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Based on policy review, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings included:

1. The hospital failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 2 of 8 sampled patients who presented with psychiatric or substance abuse symptoms, (Patient #14 and #16).

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

2. The hospital failed to ensure stabilization of a patient with an emergency medical condition for 2 of 8 sampled psychiatric or substance abuse patients, (Patient #14 and #16).

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

The hospital failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 2 of 8 sampled patients ( Pts #14, 16) who presented with psychiatric or substance abuse symptoms.

The findings included:

Review of the policy "'EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA) COMPLIANCE", reviewed 02/2019, revealed " ...POLICY 1. When an individual presents or is brought to the Emergency Department of (Hospital Name) and a request is made on the individual's behalf for the examination and treatment of a medical condition, a physician or allied health member will provide a medical screening examination within the capabilities of the Hospital, including ancillary services routinely available to the Emergency Department, for the purpose of determining the presence or absence of an Emergency Medical Condition.....DEFINITIONS....2. Medical Screening Examination - The initial and on-going evaluation of the presenting patient conducted by a physician or allied health member. Evaluation includes history, physical examination, appropriate testing, completion of appropriate documentation and evaluation of the patient, within the capabilities of this hospital... ."

1. DED medical record review, on 01/15/2020, revealed Patient #14 arrived by police on 01/05/2020 at 0338 under involuntary commitment. Review of "Chief Complaints Updated" at 0350 revealed "+ Drug Problem". Review revealed a note at 0350 that stated "patient was placed under IVC (involuntary commitment) for alleged aggressive behavior due to substance abuse." Review revealed an ED Behavioral Health Screening at 0352 that stated "Are you having thoughts of wanting to harm yourself or others? Denies." Vital signs at 0401 were recorded at Temperature (T) 98.2, Pulse (P) 126, Respirations (R) 16, Blood Pressure (BP) 155/93, and Pulse Oximetry (Pulse Ox) 100% on room air (RA). Review of "ED Provider Notes", on 01/05/2020 at 0350, revealed "37-year-old male with history of Crohn's disease, chronic pain, anxiety who presents for gastric evaluation with IVC papers. He has absolutely no complaints at this time. He states that he takes Adderal for ADHD but does not take any other medications or abuse any substances. He denies any alcohol use prior to arrival. He denies any suicidal or homicidal ideation. He denies any visual or auditory hallucinations. His IVC papers state that he has had abnormal and bizarre behavior at home and drug paraphernalia has been found in the home....REVIEW OF SYSTEMS ....Psychiatric/ Behavioral: Negative for dysphoric mood, hallucinations, self-injury and suicidal ideas....PHYSICAL EXAM:...Psychiatric: His mood appears anxious. His speech is rapid and/or pressured. He is hyperactive. He is not agitated and not aggressive. Thought content is not paranoid and not delusional. He expresses no homicidal and no suicidal ideation. He expresses no suicidal plans and no homicidal plans....MDM.... presents for evaluation and medical clearance with IVC papers. I do not see any acute findings on his physical exam, he is slightly anxious and with pressured speech, but is not agitated and does not require any medications. He does not have any evidence of psychosis, denies suicidal or homicidal ideations. He denies any substance abuse. He will need psychiatric assessment. Anticipate medical clearance. For me he is contracting for safety, but will still order psychiatric assessment due to his IVC. DIAGNOSTICS....Labs reviewed .... CBC WITH DIFFERENTIAL COMPREHENSIVE METABOLIC SCREEN (CMP) RAPID DRUG SCREEN W THC, URINE ALCOHOL, ETHYL BLOOD....CLINICAL IMPRESSION Final diagnoses: None. ..." Review of Lab Testing revealed CBC with Differential results, CMP results, and serum alcohol results. Review revealed the rapid urine drug screen was ordered but failed to reveal it was collected or resulted. Review of ED Notes, at 0405, revealed "Patient ambulated to psych suite with the escort of tech and security. Patient is alert and oriented x4 and cooperative. ...." At 0404 a Flowsheet note stated "Lives with his (relative), but he reports he does not have a number for her". Review of ED Notes by a Registered Nurse at 0415 revealed "...Service: Psych....37 yo male who is alert, oriented x4, cooperative. Pt has an ankle monitor on and reports he is on post release parole for Felony B&E (breaking and entering) He denies. SI, HI, or AVH. He reports that tonight his (other relative) was trying to get into his medication, specifically Adderal, and when he caught her, she took out IVC papers in retaliation. Pt denies any history of trying to harm himself or anyone else. He reports Dr. (name) diagnosed him with ADHD and prescribes Adderal. He also reports using THC, Xanax, and Hydrocodone. He reports he has chronic pain issues. Pt reports his sleep and appetite are good. He lives with his (relative) and his (other relative) lives behind them. Pt contracts for safety. PMH: Crohn's Disease, Anxiety, COPD Hep B. Unfortunately, there is not a good phone number for pt's (other relative). IVC does not have a number listed and the number in the chart is disconnected. Pt reports he does not have any other number for his (other relative). IVC does not mention anything about pt trying to harm himself or others. It talks about pt having behaviors, such as stomping his feet at 4am, finding a drug spoon and syringes. It also reports pt has torn up the house and is verbally abusive. Given pt is denying SI, HI, or AVH, he is not psychotic, and there is nothing written in the IVC to indicate there is an acute danger, it is likely he will be discharged. Will discuss with Dr. (name). Record review revealed the assessment was completed by a Registered Nurse (RN Psych Assessor). Record review did not reveal evidence of telepsychiatry. At 0423, DED Flowsheet review revealed Patient #14 denied access to firearms, stating patient was a felon. A Mental Health Assessment, noted at 0423, stated "...Behavior Cooperative, Appropriate to situation...Observed Emotional State accepting.... Judgment Difficulty in problem solving;Poor decisions (sic) .... Insight Poor. ..." Suicide risk was evaluated, per the Flowsheet at 0424, with no suicidal ideation noted, no suicidal plan, and no previous attempts. At 0424, a note stated "...Family and Support System ....Lives with his (relative), but he reports he does not have a number for her. ..." At 0425 Flowsheet review noted the patient used the following substances "Marijuana; Amphetamines; Opiates; Benzodiazepines".

Review of the Involuntary Commitment paperwork "FINDINGS AND CUSTODY ORDER INVOLUNTARY COMMITMENT" revealed it was signed by the magistrate on 01/05/2020 at 0238. Review revealed Patient #14 was taken to the hospital at 0345 by the (City) Police Department. Review of the document revealed a statement that indicated "...THE PET (petitioner) STATES THAT THE RESP. (respondent) IS VERY DESTRUCTIVE HAVING TORN UP HER HOUSE AND VERBALLY ABUSIVE TO THE PET. THE PET. HAS FOUND A DRUG SPOON AND SYRINGES IN HER HOME. THE PET. STATED THAT LAST NIGHT THE RESP. WAS UP AT 4 AM STOMPING HIS FEET ON THE FLOOR AND SINGING 'ITS TIME TO GET UP'. TEN MINUTES LATER THE RESP. WAS HEARD IN A DEEPER VOICE STATING 'I HOPE I FIND HER DEAD IN THE MORNING, I WOULD SPIT IN HER FACE AND TELL THEM TO BURY HER IN THE WOODS'. A MORE VIOLENT PERSONALITY CAME OUT LATER AND STARTED THROWING THING ABOUT THE HOUSE. THE PET. CALLED THE POLICE AT THIS POINT AND CHILD PERSONALITY CAME OUT AND HE STARTED CRYING AND ACTING LIKE AN INFANT. THE RESP. IS A DANGER TO HIMSELF AND TO OTHERS." Further review of the paperwork revealed a "FIRST EXAMINATION FOR INVOLUNTARY COMMITMENT" that documented the first level examination was conducted 01/05/2020 at 0428. Review revealed the statement "Release respondent and Terminate Proceedings (insufficient findings to indicate that respondent meets commitment criteria)" was marked and the form signed by the DED physician.

DED record review revealed an ED Note, at 0431, which stated "Pt attempted to urinate but was unable too (sic)-pt was given water and will attempt again in little (sic). Another note, at 0436 stated "Dr. (name) agrees that IVC does not indicate pt is a danger to himself or others....releasing pt from IVC completed, faxed to Magistrate. Pt will be discharged." At 0458 the ED disposition was set to discharge. At 0501 orders were noted to be acknowledged by a RN for the rapid urine drug screen. Vital signs at 0505 were recorded as T 97.2, P 114, R 19, BP 137/87 and Pulse Ox 96% on RA. DED review revealed Patient #14 was discharged at 0508. (1 hour 30 minutes after arrival).

Review of the "ED Disposition" note revealed "...Medical screening evaluation has been completed. No emergent medical condition was identified and (name of Patient #14) is stable at the time of disposition decision." Further review revealed no discharge diagnosis was listed; the discharge diagnosis was stated as "none". Record review did not reveal telepsychiatry was consulted. Record review failed to reveal a urine drug screen was collected and resulted prior to discharge and failed to reveal any family contact/ information received prior to discharge.

Telephone interview on 01/15/2020 at 1200 with the DED RN Psychiatric Assessor (RN Psych Assessor) revealed Patient #14 was unhappy and frustrated to be in the psych suite, but was not a problem and was cooperative and appropriate with staff. Interview revealed the RN Psych Assessor asked patients a series of questions from a manual form. Once completed the information was entered into the computer and the original form was discarded. In response to a question on past history, the RN Psych Assessor stated she normally documented past psychiatric history in the record but did not see it in the record. Interview revealed the RN Psych Assessor thought if there had been any relevant history she would have documented it. Interview revealed RN Psych Assessors were trained in the assessment process. She stated they were trained to gather the data and find out the status of the patient. The RN Psych Assessor stated the assessors worked closely with ED physicians. Interview revealed if an ED physician wanted telepsychiatry to evaluate a patient the physician would write a specific order to that effect. Interview revealed it was preferable to get collateral information, but in this case there was no way to contact Patient #14's (other relative) even if they were able to contact the (relative) it did not mean she would have any information. Further interview revealed the RN Psych Assessor normally looked for a drug screen result. In this case, interview revealed, the patient was not psychotic or under the influence of anything. Interview revealed Patient #14 had not used IV drugs and the RN Psych Assessor noted she "thought" she looked at the patient's arm. Interview revealed the staff worried more about getting a drug screen if a patient was going to be admitted.

Telephone interview with MD #1, a DED physician, on 01/15/2020 at 1230, revealed MD #1 did not see anything in the IVC paperwork to indicate an imminent danger. Interview revealed Patient #14's heart rate was fast and he was anxious, but MD #1 did not see anything to cause her to commit the patient. Interview revealed MD #1 recalled reading the IVC document. Interview revealed "I have to go with the patient in front of me and he did not display any of those behaviors." Interview revealed MD #1 ordered the drug screen. Interview revealed the drug screen was part of a protocol and not always helpful. In this case, MD #1 stated, she did not feel it would change the management of the patient so it was okay that it was not done. Interview revealed the physician would have needed to order telepsychiatry if she wanted it and she did not order it. MD #1 stated that in real time, in a busy department, she did not order telepsychiatry on every psychiatric patient. "He seemed completely coherent and completely with it." There was nothing, the physician indicated, that said the patient needed to be involuntarily committed. MD #1 stated "both of us (RN Psych Assessor and MD #1), independently, came to that conclusion." Further interview revealed MD #1 would normally document a discharge diagnosis.

2. DED record review, on 01/15/2020, revealed Patient #16 arrived to the DED on 01/03/2020 at 2241 with a chief complaint of suicidal ideation and substance abuse. Review revealed Patient #16 was triaged at 2241 as an ESI 2, emergent. Vital signs at 2242 were documented as Temperature (T) 99.3, Pulse (P) 111, Respirations (R) 18, Blood Pressure (BP) 119/74 and Pulse Oximetry 100% on room air. Review of a "Columbia Suicide Severity Screening" at 2313 by a RN revealed " ...1. In the past 30 days have your wished you were dead or wished you could go to sleep and not wake up? Yes .... 2. In the past 30 days, have you actually had any thoughts of killing yourself? Yes.... previous suicidal attempts .... 3. Have you been thinking about how you might kill yourself? (!) Yes gun but doesn't have means, OD on prescriptions drugs or cut himself .... 4. Have you had these thoughts and some intention of acting on them? (!) Yes ...5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? (!) Yes ... 6A. Have you EVER done anything, started to do anything, or prepared to do anything to end your life? (!) Yes 6B. If Yes, how long ago did you do any of these things? (!) Yes More than three months ago ... Columbia Suicide Screening Calculated Risk Level High Risk. ..." Flowsheet review revealed Patient #16 was placed on constant observation at 2315. Review of "Other ED Notes" revealed a RN Note at 2320 that stated "Pt reports being in town for a little while relocated and has a new job. He reports for the past 2 days he is feeling suicidal after experiencing several panics (sic) attacks. He reports that his hands were shaking back and forth and has never done that before. He is alert and oriented with bilat (bilateral) chest expansion noted. No acute distress noted." Review revealed a "Adult Assessment of Risk for Suicide" was completed by a RN at 2330 and noted " ...Risk for Suicide Total Score ...24 ....Does patient have a plan to commit suicide? ... Yes .... Does patient have access to the means to Carry out suicide plan while in the hospital ... Yes .... Describe ....plans to cut wrist." Review of the "ED Provider Notes", on 01/03/2020 at 2312, revealed " ...HISTORY OF PRESENT ILLNESS ....presents to the ED with a Chief Complaint of Suicidal .... Subjective .... (Name) .... with a history of psychosis, bipolar disorder, anxiety, depression, schizophrenia, and substance abuse who presents to the ED for psychological evaluation of suicidal ideations. The pt reports he relocated here from (city) to 'get away from drugs' and two days ago he states he had a 'mental break down'. He states that he felt his whole body shaking and has not stopped shaking since. He reports that he doesn't want to live anymore and has a plan to cut himself, overdose on drugs, or shoot himself. He reports that he does not have a gun. He reports marijuana use today but denies other drugs in 7.5 months.... He denies hallucinations or homicidal ideations. He has no other complaints at this time .... REVIEW OF SYSTEMS ....Psychiatric/ Behavioral: Positive for dysphoric mood and suicidal ideas. Negative for self-injury ....PHYSICAL EXAM ....Psychiatric: He has a normal mood and affect. His behavior is normal. He expresses suicidal ideation. He expresses suicidal plans ...REEVALUATION Psychiatry evaluated patient. Recommends outpatient treatment. Patient with history of factitious disorder and patient has frequent emergency visits. He does not appear to be different from his baseline. He does not appear to be a threat to himself or others at this time. ..." Review of ED Notes by a Psych RN (RN Psych Assessor) on 01/04/2020 at 0020 revealed " ...alert and oriented x4. Pt reports initially that he 'took a week off of work and came down here to visit friends and family.' He reports he has been living in (city). Pt reports he is living with a friend in (city). He is unable to keep his story straight and becomes flustered when confronted with that. Pt was released from (city) Jail on 12/17/19 after serving 2 months. None of his timelines fit this fact. He is vague as to whether or not he is suicidal. He actually reports that if he is discharged, he will 'just go to the next place', meaning another hospital. Pt reports he has not had any of his medications he was receiving in jail, which he reports were Depakote 1500 mg and Seroquel 400 mg. He reports the doctor at jail diagnosed him with Schizophrenia, Bipolar 1, Depression 1, and PTSD. Pt is not psychotic, nor is he homicidal. He is known to be homeless. When asked about collateral, he does not have a phone and states 'I got rid of it, because it was controlling my life'. He also reports he does not have contact numbers. Pt is currently laying back in a recliner, he has eaten a meal, and is watching TV. He does not appear to be in any distress. PMH includes Factitious Disorder, Substance Abuse, Adjustment Disorder, and Depression." Patient Care Timeline review revealed on 01/04/2020 at 0029 a Thought Assessment / Mental Health Assessment was completed on Patient #16. Review of the Thought Assessment revealed " ...Behavior: Fidgety; Cooperative Speech: Clear Thought Content: Impoverished Appearance: Disheveled Delusions: Not evident Hallucination Type: Denies Observed Emotional State: accepting Thought Process: Goal directed Judgment: Difficulty in problem solving; Poor decisions Mood: Anxious Affect (facial, voice or gestural behavior): Congruent Insight: Poor" Review of the Patient Care Timeline revealed an "Adult Assessment of Risk for Suicide" was completed 01/04/2020 at 0030 by the Psych RN Assessor which noted a suicide risk total score of 20. Review of the assessment revealed " ...Suicidal ideation: Intermittent or fleeting suicidal thoughts Suicidal Plan: None.... Current Morbid Thoughts: Intermittent Alcohol and/or Drug Use: Continual abuse Support Systems: None available Coping Mechanisms: Predominantly destructive Behavioral Symptoms: One to two symptoms present Does patient have a plan to commit suicide? No Prior Suicidal Attempts: Past attempts of low lethality Lethality of Plan: None Elopement Risk: Low risk Contracts for Safety: Contracts but is ambivalent or guarded Reasons to Live/Hope: Wants things to change and has some hope, has future plans Behavioral Symptoms List: *Anxiety, *Impulsive Risk for suicide Total Score 20 Does the patient have access to the means to Carry out suicide plan while in the Hospital? No..." Flowsheet review revealed on 01/04/2020 at 0032 "...Psych Assessment Completed... ." Review of ED Notes by a Psych CNA (Nurse Aide) on 01/04/2020 at 0830 revealed "Patient eating breakfast. Will dress for discharge when finished with breakfast." Review revealed Patient #16 discharged on 01/04/2020 at 0906. Record review did not indicate any further documentation of behavioral assessments/ evaluations or suicide risk assessments after 0032. DED record review revealed a document titled "AFTER VISIT SUMMARY" (AVS) which indicated personalized instructions could be found at the end of the document. Document review revealed a section labeled "Changes to Your Medication List ASK your doctor about these medications ...DEPAKOTE ...SEROQUEL ...". Document review revealed an "Instruction Section" that included a list of resources both inside and outside the immediate area but did not highlight any specific resources. Review of the "AFTER VISIT SUMMARY" did not reveal any specific information related to when or where to seek follow-up and/or to obtain needed medications.

Telephone interview, on 01/17/2020 at 1030, with the RN Psych Assessor revealed Patient #16 was known to the Psych Assessor and the presentation on 01/03/2020 was a typical presentation for the patient. Interview revealed there were inconsistencies in what the RN Psych Assessor heard from the patient and the doctor but could not recall what the inconsistencies were. In relation to the physician documentation that psych recommended outpatient, the RN Psych Assessor stated she generally presented the case and talked it over with the doctor, but could not say if a recommendation was made. In relation to medications, interview revealed there was no way to verify medications during the night. When the patient was discharged, the RN Psych Assessor stated, a nurse (not the RN Psych Assessor) would go over the AVS with the patient. The RN Psych assessor indicated she separately went over resources for the patient and gave Patient #16 another form with more specific instructions. Interview revealed the form listed outpatient providers. The RN Psych Assessor stated one provider was highlighted and Patient #16 was instructed to to go to that outpatient provider the next morning. Interview revealed that form with specific instructions was not part of the patient's medical record.

Telephone interview with MD #2, a DED physician, on 01/16/2020 revealed when DED physicians order a Psych Assessment, they were ordering a RN psych assessment. Interview revealed physicians medically cleared the patients, then sent them to the psych holding area. Interview revealed MD #2 used the RN psych assessor first, then if there were questions, would involve telepsych or another physician. Interview revealed MD #2 generally spoke with patients about medications, but in this case did not see in the record if that happened. Interview revealed MD #2 would not write prescriptions for psych meds because he wanted a provider managing the meds who knew the patient and would continue as the provider. MD #2 stated follow-up was generally recommended to occur in 24-48 hours. Interview revealed patients were typically reassessed before discharge to be sure everyone was still okay with the discharge. Interview revealed staff tried to document reassessments but not always.

Telephone interview with MD #3, the Psychiatry Medical Director, on 01/16/2020 at 1415, revealed psychiatric patients who arrived to the DED received the normal medical screening by the DED physician. Then, if it was determined that the patient appeared to be a primary psych patient, the DED physician could order a psych assessment with the RN Psych Assessor. The RN Psych Assessor gathered information from the patient, other sources, information on the petition for IVC or transfer needs, and then pulled all that into an assessment. The information was presented to the DED physician for decisions on what needed to happen related to care and treatment. Generally, MD #3 stated, the Psych Assessor and DED physician would have a conversation after which the RN Psych Assessor would write a report in the medical record. Interview revealed the Psych Assessors acted like Case Managers/ Social Workers, they completed an assessment and made recommendations to the ED physician. Interview revealed the ED physician could call for a face to face evaluation with either telepsychiatry or a psychiatric provider. Interview revealed telepsychiatry was available 24 hours a day, 7 days a week. Interview revealed telepsychiatry was most often used when there was confusion or disagreement on whether a patient needed admission. MD #3 stated he expected Psych Assessors to document as much as was reasonable. Interview revealed they would not make or document decisions to admit or discharge patients. Follow-up interview on 01/17/2020 at 1125 revealed MD #3 did not see Patient #16 while in the ED, but reviewed the medical record. Interview revealed MD #3 had no concerns related to the patient's care and disposition in the ED.

In summary, complete medical screening exams were not provided to determine if emergency medical conditions existed for Patients #14 and 16. With Patient #14, the RN Psych Assessor stated "... IVC does not mention anything about pt trying to harm himself or others. It talks about pt having behaviors, such as stomping his feet at 4am, finding a drug spoon and syringes. It also reports pt has torn up the house and is verbally abusive. ..." The IVC document stated "...THE RESP. WAS HEARD IN A DEEPER VOICE STATING 'I HOPE I FIND HER DEAD IN THE MORNING, I WOULD SPIT IN HER FACE AND TELL THEM TO BURY HER IN THE WOODS'. A MORE VIOLENT PERSONALITY CAME OUT LATER AND STARTED THROWING THING ABOUT THE HOUSE. ..." Patient #14 remained in the hospital 90 minutes during the night, from 0338-0508. There was no contact from the petitioner during that time and no collateral information was obtained from anyone prior to discharge. The urine drug screen was not obtained and no diagnosis was assigned. Related to Patient #16, there was no indication if the patient was reevaluated by a physician or Psych Assessor after the RN Psych Assessment was completed at 0032 until discharge. In the initial screening Patient #16 was stated to be high risk for suicide, and in the later suicide risk screening (at 0032) was lower risk. It was noted the patient contracted for safety but was "ambivalent or guarded". The patient was stated to have "difficulty in problem solving", "poor decisions", and was noted to be "impulsive".

The hospital failed to ensure stabilization of a patient with an emergency medical condition for 2 of 8 sampled psychiatric or substance abuse patients, (Patients #14 and #16).

The findings included:

Review of the policy "'EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA) COMPLIANCE", reviewed 02/2019, revealed " ...POLICY ....2. An individual with an Emergency Medical Condition will receive either: (1) such further medical examination and treatment within the capabilities of the staff and facilities available as may be required to stabilize the Emergency Medical Condition....DEFINITIONS ....3. Stabilizing Treatment - That medical care appropriate and necessary to reduce the risk of material deterioration of the patient's medical condition prior to discharge or transfer. 4. Stabilize - A patient is deemed to have been stabilized when, with respect to the Emergency Medical Condition, no material deterioration of the patient's condition is likely, within reasonable medical probability, to result from or occur during transfer (including discharge or referral). ..."

1. 1. DED medical record review, on 01/15/2020, revealed Patient #14 arrived by police on 01/05/2020 at 0338. Review of "Chief Complaints Updated" at 0350 revealed "+ Drug Problem". Review revealed a note at 0350 that stated "patient was placed under IVC (involuntary commitment) for alleged aggressive behavior due to substance abuse." Review revealed an ED Behavioral Health Screening at 0352 that stated "Are you having thoughts of wanting to harm yourself or others? Denies." Vital signs at 0401 were recorded at Temperature (T) 98.2, Pulse (P) 126, Respirations (R) 16, Blood Pressure (BP) 155/93, and Pulse Oximetry (Pulse Ox) 100% on room air (RA). Review of "ED Provider Notes", on 01/05/2020 at 0350, revealed "37-year-old male with history of Crohn's disease, chronic pain, anxiety who presents for gastric evaluation with IVC papers. He has absolutely no complaints at this time. He states that he takes Adderal for ADHD but does not take any other medications or abuse any substances. He denies any alcohol use prior to arrival. He denies any suicidal or homicidal ideation. He denies any visual or auditory hallucinations. His IVC papers state that he has had abnormal and bizarre behavior at home and drug paraphernalia has been found in the home....REVIEW OF SYSTEMS....Psychiatric/Behavioral: Negative for dysphoric mood, hallucinations, self-injury and suicidal ideas....PHYSICAL EXAM:...Psychiatric: His mood appears anxious. His speech is rapid and/or pressured. He is hyperactive. He is not agitated and not aggressive. Thought content is not paranoid and not delusional. He expresses no homicidal and no suicidal ideation. He expresses no suicidal plans and no homicidal plans....MDM.... presents for evaluation and medical clearance with IVC papers. I do not see any acute findings on his physical exam, he is slightly anxious and with pressured speech, but is not agitated and does not require any medications. He does not have any evidence of psychosis, denies suicidal or homicidal ideations. He denies any substance abuse. He will need psychiatric assessment. Anticipate medical clearance. For me he is contracting for safety, but will still order psychiatric assessment due to his IVC. DIAGNOSTICS....Labs reviewed .... CBC WITH DIFFERENTIAL COMPREHENSIVE METABOLIC SCREEN (CMP) RAPID DRUG SCREEN W THC, URINE ALCOHOL, ETHYL BLOOD....CLINICAL IMPRESSION Final diagnoses: None. ..." Review of Lab Testing revealed CBC with Differential results, CMP results, and serum alcohol results. Review revealed the rapid urine drug screen was ordered but failed to reveal it was collected or resulted. Review of ED Notes, at 0405, revealed "Patient ambulated to psych suite with the escort of tech and security... ." At 0404 a Flowsheet note stated "Lives with his (relative), but he reports he does not have a number for her". Review of ED Notes by a Registered Nurse at 0415 revealed "...Service: Psych....37 yo male who is alert, oriented x4, cooperative. Pt has an ankle monitor on and reports he is on post release parole for Felony B&E (breaking and entering) He denies. SI, HI, or AVH. He reports that tonight his (other relative) was trying to get into his medication, specifically Adderall, and when he caught her, she took out IVC papers in retaliation. Pt denies any history of trying to harm himself or anyone else. He reports Dr. (name) diagnosed him with ADHD and prescribes Adderal. He also reports using THC, Xanax, and Hydrocodone. He reports he has chronic pain issues. Pt reports his sleep and appetite are good. He lives with his (relative) and his (other relative) lives behind them. Pt contracts for safety. PMH: Crohn's Disease, Anxiety, COPD Hep B. Unfortunately, there is not a good phone number for pt's (other relative). IVC does not have a number listed and the number in the chart is disconnected. Pt reports he does not have any other number.... IVC does not mention anything about pt trying to harm himself or others. It talks about pt having behaviors, such as stomping his feet at 4am, finding a drug spoon and syringes. It also reports pt has torn up the house and is verbally abusive. Given pt is denying SI, HI, or AVH, he is not psychotic, and there is nothing written in the IVC to indicate there is an acute danger, it is likely he will be discharged. Will discuss with Dr. (name). Record review revealed the assessment was completed by a Registered Nurse (RN Psych Assessor). Record review did not reveal any evidence of telepsychiatry being used. At 0423, DED Flowsheet review revealed Patient #14 denied access to firearms, stating patient was a felon. A Mental Health Assessment, noted at 0423, stated "...Behavior Cooperative, Appropriate to situation...Observed Emotional State accepting.... Judgment Difficulty in problem solving;Poor decisions (sic).... Insight Poor. ..." Suicide risk was evaluated, per the Flowsheet at 0424, with no suicidal ideation noted, no suicidal plan, and no previous attempts. At 0424, a note stated "...Family and Support System ....Lives with his (relative), but he reports he does not have a number for her. ..." At 0425 Flowsheet review noted the patient used the following substances "Marijuana; Amphetamines; Opiates; Benzodiazepines".

Review of the Involuntary Commitment paperwork "FINDINGS AND CUSTODY ORDER INVOLUNTARY COMMITMENT" revealed it was signed by the magistrate on 01/05/2020 at 0238. Review revealed Patient #14 was taken to the hospital at 0345 by the (City) Police Department. Review of the document revealed a statement that indicated "...THE PET (petitioner) STATES THAT THE RESP. (respondent) IS VERY DESTRUCTIVE HAVING TORN UP HER HOUSE AND VERBALLY ABUSIVE TO THE PET. THE PET. HAS FOUND A DRUG SPOON AND SYRINGES IN HER HOME. THE PET. STATED THAT LAST NIGHT THE RESP. WAS UP AT 4 AM STOMPING HIS FEET ON THE FLOOR AND SINGING 'ITS TIME TO GET UP'. TEN MINUTES LATER THE RESP. WAS HEARD IN A DEEPER VOICE STATING 'I HOPE I FIND HER DEAD IN THE MORNING, I WOULD SPIT IN HER FACE AND TELL THEM TO BURY HER IN THE WOODS'. A MORE VIOLENT PERSONALITY CAME OUT LATER AND STARTED THROWING THING ABOUT THE HOUSE. THE PET. CALLED THE POLICE AT THIS POINT AND CHILD PERSONALITY CAME OUT AND HE STARTED CRYING AND ACTING LIKE AN INFANT. THE RESP. IS A DANGER TO HIMSELF AND TO OTHERS." Further review of the paperwork revealed a "FIRST EXAMINATION FOR INVOLUNTARY COMMITMENT" that documented the first level examination was conducted 01/05/2020 at 0428. Review revealed the statement "Release respondent and Terminate Proceedings (insufficient findings to indicate that respondent meets commitment criteria)" was marked and the form signed by the DED physician.

DED record review revealed an ED Note, at 0431, which stated "Pt attempted to urinate but was unable too (sic)-pt was given water and will attempt again in little (sic). Another note, at 0436 stated "Dr. (name) agrees that IVC does not indicate pt is a danger to himself or others....releasing pt from IVC completed, faxed to Magistrate. Pt will be discharged." At 0458 the ED disposition was set to discharge. At 0501 orders were noted to be acknowledged by a RN for the rapid urine drug screen. Vital signs at 0505 were recorded as T 97.2, P 114, R 19, BP 137/87 and Pulse Ox 96% on RA. Further DED review revealed Patient #14 was discharged at 0508 (1 hour 30 minutes after arrival). Review of the "ED Disposition" note revealed "...Medical screening evaluation has been completed. No emergent medical condition was identified and (name of Patient #14) is stable at the time of disposition decision." Record review failed to reveal a urine drug screen was collected and resulted prior to discharge. Review revealed Patient #14 was in the ED a total of 90 minutes and no drug screen or collateral information was obtained. Further, no diagnosis was recorded and no post-discharge treatment was noted.

Telephone interview on 01/15/2020 at 1200 with the DED RN Psychiatric Assessor (RN Psych Assessor) revealed Patient #14 was unhappy and frustrated to be in the psych suite, but was not a problem and was cooperative and appropriate with staff. Interview revealed the RN Psych Assessor asked patients a series of questions from a manual form. Once completed the information was entered into the computer and the original form was discarded. The RN Psych Assessor stated she did not locate any past psychiatric history in the electronic medical record. Interview revealed it was normally documented and she thought if there had been any relevant history she would have noted it. Interview revealed the RN Psych Assessors were trained in this assessment process. She stated they were trained to gather the data and find out the status of the patient. The RN Psych Assessor stated the assessors worked closely with ED physicians. Interview revealed if an ED physician wanted telepsychiatry to evaluate a patient they would write a specific order to that effect. Interview revealed it was preferable to get collateral information, but in this case there was no way to contact Patient #14's petitioner even if they were able to contact the (relative) it did not mean she would have any information. Further interview revealed the RN Psych Assessor normally looked for a drug screen result. In this case, interview revealed, the patient was not psychotic or under the influence of anything. Interview revealed Patient #14 had not used IV drugs and the RN Psych Assessor noted she "thought" she looked at the patient's arm. Interview revealed the staff worried more about getting a drug screen if a patient was going to be admitted and further stated they "don't IVC people because of drugs."

Telephone interview with MD #1, a DED physician, on 01/15/2020 at 1230, revealed MD #1 did not see anything in the IVC paperwork to indicate an imminent danger. Interview revealed Patient #14's heart rate was fast and he was anxious, but the physician did not see anything to cause the physician to commit the patient. Interview revealed MD #1 recalled reading the IVC document. Interview revealed "I have to go with the patient in front of me and he did not display any of those behaviors." Interview revealed MD #1 ordered the drug screen. Interview revealed the drug screen was part of a protocol and not always helpful. In this case, MD #1 stated, she did not feel it would change the management of the patient so it was okay that it was not done. Interview revealed the physician would have had to order Telepsychiatry. MD #1 stated that in real time, in a busy department, she did not order telepsychiatry on every psychiatric patient. "He seemed completely coherent and completely with it." There was nothing, the physician indicated, that said the patient needed to be involuntarily committed. MD #1 stated "both of us (RN Psych Assessor and MD #1), independently, came to that conclusion." Further interview revealed MD #1 would normally document a discharge diagnosis.

2. DED record review, on 01/15/2020, revealed Patient #16 arrived to the DED on 01/03/2020 at 2241 with a chief complaint of suicidal ideation and substance abuse. Review revealed Patient #16 was triaged at 2241 as an ESI 2, emergent. Vital signs at 2242 were documented as Temperature (T) 99.3, Pulse (P) 111, Respirations (R) 18, Blood Pressure (BP) 119/74 and Pulse Oximetry 100% on room air. Review of a "Columbia Suicide Severity Screening" at 2313 by a RN revealed " ...1. In the past 30 days have your wished you were dead or wished you could go to sleep and not wake up? Yes .... 2. In the past 30 days, have you actually had any thoughts of killing yourself? Yes.... previous suicidal attempts .... 3. Have you been thinking about how you might kill yourself? (!) Yes gun but doesn't have means, OD on prescriptions drugs or cut himself .... 4. Have you had these thoughts and some intention of acting on them? (!) Yes ...5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? (!) Yes ... 6A. Have you EVER done anything, started to do anything, or prepared to do anything to end your life? (!) Yes 6B. If Yes, how long ago did you do any of these things? (!) Yes More than three months ago ... Columbia Suicide Screening Calculated Risk Level High Risk. ..." Flowsheet review revealed Patient #16 was placed on constant observation at 2315. Review of "Other ED Notes" revealed a RN Note at 2320 that stated "Pt reports being in town for a little while relocated and has a new job. He reports for the past 2 days he is feeling suicidal after experiencing several panics (sic) attacks. He reports that his hands were shaking back and forth and has never done that before. He is alert and oriented with bilat (bilateral) chest expansion noted. No acute distress noted." Review revealed a "Adult Assessment of Risk for Suicide" was completed by a RN at 2330 and noted " ...Risk for Suicide Total Score ...24 ....Does patient have a plan to commit suicide? ... Yes .... Does patient have access to the means to Carry out suicide plan while in the hospital ... Yes .... Describe ....plans to cut wrist." Review of the "ED Provider Notes", on 01/03/2020 at 2312, revealed " ...HISTORY OF PRESENT ILLNESS ....presents to the ED with a Chief Complaint of Suicidal .... Subjective .... (Name) .... with a history of psychosis, bipolar disorder, anxiety, depression, schizophrenia, and substance abuse who presents to the ED for psychological evaluation of suicidal ideations. The pt reports he relocated here from (city) to 'get away from drugs' and two days ago he states he had a 'mental break down'. He states that he felt his whole body shaking and has not stopped shaking since. He reports that he doesn't want to live anymore and has a plan to cut himself, overdose on drugs, or shoot himself. He reports that he does not have a gun. He reports marijuana use today but denies other drugs in 7.5 months.... He denies hallucinations or homicidal ideations. He has no other complaints at this time .... REVIEW OF SYSTEMS ....Psychiatric/ Behavioral: Positive for dysphoric mood and suicidal ideas. Negative for self-injury ....PHYSICAL EXAM ....Psychiatric: He has a normal mood and affect. His behavior is normal. He expresses suicidal ideation. He expresses suicidal plans ...REEVALUATION Psychiatry evaluated patient. Recommends outpatient treatment. Patient with history of factitious disorder and patient has frequent emergency visits. He does not appear to be different from his baseline. He does not appear to be a threat to himself or others at this time. ..."

Review of ED Notes by a Psych RN (RN Psych Assessor) on 01/04/2020 at 0020 revealed " ...alert and oriented x4. Pt reports initially that he 'took a week off of work and came down here to visit friends and family.' He reports he has been living in (city). Pt reports he is living with a friend in (city). He is unable to keep his story straight and becomes flustered when confronted with that. Pt was released from (city) Jail on 12/17/19 after serving 2 months. None of his timelines fit this fact. He is vague as to whether or not he is suicidal. He actually reports that if he is discharged, he will 'just go to the next place', meaning another hospital. Pt reports he has not had any of his medications he was receiving in jail, which he reports were Depakote 1500 mg and Seroquel 400 mg. He reports the doctor at jail diagnosed him with Schizophrenia, Bipolar 1, Depression 1, and PTSD. Pt is not psychotic, nor is he homicidal. He is known to be homeless. When asked about collateral, he does not have a phone and states 'I got rid of it, because it was controlling my life'. He also reports he does not have contact numbers. Pt is currently laying back in a recliner, he has eaten a meal, and is watching TV. He does not appear to be in any distress. PMH includes Factitious Disorder, Substance Abuse, Adjustment Disorder, and Depression." Patient Care Timeline review revealed on 01/04/2020 at 0029 a Thought Assessment / Mental Health Assessment was completed on Patient #16. Review of the Thought Assessment revealed " ...Behavior: Fidgety; Cooperative Speech: Clear Thought Content: Impoverished Appearance: Disheveled Delusions: Not evident Hallucination Type: Denies Observed Emotional State: accepting Thought Process: Goal directed Judgment: Difficulty in problem solving; Poor decisions Mood: Anxious Affect (facial, voice or gestural behavior): Congruent Insight: Poor" Review of the Patient Care Timeline revealed an "Adult Assessment of Risk for Suicide" was completed 01/04/2020 at 0030 by the Psych RN Assessor which noted a suicide risk total score of 20. Review of the assessment revealed " ...Suicidal ideation: Intermittent or fleeting suicidal thoughts Suicidal Plan: None .... Current Morbid Thoughts: Intermittent Alcohol and/or Drug Use: Continual abuse Support Systems: Non available Coping Mechanisms: Predominantly destructive Behavioral Symptoms: One to two symptoms present Does patient have a plan to commit suicide? No Prior Suicidal Attempts: Past attempts of low lethality Lethality of Plan: None Elopement Risk: Low risk Contracts for Safety: Contracts but is ambivalent or guarded Reasons to Live/Hope: Wants things to change and has some hope, has future plans Behavioral Symptoms List: *Anxiety, *Impulsive Risk for suicide Total Score 20 Does the patient have access to the means to Carry out suicide plan while in the Hospital? No..." Flowsheet review revealed on 01/04/2020 at 0032 "...Psych Assessment Completed... ."

Review of ED Notes by a Psych CNA (Nurse Aide) on 01/04/2020 at 0830 revealed "Patient eating breakfast. Will dress for discharge when finished with breakfast." Review revealed Patient #16 discharged on 01/04/2020 at 0906. Record review did not indicate any further documentation of behavioral health or physician assessments, including suicide risk assessments, after 0032. DED record review revealed a document titled "AFTER VISIT SUMMARY"(AVS) which indicated personalized instructions could be found at the end of the document. Document review revealed a section labeled "Changes to Your Medication List ASK your doctor about these medications ...DEPAKOTE ...SEROQUEL ...". Document review revealed an "Instruction Section" that included a list of resources both inside and outside the immediate area but did not highlight any specific resources. Review of the "AFTER VISIT SUMMARY" did not reveal any specific information related to when or where to seek follow-up and/or to obtain needed medications.

Telephone interview, on 01/17/2020 at 1030, with the RN Psych Assessor revealed Patient #16 was known to the Psych Assessor and the presentation on 01/03/2020 was a typical presentation for the patient. Interview revealed there were inconsistencies in what the RN Psych Assessor heard from the patient and the doctor but could not recall what the inconsistencies were. In relation to the physician documentation that psych recommended outpatient, the RN Psych Assessor stated the assessors generally presented the case and talked it over with the doctor, but could not say if a recommendation was made. In relation to medications, interview revealed there was no way to verify medications during the night. When the patient was discharged, the RN Psych Assessor stated, a nurse (not the RN Psych Assessor) would go over the AVS. The RN Psych assessor indicated she separately went over resources and gave the patient a different form with more specific instructions. Interview revealed the form listed outpatient providers. The RN Psych Assessor stated one provider was highlighted and Patient #16 was instructed to to go to that outpatient provider the next morning. Interview revealed that form with specific instructions was not part of the patient's medical record.

Telephone interview with MD #2, a DED physician, on 01/16/2020 revealed when DED physicians order a Psych Assessment, they were ordering a RN psych assessment. Interview revealed the physicians medically cleared the patients, then sent them to the psych holding area. Interview revealed MD #2 used the RN psych assessor first, then if there were questions, would involve telepsych or another physician. Interview revealed MD #2 generally spoke with patients about medications, but in this case did not see in the record if that happened. Interview revealed MD #2 would not write prescriptions for psych meds because he wanted a provider managing the meds who knew the patient and would continue as the provider. MD #2 stated follow-up was generally recommended to occur in 24-48 hours. Interview revealed patients were typically reassessed before discharge to be sure everyone was still okay with the discharge. Interview revealed staff tried to document reassessments but not always. Interview revealed it seemed the outpatient team reassessed Patient #16 and thought it was okay to discharge.

Telephone interview with MD #3, the Psychiatry Medical Director, on 01/16/2020 at 1415, revealed psychiatric patients who arrived to the DED received the normal medical screening by the DED physician. Then, if it was determined that the patient appeared to be a primary psych patient, the DED physician could order a psych assessment with the RN Psych Assessor. The RN Psych Assessor gathered information from the patient, other sources, information on the petition for IVC or transfer needs, and then pulled all that into an assessment. The information was presented to the DED physician for decisions on what needed to happen related to care and treatment. Generally, MD #3 stated, the Psych Assessor and DED physician would have a conversation after which the RN Psych Assessor would write a report in the medical record. Interview revealed the Psych Assessors acted like Case Managers/ Social Workers, they completed an assessment and made recommendations to the ED physician. Interview revealed the ED physician could call for a face to face evaluation with either Telepsychiatry or a psychiatric provider. Interview revealed telepsychiatry was available 24 hours a day, 7 days a week. Interview revealed Telepsychiatry, per interview, was most often used when there was confusion or disagreement on whether a patient needed admission. MD #3 stated he expected Psych Assessors to document as much as was reasonable. Interview revealed they would not make or document decisions to admit or discharge patients. Follow-up interview on 01/17/2020 at 1125 revealed MD #3 did not see Patient #16 while in the ED, but reviewed the medical record. Interview revealed MD #3 had no concerns related to the patient's care and disposition in the ED.

In summary, there was not stabilizing treatment provided to either Patient #14 or #16. Patient #14 did not receive a diagnosis and no recommendations for treatment or follow-up were made. Related to Patient #16, there was no indication if the patient was evaluated again by a physician or Psych Assessor after the RN Psych Assessment was completed at 0032 until discharge. In the initial screening Patient #16 was stated to be high risk for suicide, and in the last suicide risk screening (at 0032) was a lower risk. It was noted the patient contracted for safety but was "ambivalent or guarded". The patient was stated to have "difficulty in problem solving", "poor decisions", and was noted to be "impulsive". There was no documentation in the record related to any discussion or evaluation of medications. Although interview revealed follow-up provider information was given, there was no medical record documentation noted of a provider or timing of follow-up for Patient #16 for care and medications.