snow on the ground he was concerned for the patient's well-being so he went outside and called out to the patient. The patient paused and looked at him again but continued walking down the parking lot. Staff F went back inside to get his coat and then went outside. By the time he got outside, the patient had walked approximately 300 feet across the parking lot and a street in front of the parking lot.

Staff F reported he continued walking towards the patient and at one point the patient turned and looked back at him again. At that point the patient was a "big" distance ahead of him and he lost sight of the patient. He said he turned and walked back to the hospital and called the police to inform them a patient had left the hospital and was not dressed to be out in the type of weather conditions that existed at the time. He went back to the security office at 10:00 AM and contacted the house supervisor. Staff F said they had a security policy directing security staff if a patient is "free to go" they did not have the authority to detain them. Staff F denied any attempts to intervene or redirect the patient physically while he observed the patient walking for 30 minutes from the hospital because the patient was "free to go."

e. During an interview on 3/17/15 at 9:15 AM, Staff G, Security Officer, said he went to the ED around 8:35 AM and observed Patient #16 exiting a bathroom in the ED outer core while accompanied by Staff H. He watched them walking toward a behavior room in the ED. Staff G spoke with Staff H and she told him there were communication issues with Patient #16's family. He said she told him they didn't speak English very well. Staff G left the area after the conversation. Approximately 5 minutes later, he received a call from Staff F informing him a patient had eloped form the ED and was walking outside. He reported he did not go to the ED or respond to the call at that time. Staff G said at 8:47 AM he made a non-emergent call to the police to alert them a patient had eloped from the hospital because at that point they were concerned the patient was not dressed properly for the bitter cold temperatures. Staff G said the patient was "free to go" and was being discharged. Staff G said security did not have the authority to detain the patient.

f. During an interview on 3/17/15 at 9:30 AM, Staff I, Behavior Health Unit Director, reported she was not involved with Patient #16 while he was in the ED. Staff I acknowledged the hospital policy directs staff to put patients in paper scrubs for their safety and limiting them access to contraband or objects that could be used as weapons. Staff I said when a patient presents to the ED with behaviors that are unusual or out of the ordinary this may indicate the patient is on "edge" and staff should consider mental health issues and immediate safety concerns. Staff I said insomnia (lack of sleep) exacerbates paranoid or psychotic behaviors and acknowledged Patient #16 met the criteria for 23 hour observation in their behavior health unit.

Staff I confirmed after reviewing call logs for the behavior health unit on the morning of 2/22/15, they did not receive any notice from the ED for a psychiatric evaluation for Patient #16. She acknowledged if the ED staff had searched the patient's belongings and found the knife it would warrant additional investigation. Had the ED Staff been aware of the the knife, they could have asked the patient why he was carrying a knife and what he intended to do with the knife. Staff I reported that her opinion was this clearly indicated that Patient #16 exhibited poor judgement placing the patient at "jeopardy".

During a follow-up interview on 3/18/15 at 10:35 AM, Staff I emphasized the importance of documenting anything a patient may say or a family's story of what is happening in the medical record because it is going to be vital in how a physician provides care and treatment to the patient. Staff I said if a patient exhibiting poor judgement, leaves the hospital, placed the patient at risk for their own personal safety and well being. Staff I reported she would have followed the patient, called 911, approached the patient and attempted to redirect the patient back to safety. Staff I said if nursing staff had documented Patient #16's behaviors in his medical record, an Access Nurse would have been contacted for consultation and possible admission to the behavioral health unit. Staff I confirmed on the morning of 2/22/15, the behavioral health unit had 5 beds available for patient admissions. Staff I said the hospital had a policy/procedure containing criteria guidelines for admission of patients to the behavior health unit.

On 3/18/15 following the second interview with Staff I, she provided a hospital policy titled "Admission Criteria" for Psychiatric patients that is accessible by all departments through the intranet policy manuals revealed the following in part, ..."Admission Criteria - inpatient adult...imminently dangerous to self...severe depression...decreased level of function...fixed delusions...hallucinations." Review of documentation from Staff I, on the policy, revealed: "20/20 hindsight, could the Patient #16 been admitted - yes."

During a phone conversation on 4/9/15 at 1:50 PM, Staff I clarified the behavioral health unit had monthly schedules identifying the charge nurse (Access Nurse) that is responsible to take phone calls each shift. The Access Nurse would consult with the ED staff by phone when needed and would go to the ED only if a behavior health patient was boarding in the ED while waiting for an inpatient bed.

g. During an interview on 3/18/15 at 9:15 AM, Staff N, RN/House Supervisor said she was in the ED on the morning of 2/22/15 around 8:30 AM. Staff N said she observed Patient #16 walking out into the inner core and talking with Practitioner C, the PA. She recalled Practitioner C telling her the patient came in with a known history of schizophrenia but was not suicidal. Practitioner C was planning on discharging the patient. Staff N said, Staff H called her minutes later reporting a patient had eloped. Staff N said upon returning to the ED, Staff H, RN, reported when evaluating the patient he seemed paranoid and had a known history of paranoia. Staff N instructed nursing and security staff to complete an incident report. She contacted the Risk Management/Quality Director and the ED nurse manager. Staff N said she checked with the police approximately 2 hours after Patient #16 eloped and they said a missing persons report had been filed.

h. During an interview on 3/18/15 at 2:45 PM, Staff K, RN, Director of Nursing Operations for the ED said when Patient #16 presented to the ED the morning of 2/22/15 it was "unusually busy". Staff K acknowledged Staff J, RN completed and documented a "limited assessment" of the patient. Staff K said Staff H, RN failed to document a more "descriptive assessment" of the patient's behaviors, what they had observed and felt, and what the patient's family told them.

3. Observations on 3/16/15 at approximately 3:00 PM by the surveyor and Staff D RN/ED Nurse Manager of the route Patient #16 walked from the behavioral health examination room to the street on 2/22/15 revealed the following information.

The patient walked down the inner core of the ED to the lobby exit doors. Then walked through the lobby to the main entrance doors where the patient left the building. The patient walked down the hospital's parking lot to the street. At the time of the observation, Staff D said the patient lived in an apartment building located on the very street he crossed that day approximately 2 to 3 blocks from the entrance to the hospital's parking lot.

4. On 3/17/15 at 11:32 AM, Staff P Plant Operations, provided materials showing the distance traveled by Patient #16 from the time he walked out of the ED to the area where Staff F, Security lost sight of the patient. The total distance was 1,175 feet or approximately 2 blocks. Staff P also provided an exact total distance from the hospital where the patient's body was discovered 17 days later, was only 300 feet from the east side of the hospital campus.

Review of video footage from the hospital's security cameras with Staff Q Security Manager revealed:

On 2/22/15 at 6:03 AM Patient #16 entered the ED wearing a winter coat and accompanied by two men and one woman. The patient approached the admissions desk accompanied by one of the men.

From 6:08 AM to 6:36 AM, the patient sat in the ED lobby along with the 3 people who brought him to the hospital. Then Staff J, RN came out to the lobby and took the patient back to exam room #3 in the ED.

At 7:27 AM, Patient #16 came out of room #3 accompanied by Staff H carrying his coat and shoes. The patient walked towards a bathroom located in the outer core of the ED. The patient was wearing a shirt and pants. Staff H carried paper scrubs and waited with the patient and a family member. Staff H went into the bathroom with the patient and immediately stepped out into the hallway. She stood in front of the bathroom door.

At 7:30 AM, Patient #16 handed his belongings to Staff H and they were placed in a clear bag. The patient exited the bathroom and walked down the hallway barefoot and wearing paper scrubs. He was taken to a behavior room accompanied by Staff H and a family member.

At 8:27 AM, Patient #16, barefoot and wearing paper scrubs, walked down the ED south corridor and exited the first set of double doors leading to the outside. Staff H and an Emergency Medical Technician (EMT) approached Patient #16 and effortlessly directed him to re-enter the ED. Staff H led the patient back down the ED south corridor and both paused briefly to talk with someone who was not visible in the video footage. Staff H then continued to lead the patient through the ED until out of the camera ' s view.

At 8:37 AM, the patient came out of the behavioral room walked slowly down the outer corridor alone, glanced from side to side, as if he was looking for something or someone. Staff H approached the patient and lead the patient towards the bathroom. At 8:39 AM, the patient exited the bathroom accompanied by Staff H and returned to the behavior room.

At 8:46 AM, the patient came out of the behavior room into the inner core of the ED. He paused to speak with Practitioner C and then walked down the inner core and exited the inner core to the ED lobby. His stride was slow. At 8:46 and 20 seconds the camera in the front lobby picked up Patient #16's movements as he walked across the lobby and exited the building through the exit doors at the visitors entrance.

At 8:47 AM, Staff H (RN) and Staff F (Security) were viewed, the patient turned to look at them but resumed walking out the entrance doors to the parking lot. Staff F went out the ED lobby door and walked toward the patient but turned around and went back into the hospital to get his coat. The patient continued walking down the parking lot towards the street. At 8:47 and 49 seconds the patient reached the street and was not in plain view of cameras. At 8:48 AM, Staff F exited the hospital wearing a coat on and walked down the parking lot.

At 9:00 AM, Staff F reentered the hospital. At no time did any physician, nursing or security staff attempt to approach or redirect Patient #16. Staff Q acknowledged the patient was walking not running and hospital security and nursing staff did not attempt to approach or redirect the patient at any time as he was walked out of the hospital into frigid weather conditions dressed only in paper scrubs and barefoot.

5. During an interview on 3/23/15 at 10:35 AM, the State Climatologist reported the following frigid weather conditions at the Waterloo airport on 2/22/14. At 8:54 AM - Actual temperature 2 degrees. Winds North Northwest (WNN) at 24 miles per hour (mph) creating a wind chill of -21 degrees below 0. The climatologist confirmed there was still some snow on the ground.

6. During an interview on 3/24/15 at 3:00 PM, Patient #16's uncle stated the patient lived with them in an apartment complex located approximately 3 blocks from the hospital's parking lot. Patient #16's uncle and a close friend reported they took Patient #16 to the hospital because his behaviors in the past weeks had changed. He was confused, agitated, hearing voices, not eating, not sleeping, and was afraid people were after him. Patient #16's uncle said the close family friend who stayed with him at the hospital understood English very well but could not speak English. They also said Patient #16 understood English but at times his accent was thick and it could be difficult to understand. They reported earlier that morning on 2/22/15 around 3:00 AM they found Patient #16 outside dressed in a T shirt and pants without a coat. Family became concerned because the patient had just moved to the US and was unfamiliar with winter weather. The family decided it was time to take the patient to the hospital because they thought he was depressed and were concerned with his changes in behavior.

Patient #16's uncle said he told the staff at the front desk that Patient #16 was running away, acting confused, and he thought someone was trying to kill him. The patient's uncle reported Patient #16 kept sighing, breathing deep, and kept touching his head while in the ED.

The uncle said a male nurse came out to take Patient #16 back to a room and they went with them. They told the male nurse (Staff J) they thought Patient #16 was having anxiety or depression and that he was hearing voices and thought someone was going to kill him.

The close family member said at 7:45 AM nursing staff said they were going to put Patient #16 in another room. A family friend who stayed with the patient and the close family member left the hospital. At that point in the interview, the uncle began interpreting for the family friend. The family friend said a nurse took Patient #16 to a bathroom, changed him into paper scrubs and the nurse put his clothes in a bag. The family friend said Patient #16 told the same nurse, who was female, he was running away, wasn't familiar with this country, wasn't eating or sleeping, and was confused.

The family friend said although no one told her Patient #16 was going to be admitted to the hospital, she thought when they undressed him and put Patient #16 in paper scrubs this meant they were admitting him to the hospital. She said because it was taking so long and she needed to return home to take her medicine. When she left the hospital around 8:30 AM, Patient #16 was still in the examination room waiting for blood and urine test results.

Patient #16's uncle said when they got back to the hospital a nurse told them the patient had left the hospital. The nurse said the patient had the right to walk out even if he only had on paper scrubs.

7. The medical examiner's report, dated 3/11/15 indicated the Patient #16's death was attributable to acute cardiac ventricular arrhythmia due to hypothermia due to prolonged exposure with a contributing factor of extreme cold of 20 degrees below 0, and the patient's psychiatric history. There was no evidence of foul play or physical trauma. An autopsy was not needed. The documents were signed by the county medical examiner. This document was received by the State Agency on 4/9/15.

8. On 4/9/15 about 1:50 PM, during a phone interview, Staff C Risk Management and Quality Director clarified that the ED medical record electronic program included a psychiatric assessment in the Health Summary screen for the medical staff to reference and add additional findings if the ED nurse completed it. This information would appear in the printed medical record for the patient if triggered by the ED nursing staff.

B. The information in this section relates to the care Patient #9 received in the ED.

1. The medical record for Patient #9 revealed the patient presented to the ED on 2/22/15 8:15 PM for a psychiatric evaluation. The triage assessment by Staff A, ED RN, revealed the patient was brought in by his father. The patient's father reported the patient had kicked his sister, a caregiver, pushed another caregiver, and threw a phone hitting his brother. The father reported the patient sees a psychiatrist and had a previous inpatient hospitalization for the same behavior. The patient's father reported the patient's mother will not take him back and would like the patient to "get a bed somewhere". The patient had a history of Down's Syndrome, fetal alcohol syndrome, and oppositional defiant disorder. After the triage, the patient remained in the waiting room for the ED with his father.

Patient #9 was examined at 10:23 PM by Practitioner A, a physician. After the physical exam was completed, the note under the psychiatric section of the Physical Exam was "Mood and affect normal."

Documentation under the Progress Notes section of the medical record indicated there were no pediatric psych beds available tonight. Discussed with patients father and he [will] take the patient home for the night and call Iowa City or here tomorrow to check for an opening. The time was 10:29 PM. The primary diagnosis was "Oppositional defiant disorder".

Documentation under the Disposition section at 10:32 PM included the following information. Decision to discharge the patient. Destination - Home. " Arrange for a follow up appointment with your Primary Care Physician/Specialist as advised by the Emergency Physician. If you have further concerns call your Primary Care Physician or return to the Emergency Department. Please follow up with Iowa City tomorrow or call to see if any beds are open here."

The Discharge Summary on the Patient #9's medical record was electronically signed by the examining physician on 2/23/15 at 1:34 PM. The documentation included the following notes: Psychiatric evaluation...Primary Diagnosis: Oppositional defiant disorder." It also included information previously in the Disposition section.

Patient #9's medical record lacked any follow up by the physician regarding the patient's reported aggressive behaviors or the reason the patient's mother said she would not take him back. The patient was discharged home with his father.

There was no evidence that contact was made with the psychiatrist on call. According to the ED's on call schedule for February 2015, Patient #9's psychiatrist was on call on 2/22/15. The patient's medical record lacked evidence of consultation with the on-call psychiatrist regarding Patient #9.

2. On 3/23/15 at 10:38 AM, Practitioner A added an Addendum Note to Patient #9's medical record after he was notified of an interview with the surveyor and reviewed his notes for the patient's ED visit on 2/22/15. The "Addendum Notes" section of Patient #9's medical record included this additional information. "In the discussion with the father, I offered to let [Patient #9] stay in the ER until a bed became available. In spite of my offer [Patient #9's] father felt he would rather take him home and try again tomorrow."

3. During an interview on 3/23/15 at 1:00 PM with Staff A, the ED RN