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Based on interview and record review, the facility failed to provide timely specialized admission/transfer for 3 (#23, 24, 25) of 11 patients reviewed for psychiatric admission and/or transfer resulting in the delay of specialized services and the potential for poor patient outcomes. Findings include:

During the initial tour of the facility on 8/27/2024 at 0920, the Behavioral Health (BH) annex (a locked unit for behavioral health patients in the ED) was toured. Accreditation Specialist Staff E stated the staff in the annex were currently under behavioral health management.

On 8/27/2024 at 0959, Confidential Informant #1 stated annex staff were being told by Behavioral Health (BH) Director Staff N and BH Manager Staff O to hold patients in the Emergency Department (ED) up to 24 hours or until given permission by Staff N or Staff O to send packets to outside facilities, even if there were no beds currently available. Confidential Informant #1 stated, "I don't think it's good patient care to wait 24 hours to place a patient when there are external beds available."

On 8/28/2024 at 1002, Confidential Informant #2 stated 1N management "has to give permission to look outside of the hospital for a bed. It could be hours or days. We will be written up if the process is not followed."

Review of the medical record for P-23 revealed he was a 38-year-old male who presented to the ED 8/11/2024 at 0042 with a chief complaint of feeling possessed. His wife reported he had increased aggression both verbally and physically. He was evaluated by the screener (a social worker, licensed counselor, or psychiatrist that conducts a mental health evaluation) 8/11/2024 from 1630-1800. The findings were discussed with the ED physician 8/11/2024 at 1700. In an addendum on the BH evaluation dated 8/11/2024 at 1808, documentation states, "This screener did explain that 1 North (1N) currently does not have any beds ..." On 8/11/2024 at 1956, another addendum to the BH evaluation states, " ...this patient was accepted to 1N by (Physician Staff Q) pending bed availability." A final addendum to the BH evaluation dated 8/12/2024 at 0943 states, "Accepted to (outside psychiatric facility)." P-23 was transferred to the outside facility 8/12/2024 at 2205.

On 8/28/2024 at 1640 review of the BH Facility Placement Log revealed the reason for transfer of P-23 stated, "Accepted by 1N doctor-Per management okay to send out due to length of stay in ED."

In an email dated 8/28/2024 at 1118, Confidential Informant #2 stated, "Patient (#23) was screened in the ED on 8/11 and accepted to 1N on 8/11. However, a bed was never available (sic) and the patient had to then be sent to an external hospital on 8/12 at 2200 after 1N management gave approval to send the patient out."

Review of the medical record for P-24 revealed he was a 32-year-old male who presented to the ED on 8/10/2024 at 1259 with a chief complaint of suicidal ideation. He was also experiencing visual and auditory hallucinations. P-24 was evaluated by the screener on 8/10/2024 from 1700-1845 who documented medical clearance had been achieved. He was accepted as an admit to 1N by Physician Staff Q on 8/12/2024 at 1001. P-24 was admitted to the unit on 8/12/2024 at 1158.

No documentation is present on the BH Facility Placement Log regarding the long wait. Confidential Informant #2 stated via email dated 8/28/2024 at 1118, "Patient (#24) was screened in the ED on 8/10 and accepted to 1N on 8/10. However, no beds were available (sic) and the patient had to wait for admission to 1N until 8/12."

Review of the medical record for P-25 revealed he was a 34-year-old male who presented to the ED on 8/3/2024 at 0933 for hearing voices and had been petitioned by the police. BH evaluation was performed by the screener 8/3/2024 from 1600-1930. In an addendum to the BH evaluation on 8/3/2024 at 2035, it states, " ...patient is accepted to 1N ... There are no available beds on 1N at this time. A packet was created in the event it needs to be sent out ..." The patient was admitted to 1N 8/5/2024 at 1544.

No documentation is present on the BH Facility Placement Log regarding the long wait. Confidential Informant #2 stated via email on 8/28/2024 at 1118, "Patient (#25) was accepted to 1N on 8/3. Patient was not admitted to 1N until 8/5 at 1545."

Review of the medical record for P-26 revealed he was a 20-year-old male who presented to the ED on 7/24/2024 at 0038 with a chief complaint of suicidal and homicidal ideation. He was petitioned and the physician signed a clinical certification. BH evaluation performed by the screener was done 7/24/2024 from 0340-0346. Medical clearance was achieved 7/24/2024 at 0628. An addendum to the BH evaluation on 7/25/2024 at 0951 indicated P-26 was accepted for admission on 1N.

No documentation is present in the BH Facility Placement Log regarding the long wait. Confidential Informant #2 stated via email on 8/28/2024 at 1118, "Patient was accepted to 1N on 7/24. 1N was full on 7/24 and ED screeners were told by 1N management that the patient would need to wait in the ED until he could be admitted to 1N on 7/25."

On 8/28/2024 at 1127, Confidential Informant #1 provided an email regarding the transfer of P-22 from BH Director Staff N dated 7/24/2024 at 0932 that states, "I need to know why the guideline wasn't followed where the patient packets aren't sent anywhere for 24 hours to allow 1N docs to determine if they will accept and 1N to determine when. Being full is not a reason to bypass the 24 hour (sic) process ..."

On 8/28/2024 at 1314, BH Director Staff N stated a "disconnect" had been discovered earlier this year in which psychiatric patients in the ED were all being sent out to outside facilities when there were beds available in house. A process was developed which included input from "1N management, providers, and ED leadership" to have patients wait up to 24 hours in the ED for placement in house prior to sending out packets to outside facilities even if there were no beds currently available. "We will not hold a patient if we don't foresee a discharge within 24 hours."

On 8/28/2024 at 1334, BH Manager Staff O stated the process was for the screener to go to the unit and evaluate the patient and once the need for admission was determined, call the physician to admit. If there were no beds and it was safe, the patient was kept in the ED annex for 24 hours. If a bed was not available within 24 hours, then packets could be sent to outside facilities seeking patient placement. When queried as to if this was a delay in the patient's treatment, Staff O stated, "We don't see this as a delay in care." She further stated the patient was receiving treatment in the ED in the form of vital sign monitoring, safety monitoring, and medication administration. She admitted therapies were unavailable as well as sessions with the psychiatrist regarding their psychiatric concerns.

On 8/28/2024 at 1504, Psychiatrist Staff Q stated she had heard about the admission process that was put into place in February 2024 but she was not part of the development of it. She stated if the patient was waiting in the ED and it was known there was no bed available, it was considered a delay in treatment because treatment could begin elsewhere. She stated she worked mostly with the geriatric patients. "The (geriatric) patients need interaction and need to be able to move around. Treatment should be as soon as possible. ED is not the place for that. It needs to be in the least restrictive setting. This practice goes against the Michigan Mental Health Code." Staff Q was queried as to if the patient were considered stable after being medically cleared in the ED and having the BH evaluation to which she stated they were not stable because they had not yet received treatment.

Michigan Mental Health Code 330.1708 states, "Suitable services; treatment enviornment; setting; rights. Sec.708. (1) A recipient shall receive mental health services suited to his or her condition. (2) Mental health services shall be provided in a safe, sanitary, and humane treatment environment. (3) Mental health services shall be offered in the least restrictive setting that is appropriate and available. (4) A recipient has the right to be treated with dignity and respect."

On 8/28/2024 at 1512, ED Medical Director Staff P stated he had voiced concerns about delays to the former ED nursing director. He stated obtaining a bed for the psychiatric patient was a "balancing act" as admission was preferable, and it was unknown how long it might take to get an outside facility to accept. "If we are pretty sure there are no beds available for a certain amount of time, we need to be careful not to hang onto that (patient)."

Facility policy #10835619 titled "Admission and Transfer of Emergency Psychiatric Patients" effective 10/2022 states, "It is the policy of [facility name] to provide an appropriate Medical Screening Examination ("MSE")
and stabilizing treatment within its capabilities and capacity and appropriate transfer of all
individuals who come to [facility name] Emergency Department seeking evaluation and/or treatment
for a psychiatric or mental health condition. 2. It is the policy of [facility name] to comply with EMTALA and Policy - Screening, Stabilization and Transfer of Emergency Patients (EMTALA) in the examination, treatment, admission, and transfer of all individuals who come to [facility name] Emergency Department seeking evaluation
and/or treatment for a psychiatric or mental health condition...The MHS [mental health screener] will discuss the case with the Emergency Department physician attending the patient who will review and approve the disposition. As determined to be appropriate by the MHS or Emergency Department physician, the psychiatrist on-call may be consulted to review the case and, if appropriate, examine the patient. A MSE under this Policy shall be conducted by the emergency department physician, the attending physician, or an MHS in consultation with the emergency department or attending physician to determine if an EMC [emergency medical condition] exists. 3. If the emergency department physician or attending physician determines that an EMC exists, the individual shall be provided stabilizing treatment within [facility name] capabilities and capacity or an appropriate transfer in accordance with Screening, Stabilization and Transfer of Emergency Patients (EMTALA) Policy... If [facility name] does not have the capability or capacity to treat the patient's emergency medical condition, the patient may be transferred to an appropriate facility..."

Facility process titled "Admission from ED to 1N" dated 8/7/2024 states, "ED screener completes screen and determines need for inpatient placement...ED Screener calls the admitting doctor for acceptance or denial for next available bed. If no current available bed, screener to escalate to 1N supervisor or manager on call for after hours. Once accepted, ED Screener to call 1N for screener report. BA (Business associate-unit clerk) will get ED Screener report and gather appropriate packet and notify 1N Charge RN of potential admission. 1N Charge RN will determine admission time with coordination of Nursing Supervisor/Manager on call. If admission time is greater than 24 hours, decision to hold will be escalated to leadership for 1N and ED (on call for after hours) 1N Charge RN or designee will notify admitting unit of admission day/time. ED Nurse gives report to 1N Nursing ED calls for Transport Patient Transported and Admitted to 1N"

Based on interview and record review, the facility failed to provide a medical screening exam for 2 (#22,26) of 26 patients reviewed and failed to provide appropriate transfer for 5 (#4, 10, 11, 22, 23) of 5 patients reviewed for transfer resulting in the potential for unrecognized, unmet patient needs and the potential for poor patient outcomes. Findings include:

See Specific Tags:

A-2406 Failure to provide a medical screening exam
A-2409 Failure to provide appropriate transfer

Based on interview and record review, the facility failed to provide a medical screening exam to 2 (P-22, 26) of 26 patients reviewed resulting in the potential for unmet patient needs and poor patient outcomes. Findings include:

Review of the medical record of P-22 revealed she was a 27-year-old female who presented to the Emergency Department (ED) on 7/23/2024 at 0114 with a chief complaint of umbilical abdominal pain with nausea and vomiting for the past 3 days. She was given an ESI (emergency severity index-tool used to determine the acuity of the patient) of 3. The behavioral health indicators in triage indicated P-22 had suicidal ideation and she wished she were dead or could go to sleep and never wake up. She denied thoughts of how to kill herself or preparing to end her life. The suicide risk score indicated she was low risk for suicide.

Orders were found for suicide precautions and suicidal discharge instructions. Discharge disposition indicated P-22 left without being seen. The discharge summary where physician documentation would normally be, it was written, "Patient eloped prior to Dr. exam." Time of discharge was 0146.

Incidentally, P-22 returned to the ED 7/23/2024 at 1235 with abdominal pain with nausea and vomiting and suicidal ideation. The behavioral health evaluation dated 7/23/2024 at 1626 stated, "Per the patient she attempted to drown herself in the tub this morning." P-22 received a petition and clinical certificate and was transferred to an outside psychiatric hospital.

Review of the medical record of P-26 revealed he was a 20-year-old male who presented to the ED on 7/23/2024 at 2105 with a chief complaint of suicidal ideation and homicidal ideation. He stated his plan was to jump from a building, and he wanted to "harm his father." He was triaged at 2124 and placed in the ED waiting room.

Review of triage documentation revealed the CSSRS (Columbia Suicide Severity Rating Scale-used to determine risk of suicide) evaluation placed P-26 at high risk for suicide. The VAAC (Violence Aggression Assessment Checklist-used to determine risk for violence) evaluation indicated he was low risk for violence. P-26 did have a past psychiatric history of being bipolar (mood swings), ADHD (Attention Deficit Hyperactivity Disorder-chronic condition including attention difficulty, hyperactivity, and impulsiveness), and depression. It was noted he had been off of his medications for the past three months.

Further documentation of ED disposition by the same triage nurse on 7/23/2024 at 2340 stated, "Condition at Discharge: Stable Discharge To: LWBS (left without being seen)." The discharge summary where physician documentation would normally be, it was written, "Patient eloped prior to Dr exam."

Incidentally, P-26 returned to the ED 7/24/2024 at 0038 for suicidal and homicidal ideation. He received a petition and clinical certificate and was admitted to the in-patient psychiatric unit.

On 8/28/2024 at 1431, ED Manager Staff A was queried as to what her expectations were regarding a suicidal patient coming in through triage. She stated their practice and her expectation was that someone either sit with the patient or the patient would be brought back to the (ED) room immediately following triage.

On 8/28/2024 at 1512, ED Medical Director Staff P stated "a suicidal patient is considered an ESI-2. We try to get them into a room as quickly as possible." He described the process of the provider quickly evaluating to decide if placement was needed in the main ED for medical clearance or if the patient could be sent to the behavioral health annex (locked psychiatric area of the ED).

Review of facility policy #12972721 titled "(facility name redacted) Michigan Emergency Medical Treatment & Active Labor Act (EMTALA) Policy" effective 1/12/2023 states, "Definitions...Emergency Medical Condition - 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: 1. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or the unborn child) in serious jeopardy... Medical Screening Examination (MSE) - The process required to reach with reasonable clinical confidence the point at which it can be determined whether an Emergency Medical Condition exists. The Medical Screening Examination must be the same Medical Screening Examination that the Hospital would perform on any individual coming to the Hospital's emergency department with those signs and symptoms, regardless of the individual's ability to pay for medical care... Qualified Medical Person or Personnel (QMP) - An individual in addition to a licensed physician who is license or certified and who has demonstrated current competence in the performance of Medical Screening Examinations, for example: 1. Registered Nurse in Perinatal Services 2. Psychiatric Social Worker 3. Registered Nurse in Psychiatric Services 4. Psychologist 5. Physician Assistant 6 Advanced Registered Nurse Practitioner 7. Certified Registered Nurse Midwife... 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 for who a Prudent Layperson Standard would indicate, on the basis of the individual's appearance or behavior, requires examination or treatment for a medical condition, will be provided an appropriate Screening Examination within the capabilities of the Dedicated Emergency Department including ancillary services routinely available to the emergency department to determine whether an Emergency Medical Condition exists regardless of their ability to pay for medical care...Patients who come to a Dedicated Emergency Department requesting service will receive a triage exam. If the triage exam detects a possible Emergency Medical Condition that needs immediate attention, the patient will be immediately brought to the examining area where the Medical Screening Examination will continue by a physician or Qualified Medical Person. b. The triage exam initiates a Medical Screening Examination, but does not constitute a Medical Screening Examination in and of itself. The Medical Screening Examination extends until the point that the Qualified Medical Person or physician determines that an Emergency medical Condition Does not exist... When an individual presents with psychiatric symptoms, the Medical Screening Exam should include an assessment of suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates danger to self or others. When the Hospital determines that an individual poses a danger to self or others, this is considered an Emergency Medical Condition."

Based on interview and record review, the facility failed to indicate staffing and equipment resources required during transfer for 5 (P-4, 10, 11, 22, 23) of 5 patients reviewed for transfer resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include:

Review of the medical record for P-4 revealed she was a 54-year-old female who presented to the Emergency Department (ED) on 7/3/2024 at 1506 after being petitioned by police for paranoia. Following her medical and behavioral health (BH) evaluations, it was determined the patient needed to be transferred to an outside psychiatric hospital. Review of the transfer documentation revealed there was no indication present of what staff or equipment resources were needed for the transfer.

Review of the medical record for P-10 revealed she was a 69-year-old female who presented to the ED on 7/10/2024 at 0142 with a chief complaint that read "D/C (discharge) to inpatient and then they realized they didn't have a bed so they sent her back waiting (sic) for placement."

A review was conducted of her previous visit which started on 7/6/2024 at 1651 when she had presented to the ED in police custody in "CRISIS" and "suicidal." P-10 was medically cleared and had her BH evaluation on 7/7/2024 at 1730. On 7/7/2024 at 2039, packets were sent to multiple outside psychiatric hospitals seeking admission placement. She was accepted to a psychiatric hospital in Indiana. Review of the transfer documentation revealed there was no indication present of what staff or equipment resources were needed for the transfer.

Further review of P-10's medical record indicated the medical clearance was rescinded on 7/8/2024 at 1030 as some lab values came back abnormal and needed to be addressed. The transfer was cancelled at that time. Medical clearance was reinstated 7/9/2024. The transfer process was started again, and the patient was accepted 7/9/2024 at 0911 at another psychiatric facility (same hospital system as the original accepting hospital) in Indiana. It was noted the transfer document was also re-done and still did not include staff or resources needed for the transfer.

Review of the medical record for P-11 revealed she was a 50-year-old female who presented to the ED 7/10/2024 at 0910 with a chief complaint of suicidal ideation without a plan. Following medical clearance and a mental health screening, it was determined she would be transferred to an outside psychiatric facility. Review of transfer documentation revealed there was no indication present of what staff or equipment resources were needed for the transfer.

Review of the medical record for P-22 revealed she was a 27-year-old female who presented to the ED on 7/23/2024 at 1235 with a chief complaint of abdominal pain with nausea and vomiting and suicidal ideation. Following medical clearance and mental health screening, it was determined she would be transferred to an outside psychiatric facility. Review of transfer documentation revealed there was no indication present of what staff or equipment resources were needed for the transfer.

Review of the medical record for P-23 revealed he was a 38-year-old male who presented to the ED on 8/11/2024 at 0042 with a chief complaint of feeling possessed. Following medical clearance and mental health screening, it was determined he would be transferred to an outside psychiatric facility. Review of transfer documentation revealed there was no indication present of what staff or equipment resources were needed for the transfer.

On 8/28/2024 at 1512, ED Medical Director Staff P stated the provider was to complete the risks/benefits of transfer, the accepting physician, the hospital to which the patient was being transferred and sign the transfer form. Other staff would finish filling out the form.

Facility policy #12972721 titled "(facility name redacted) Michigan Emergency Medical Treatment & Active Labor Act (EMTALA) Policy" effective 1/12/2023 states, "An appropriate transfer is a transfer in which...The transfer is completed through the appropriate medical personnel and utilizing the appropriate equipment for the patient... The physician or Qualified Medical Person shall complete the "TRANSFER FORM" prior to transfer."