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Based on staff interviews, record reviews, and review of the facility's policies, it was determined the facility failed to comply with 42 CFR 489.24(a)(1) and 42 CFR 489.24(d)(1) regarding not performing an appropriate medical screening examination (MSE) and not providing stabilizing treatment to a patient with an unstable, emergent condition for one (1) of twenty one (21) sampled patients, Patient #1, on 02/13/2021.

Refer to findings in Tag A-2406 and A-2407.

Based on interview, record review, Emergency Medical Services (EMS) Run Sheet review, review of the facility's Self-Report Sentinel Event, and review of the facility's policies, it was determined the facility failed to ensure all individuals that presented to the Emergency Department (ED) seeking assistance, received an appropriate medical screening exam that would accurately determine if there was an acute, emergency medical condition that required treatment, for one (1) of twenty-one (21) sampled patients, Patient #1.

Patient #1 presented to the Emergency Department (ED), on 02/13/2021 at 1:45 AM, via Emergency Medical Services (EMS) with the complaint of a suicide attempt by jumping off a bridge. The patient was assessed and sent to Emergency Psychiatric Services (EPS), a locked unit located down the hall from the ED. Patient #1 was intoxicated and was allowed to sober up before final evaluations were performed. Despite the suicide attempt and, per the assessment, when intoxicated (he/she drank daily, to the point of passing out) he/she might be at risk of engaging in dangerous behaviors to harm self, Patient #1 was determined not to have an acute, emergent condition, but a chronic condition. Patient #1 was determined to be stable for discharge to self (not a threat to self or others), on 02/13/2021 at 10:46 AM.

Patient #1 again presented to the ED (first revisit/second visit), on 02/13/2021 at 1:15 PM, ambulatory, and stated he/she had suicidal ideation (SI) of jumping from a parking garage but just "couldn't do it." Patient #1 requested to be "put in a nuthouse for a long time." Despite the patient's continued SI, request for hospitalization, and, per the assessment, when intoxicated (he/she drank daily, to the point of passing out) he/she might be at risk of engaging in dangerous behaviors to harm self, EPS staff assessed Patient #1 and determined there had been no changes in his/her condition from the first encounter, and the patient was stable for discharge (not a threat to self or others). Patient #1 was discharged to self, on 02/13/2021 at 2:25 PM.

Patient #1 again presented to the ED, on 02/13/2021 at 8:04 PM, via EMS receiving cardiopulmonary resuscitation. The EMS run sheet, dated 02/13/2021, Incident #E21015269, reported the patient had been found pulseless by bystanders at the base of an open area to a parking structure, and he/she was a suspected long fall from the parking structure with an unknown intent, since the event was not witnessed. Patient #1 had severe traumatic head and thoracic injuries, and despite resuscitative effort by the facility, Patient #1 was pronounced dead, on 02/13/2021 at 8:09 PM. A facility investigation report, dated 02/16/2021, revealed a nearby hospital (approximately 0.6 miles from the facility) had informed the facility they had video footage of someone jumping from their parking garage, which matched the address where EMS responded to the incident with Patient #1.

The findings include:

Review of the facility's policy titled, "EMTALA: Treatment and Transfer of Individuals in Need of Emergency Medical Services," Number 840-0004, revised 05/18/2020, revealed the purpose statement required the facility to provide an appropriate medical screening exam (MSE) to any individual, to provide stabilizing treatment for any emergency medical condition (EMC), discovered in a MSE, and either admit the patient, discharge the patient, or provide an appropriate transfer of the patient.

Continued review of the policy revealed it defined an EMC as a medical condition manifesting itself by acute symptoms of sufficient severity (including psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. The policy stated, with respect to an individual with psychiatric symptoms, the EMC addressed the acute psychiatric or acute substance abuse symptoms that were manifested; or that individuals were expressing suicidal or homicidal thoughts or gestures and were determined to be a threat to self or others. In addition, review of the policy revealed that to be considered a "stable discharge," for an individual with a psychiatric condition, the Physician would determine if the patient was no longer considered to be a threat to self or others.

Review of the facility's policy titled, "EMTALA: Medical Screening Exam," Number 840-0002, revised 05/18/2020, revealed the purpose was to establish guidelines for providing an appropriate MSE and complete any necessary stabilizing treatment. Further review revealed that for individuals with psychiatric symptoms, the medical record should include the MSE and a psychiatric screening exam. The psychiatric MSE included an assessment of suicide/homicide attempt or risk, orientation, and assaultive behavior that indicated a danger to self or others.

Review of the facility's Self-Report Sentinel Event documentation, dated 03/31/2021, revealed a time-line of events that included summaries of Physician documentation and Mental Status Exams. The facility determined, during each of Patient #1's visits, on 02/13/2021, he/she was appropriately evaluated. Per the report, although he/she had voiced suicidal ideation, on 02/13/2021 at 1:45 AM, and a plan, he/she spoke multiple times of not being able to carry out the plan. The report stated Patient #1 was future focused, especially when it came to securing housing.

1. Review of the Emergency Department (ED) log, for 02/13/2021, revealed Patient #1 arrived at 1:45 AM. Review of Patient #1's medical record revealed the patient had presented to the facility via Emergency Medical Services (EMS) for a Suicidal Ideation (SI) attempt by jumping off a bridge at I-65, as witnessed by a bystander. It was documented in Physician #2's notes that Patient #1 had stated he/she had drunk a pint to a fifth of whiskey to jump off the bridge. Moreover, the ED Physician Notes, dated 02/13/2021 at 2:44 AM, revealed Patient #1 stated he/she had a long, predetermined plan to commit suicide, and he/she finally got the chance today. The patient stated he/she had no reasons to live.

Review of the EMS Run Sheet, dated 02/13/2021, Incident Number E21015009, revealed Patient #1 was in Police handcuffs for his/her safety, when they arrived. Per the run sheet, the Police stated Patient #1 was trying to jump off the bridge when the Police arrived, and he/she had to be restrained in handcuffs. The run sheet also stated Patient #1 had attempted to jump off the stretcher and run away before he/she could be secured to the stretcher. In addition, during transport, the run sheet stated Patient #1 had attempted to choke himself/herself with the safety straps of the stretcher.

Repeated attempts to obtain the Police Report, from the 02/13/2021 incident with Patient #1, were unsuccessful.

Review of Patient #1's medical record revealed a security hold order was given, on 02/13/2021 at 1:59 AM. The purpose of a security hold was to prevent a patient, considered to be a danger to themselves or others, from unauthorized departure. At that time, it was documented a Security Guard was present at Patient #1's bedside.

Review of Patient #1's ED record revealed, on 02/13/2021 at 2:17 AM, an MSE and review of systems (ROS) was completed in the ED that was unremarkable, except for Patient #1's blood alcohol level (BAL), which was one hundred thirty-nine (139) milligrams per deciliter (mg/dL). Per review of the internet source https://awareawakealive.org, an individual with a BAL at this level could experience emotional swings and depression; and motor function, speech, and judgment were severely affected. Per the record, blood work was positive for the presence of Benzodiazepines (classified as a psychoactive, depressant drug used for anxiety, sleep and seizures). For reference, a blood alcohol level of 80 (mg/dL) or above was determined to be driving under the influence in the State of Kentucky, according to Kentucky Revised Statute (KRS) 189A.010.

Review of Patient #1's medical record revealed, on 02/13/2021 at 7:02 AM, Patient #1 had been cleared medically, and a consult to Emergency Psychiatric Services (EPS) was ordered. Patient #1 was then transferred to EPS, a locked unit, down the hall from the ED.

Review of the EPS Evaluation Note, dated 02/13/2021, signed at 11:10 AM, revealed Patient #1 was assessed in EPS by Physician #2 with a mental screening exam and a review of systems (ROS), which were completed after he/she had sobered up (a repeat BAL was not ordered because staff used a formula to ascertain when patients were clinically sober to be interviewed). In addition, an interview with Physician #1, on 07/01/2021 at 11:40 AM, revealed a patient was not evaluated when intoxicated; an initial evaluation was completed, and then another, when the patient was deemed sober. Physician #1 stated it was unethical to evaluate the patient when he/she was impaired.

Continued review of Physician #2's EPS Evaluation Note, dated 02/13/2021, signed at 11:10 AM, revealed Patient #1 was brought in by ambulance after a bystander noticed him/her on a bridge. The patient's BAL was 139 (legally intoxicated). Patient #1 was cleared medically in the ED and referred to EPS. Further review revealed Patient #1 stated he/she had been released from a State Hospital in November 2020 after the facility would not change his/her situation or do his/her laundry. The State Hospital had sent him/her in a cab to the city where the facility was located for a substance abuse program at the local Salvation Army. Patient #1 was also on a waiting list for housing, but it was documented that he/she "may have messed that up because they caught me drinking and smoking." It was documented he/she drank daily, to the point of passing out.

Continued review of the EPS Evaluation Note, dated 02/13/2021 at 11:10 AM, revealed Patient #1 stated he/she had not attempted suicide before and denied that his/her many past hospitalizations had been beneficial. Physician #2 documented that Patient #1's suicidal ideation (SI) appeared to be situational and, at the end of the interview, the patient asked how long it would be before he/she "got a bed." Review of Physician #2's continued documentation revealed Patient #1 was not psychotic, but had conditional, chronic ("all the time, for as long as I can remember") suicidal ideation, and prior to 02/13/2021, there was no history of suicide attempts. Per the evaluation, Patient #1 did not appear to benefit from admission and did not meet inpatient criteria. The Physician stated Patient #1 needed substance use treatment and mental health counseling, which could be met outside of a hospital setting. In addition, the Physician stated he/she was receiving medications from a resource center and needs were being met outside of a hospital setting. The plan was to discharge Patient #1.

Continued review of Patient #1's EPS Evaluation Note, dated 02/13/2021 at 11:10 AM, completed by Physician #2, revealed the Review of Systems (ROS) and Physical Exam (PE) were unremarkable. Review of the History of Present Illness and Pertinent Medical, Family, and Social History revealed Patient #1 went to a local resource center for mental health treatment and antidepressants (low dose Seroquel and Selective Serotonin Reuptake Inhibitor's (SSRI, a class of drugs used to treat major depressive disorders and anxiety disorders) which he/she did not take because of drinking every day. The Evaluation Note also stated homelessness was a major stressor for Patient #1.

Continued review of Patient #1's EPS Evaluation Note, dated 02/13/2021 at 11:10 AM, by Physician #2, revealed Patient #1 had considered jumping off bridges and buildings several times, self-rescued most often, and had not required medical care for prior attempts. Further review of the Mental Status Exam, in the Note, revealed Patient #1's concentration and attention was good, and he/she was oriented to person, place, and time; his/her mood/affect was irritable and dysthymic (persistent depressive disorder); he/she had no delusions and limited insight; his/her judgment was fair and advocated for self and knew how to obtain needed resources; and suicidal ideation was present, but chronic, with a chronic plan to jump from a bridge; and was future oriented.

Continued review of Patient #1's EPS Evaluation Note, dated 02/13/2021 at 11:10 AM, by Physician #2, of the Assessment and Plan, revealed the patient was intoxicated upon arrival to the ED/EPS; but he/she was interviewed when clinically sober. Per assessment, on interview, he/she was forthcoming, appeared irritated, stating no one ever helped him/her, despite naming numerous community resources in which he/she was currently involved and despite naming resources that were previously offered during numerous other hospitalizations for the same complaint at other facilities. Continued review of Physician #2's documentation revealed Patient #1 advocated for himself/herself throughout the interview and demonstrated the ability to find ways to meet his/her own needs and intended to continue to do so. Per the assessment, Patient #1 stated that having housing would make his/her life better, and he/she had been working with a resource center to obtain housing. Per the assessment, Patient #1 reported chronic suicidal ideation with chronic plans to jump off a bridge, had never done so, always self-rescued or was rescued when contemplating jumping. In addition, his/her most recent attempt occurred when intoxicated. Per the assessment, when sober, Patient #1 continued to voice suicide consistent with a chronic level of suicidal ideation but was notably future oriented for obtaining a hospital bed and was advocating for self appropriately. Per the assessment, he/she did not demonstrate dangerous behaviors during the time in EPS. However, per the assessment, when intoxicated, he/she might be at risk of engaging in dangerous behaviors, and previously the Note stated Patient #1 drank daily, to the point of passing out but was not interested in treatment for substance abuse that would address the risk. Further, per the assessment, in Patient #1's current sober condition, he/she did not appear to represent a risk to himself/herself or others. Per the plan, Patient # 1 did not meet admission criteria and would be discharged with a resource packet and a recommendation that he/she return to the resource center to continue mental health care and substance abuse counseling.

Review of the Emergency Psychiatry Evaluation, dated 02/13/2021 at 10:18 AM, signed by the Licensed Clinical Social Worker (LCSW) revealed Patient #1 was assessed as being at a low risk for suicide. The rationale for the low risk was that he/she had suicidal ideations while intoxicated, no history of prior attempts, and stated he/she was unable to bring self to follow through. According to the evaluation, Patient #1's suicidal ideation was situational, chronic, and vague. The diagnostic impression was alcohol-induced disorder with alcohol induced mood disorder.

2. Review of Patient #1's first return/second visit to EPS, on 02/13/2021 at 1:15 PM, revealed the ED Nursing Record assessed the acuity level of the visit as a three (3), which indicated urgent. It was documented Patient #1 was ambulatory and stated, after the previous discharge, less than three (3) hours ago, he/she went to a parking garage and tried to jump from seven (7) stories, but he/she could not do it. The patient stated he wanted to be locked away forever. In addition, the EPS Assessment, part of the Nursing Record, done by RN #1, revealed Patient #1 was asked several questions from the Columbia-Suicide Severity Rating Scale (CSSRS). Patient #1 answered "yes", he/she wished to be dead; "yes", he/she had suicidal thoughts; "yes", he/she had suicidal thoughts with a method; "yes", he/she had suicide intent with a specific plan; and "yes", he/she had suicide behavior. The record also revealed his/her level of observation for suicide prevention was "Line of Sight", and at 1:22 PM, a security hold was put in place.

Review of the EPS Evaluation Note, dated 02/13/2021 at 1:30 PM, by Physician #2, revealed Patient #1 returned to EPS within three (3) hours of discharge, continuing to voice SI. The Physician reported the patient once again considered jumping from a parking garage, but could not do it. Per the Note, Patient #1 was seeking hospitalization and asked to be "put in a nuthouse for a long time." The Note revealed the patient had not reviewed his/her discharge instructions from the first visit, which included outpatient treatment and resources information. In the Note, it was reported Patient #1 was once again resistant to solutions offered to address his/her chronic depressed mood and lacked insight into the effect of alcohol use on his/her mood and behavior. In addition, the Note documented the patient was future-oriented and advocating for his/her needs throughout the interview. In addition, this Note did not reveal it had been discussed with the LCSW.

Continued review of Patients #1's EPS Evaluation Note, dated 02/13/2021 at 1:30 PM, by Physician #2 for ROS documented "No physical complaints." The PE documented the patient was awake, alert, and in no acute distress. Review of the Assessment and Plan revealed Patient #1 presented again to EPS, within three (3) hours of the previous discharge with the same complaint. Per the Note, Patient #1 was seeking admission and hospitalization for a long time and was struggling with homelessness. Per the Note, the patient was chronically suicidal with a chronic plan to jump. Per the Note, Physician #2 revealed, even since the last evaluation, the morning of 02/13/2021, he/she had shown that while he/she did consider jumping from time-to-time, he/she quickly reconsidered or self-rescued. Physician #2 also documented, when the patient was intoxicated, he/she might engage in dangerous behaviors, and previously the Note stated Patient #1 drank daily, to the point of passing out, but was not interested in treatment for substance abuse that would address the risk. Per the Note, Physician #2 documented, in the patient's current sober condition, he/she did not represent a danger to self or others. Per the Note, the patient did not meet criteria for inpatient admission, and the team agreed that the patient be discharged with a recommendation that he/she return to the outpatient provider for mental health care and seek treatment for alcohol use. Patient #1 was discharged again, on 02/13/2021 at 2:25 PM.

There was no documented evidence of an additional Emergency Psychiatry Evaluation by the LCSW, with an updated suicide risk assessment for this visit.

3. Review of Patient #1's medical record for his/her second return to the facility, on 02/13/2021 at 8:04 PM, revealed he/she was brought in via ambulance after being found down and pulseless with a pool of blood around his/her face. It was documented that Patient #1 had received fifteen (15) minutes of pre-facility advanced cardiac life support (ACLS). No pulse was regained after three (3) rounds of cardiopulmonary resuscitation (CPR) in the ED, and the patient was pronounced dead at 8:09 PM. The record stated Patient #1 had gross facial trauma. Further review of the Death Notification revealed Patient #1's cause of death was traumatic brain injury with cardiac arrest.

Review of the EMS run sheet, dated 02/13/2021, Incident Number E21015269, revealed Patient #1 was found at the bottom level of a parking structure by passing bystanders. In addition, it stated due to the location of the patient at the base of an open area to the parking structure, the patient was a suspected long fall from the parking structure.

Interview with EPS RN #1, on 07/01/2021 at 10:40 AM, revealed she cared for Patient #1, on 02/13/2021, but was unable to remember specifics. She had been certified in psychiatric (psych) nursing and had twenty (20) years of psych experience. The kinds of assessments done in EPS included reports from EMS and the Police, and the RN did a full triage. She stated the triage nurse in the ED would assess patients with a psychiatric complaint, and if they were cleared medically, Security would transport to the EPS for evaluation and treatment. RN #1 stated the decision to admit or discharge patients was a collaborative effort between the provider and social worker. RN #1 was the nurse that completed the EPS Assessment on the second visit with a presentation time of 1:15 PM.

Interview with EPS RN #2, on 07/01/2021 at 11:00 AM, revealed he cared for Patient #1, on 02/13/2021, and remembered Patient #1 vaguely, nothing specific. He stated when a patient came to EPS, our goal was to keep them safe, with an evaluation and appropriate resources obtained. He stated patients would be evaluated when intoxicated, and there was a formula the providers used to determine when a patient was clinically sober. Providers would do an initial evaluation, and then another, when the patient was sober. RN #2 stated he received unit specific education for EPS.

Interview with ED RN #3, on 07/01/2021 at 11:11 AM, revealed she triaged patients in the ED, and staff rotated the task. If a patient was brought in by EMS with positive SI, the patient was immediately placed on a security hold. She stated the patient could not leave until a provider saw he/she, and the hold was dropped. She stated if someone tried to leave, staff would try to talk with the patient to get them to stay, but if he/she were adamant, staff would have to restrain the patient. RN #3 stated report on the patient was called to EPS, and then the patient was escorted to EPS with Security. In addition, she said the process was if a patient was going straight to EPS and bypassing the ED when there was only a psych complaint, the patient was asked if he/she had suicidal or homicidal ideations. Further, she stated if the answer was "yes," the triage RN placed the patient on a hold, and Security walked them to EPS.

Interview with ED RN #4, on 07/01/2021 at 11:25 AM, revealed he triaged patients at times, and triage nurses' responsibilities included getting report from EMS or asking questions about the patients' chief complaint. He stated Registration took the initial information unless the patient had chest pain or stroke symptoms. He stated initial screening was completed, and further questions were asked when necessary. All patients were screened to ensure there was no medical complaint along with the psychiatric complaint; and, if no medical complaint, the patient would be transferred to EPS.

Interview with the Licensed Clinical Social Worker (LCSW), on 07/01/2021 at 11:40 AM, revealed she worked exclusively in EPS. Requirements to work in EPS required her being a LCSW and receiving extra education and certification. Continued interview revealed she worked for an organization that provided mental health services in EPS. When asked how she decided a patient was ready for discharge, she stated a patient must meet all four (4) criteria for hospitalization, which included severe and persistent mental illness, must be at imminent risk for self-harm, previous hospitalizations must have been beneficial, and hospitalization should be the least restrictive treatment. When asked to explain the criteria, she stated many things were taken into account, such as: was the patient psychotic without a grasp of reality; history of SI attempts (prior to 02/13/2021, there were no documented, verbalized attempts by Patient #1), recent hospitalization, and if the hospital stay had benefited the patient, i.e. had the patient improved. Further interview revealed she was also present for Patient #1's second visit at 1:15 PM, and there were no changes from her assessment on the first visit. However, there is no documented evidence of the LCSW assessing Patient #1 during his second visit (first revisit) with an Emergency Psychiatry Evaluation.

Continued interview with Physician #1 (attending), on 07/01/2021 at 11:40 AM, revealed she worked exclusively in EPS the facility had a lot of patients that said things in the moment or out of distress, but when one did the actual evaluation, they might not present as a harm to themselves. Physician #1 stated it was hard to describe on paper the patient's body language and such, which could affect the interpretation of what the patient said.

Interview with Physician #2, on 07/01/2021 at 12:04 PM, revealed she remembered Patient #1. She was scheduled on-call for that shift in EPS. She stated Patient #1 came in, brought in by EMS from the bridge, and he/she had been thinking about jumping. She stated Patient #1 was assessed, and the patient did not appear to have the intent to end his/her life. Physician #2 stated she saw the patient again on the second visit, stating he/she had again thought about jumping but could not do it and requested hospitalization for a long time. Physician #2 stated the patient was dealing with stressors: homelessness, alcoholism, and being in an unfamiliar city. Physician #2 reported he/she wanted to be admitted to the hospital to have a place to stay. She stated the facility did not admit to psych areas for a place to stay. Physician #2 stated if she had thought for one minute that he/she was a harm to himself/herself, she would not have discharged him/her either time. The interview ended by Physician #2 stating, during the sober evaluation of the first and second visit, Patient #1 had shown future orientation, thinking about his/her life in the future and did not have an intent on ending his/her life.

Interview with the Executive Director of Quality and Safety (EDQS), on 07/02/2021 at 1:31 PM, revealed she was kept apprised of the investigation progress. She explained that the SWARM/Root Cause Analysis process was the process in which an event was discussed/analyzed for process and/or system improvements. She stated the facility did an investigation. Per interview with the EDQS, there was not a policy/process on voluntary admissions; and the Mental Health Exam drove both the involuntary/voluntary admission process, not the fact that someone came in court-ordered or walked in off the street, requesting to be admitted. She further stated the Root Cause Analysis was determined in the facility self-report Sentinel Event documentation.

Based on interview, record review, review of Kentucky Revised Statutes (KRS) 202A, and review of the facility's policies, it was determined the facility failed to ensure all individuals that presented to the Emergency Department (ED) with an emergent condition, received stabilizing medical treatment, for one (1) of twenty-one (21) sampled patients, Patient #1.

Patient #1 presented to the Emergency Department (ED), on 02/13/2021 at 1:45 AM, via Emergency Medical Services (EMS) with the complaint of a suicide attempt by jumping off a bridge. The patient was assessed and sent to Emergency Psychiatric Services (EPS), a locked unit located down the hall from the ED. Patient #1 was intoxicated and was allowed to sober up before final evaluations were performed. Patient #1 was determined to be stable for discharge to self, on 02/13/2021 at 10:46 AM. The only treatment received in the EPS was a physical examination, review of systems, mental status exam, Emergency Psychiatric examination, and discharge instructions for the patient to continue to use the same resources he/she already had, on an outpatient basis. There was no documented evidence the outpatient resource center used by the patient for mental health issues was contacted about the patient for an immediate follow-up visit after discharge. The patient was only instructed to follow-up in two (2) to three (3) days.

Patient #1 again presented to the ED, on 02/13/2021 at 1:15 PM, ambulatory, and stated he/she had suicidal ideation (SI) of jumping from a parking garage but just "couldn't do it." Patient #1 requested to be "put in a nuthouse for a long time." Staff assessed Patient #1, but did not do an Emergency Psychiatry Evaluation by the LCSW, and determined there had been no changes in his/her condition from the first encounter and discharged the patient to self, on 02/13/2021 at 2:25 PM, with the same discharge instructions which the patient had not reviewed from the first visit and additional discharge instructions on Emergency Awareness and Preventive Care. Again, there was no documented evidence the outpatient resource center used by the patient for mental health issues was contacted about the patient for an immediate follow-up visit after discharge. The patient was only instructed to follow-up in two (2) to three (3) days with the original discharge instructions.

Patient #1 again presented to the ED via EMS, on 02/13/2021 at 8:04 PM. The patient had been found pulseless at the bottom of a parking garage, and after resuscitative efforts, the patient expired, at 8:09 PM, from traumatic brain injury and cardiac arrest.

The findings include:

Review of the facility's policy titled, "EMTALA: Treatment and Transfer of Individuals in Need of Emergency Medical Services," Number 840-0004, revised 05/18/2020, revealed the purpose statement required the facility to provide an appropriate medical screening exam (MSE) to any individual, to provide stabilizing treatment for any emergency medical condition (EMC), discovered in a MSE, and either admit the patient, discharge the patient, or provide an appropriate transfer of the patient.

Continued review of the policy revealed that it defined an EMC as a medical condition manifesting itself by acute symptoms of sufficient severity (including psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. The policy stated, with respect to an individual with psychiatric symptoms, the EMC addressed the acute psychiatric or acute substance abuse symptoms that were manifested; or that individuals were expressing suicidal or homicidal thoughts or gestures and were determined to be a threat to self or others. In addition, review of the policy revealed that to be considered a "stable discharge," for an individual with a psychiatric condition, the Physician would determine if the patient was no longer considered to be a threat to self or others.

Review of the facility's policy titled, "EMTALA: Medical Screening Exam," Number 840-0002, revised 05/18/2020, revealed the purpose was to establish guidelines for providing an appropriate MSE and complete any necessary stabilizing treatment. Further review revealed that for individuals with psychiatric symptoms, the medical record should include the MSE and a psychiatric screening exam. The psychiatric MSE included an assessment of suicide/homicide attempt or risk, orientation, and assaultive behavior that indicated a danger to self or others.

Review of KRS 202A.026, Criteria for Involuntary Hospitalization, effective date 07/01/1982 revealed no person shall be involuntarily hospitalized unless such person was a mentally ill person (1) who presented a danger or threat of danger to self, family, or others as a result of the mental illness; (2) who could reasonably benefit from treatment; and (3) for whom hospitalization was the least restrictive alternative mode of treatment.

1. Review of the Emergency Department (ED) log, for 02/13/2021, revealed Patient #1 arrived at 1:45 AM. Review of Patient #1's medical record revealed the patient had presented to the facility via Emergency Medical Services (EMS) for a Suicidal Ideation (SI) attempt by jumping off a bridge at I-65, as witnessed by a bystander. It was documented in Physician #2's notes that Patient #1 had stated he/she had drunk a pint to a fifth of whiskey to jump off the bridge. Moreover, the ED Physician Notes, dated 02/13/2021 at 2:44 AM, revealed Patient #1 stated he/she had a long, predetermined plan to commit suicide, and he/she finally got the chance today. The patient stated he/she had no reasons to live.

Review of the EMS Run Sheet, dated 02/13/2021, Incident Number E21015009, revealed Patient #1 was in Police handcuffs for his/her safety, when they arrived. Per the run sheet, the Police stated Patient #1 was trying to jump off the bridge when the Police arrived, and he/she had to be restrained in handcuffs. The run sheet also stated Patient #1 had attempted to jump off the stretcher and run away before he/she could be secured to the stretcher. In addition, during transport, the run sheet stated Patient #1 had attempted to choke himself/herself with the safety straps of the stretcher.

Repeated attempts to obtain the Police Report, from the 02/13/2021 incident with Patient #1, were unsuccessful.

Review of Patient #1's medical record revealed a security hold order was given, on 02/13/2021 at 1:59 AM. The purpose of a security hold was to prevent a patient, considered to be a danger to themselves or others, from unauthorized departure. At that time, it was documented a Security Guard was present at Patient #1's bedside.

Review of Patient #1's ED record revealed, on 02/13/2021 at 2:17 AM, an MSE and review of systems (ROS) was completed in the ED that was unremarkable, except for Patient #1's blood alcohol level (BAL), which was one hundred thirty-nine (139) milligrams per deciliter (mg/dL). Per review of the internet source https://awareawakealive.org, an individual with a BAL at this level could experience emotional swings and depression; and motor function, speech, and judgment were severely affected. Per the record, blood work was positive for the presence of Benzodiazepines (classified as a psychoactive, depressant drug used for anxiety, sleep and seizures). For reference, a blood alcohol level of 80 (mg/dL) or above was determined to be driving under the influence in the State of Kentucky, according to Kentucky Revised Statute (KRS) 189A.010.

Review of Patient #1's medical record revealed, on 02/13/2021 at 7:02 AM, Patient #1 had been cleared medically, and a consult to Emergency Psychiatric Services (EPS) was ordered. Patient #1 was then transferred to EPS, a locked unit, down the hall from the ED.

Review of the EPS Evaluation Note, dated 02/13/2021, signed at 11:10 AM, revealed Patient #1 was assessed in EPS by Physician #2 with a mental screening exam and a review of systems (ROS), which were completed after he/she had sobered up (a repeat BAL was not ordered because staff used a formula to ascertain when patients were clinically sober to be interviewed). In addition, an interview with Physician #1, on 07/01/2021 at 11:40 AM, revealed a patient was not evaluated when intoxicated; an initial evaluation was completed, and then another, when the patient was deemed sober. Physician #1 stated it was unethical to evaluate the patient when he/she was impaired.

Continued review of Physician #2's EPS Evaluation Note, dated 02/13/2021, signed at 11:10 AM, revealed Patient #1 was brought in by ambulance after a bystander noticed him/her on a bridge. The patient's BAL was 139 (legally intoxicated). Patient #1 was cleared medically in the ED and referred to EPS. Further review revealed Patient #1 stated he/she had been released from a State Psychiatric Hospital in November 2020 after the facility would not change his/her situation or do his/her laundry. The State Psychiatric Hospital had sent him/her in a cab to the city where the facility was located for a substance abuse program at the local Salvation Army. Patient #1 was also on a waiting list for housing, but it was documented that he/she "may have messed that up because they caught me drinking and smoking." It was documented he/she drank daily, to the point of passing out.

Continued review of the EPS Evaluation Note, dated 02/13/2021 at 11:10 AM, revealed Patient #1 stated he/she had not attempted suicide before and denied that his/her many past hospitalizations had been beneficial. Physician #2 documented that Patient #1's suicidal ideation (SI) appeared to be situational and, at the end of the interview, the patient asked how long it would be before he/she "got a bed." Review of Physician #2's continued documentation revealed Patient #1 was not psychotic, but had conditional, chronic ("all the time, for as long as I can remember") suicidal ideation, and prior to 02/13/2021, there was no history of suicide attempts. Per the evaluation, Patient #1 did not appear to benefit from admission and did not meet inpatient criteria. The Physician stated Patient #1 needed substance use treatment and mental health counseling, which could be met outside of a hospital setting. In addition, the Physician stated he/she was receiving medications from a resource center and needs were being met outside of a hospital setting.

Continued review of Patient #1's EPS Evaluation Note, dated 02/13/2021 at 11:10 AM, completed by Physician #2, revealed the Review of Systems (ROS) and Physical Exam (PE) were unremarkable. Review of the History of Present Illness and Pertinent Medical, Family, and Social History revealed Patient #1 went to a local resource center for mental health treatment and antidepressants (low dose Seroquel and Selective Serotonin Reuptake Inhibitor's (SSRI, a class of drugs used to treat major depressive disorders and anxiety disorders) which he/she did not take because of drinking every day. The Evaluation Note also stated homelessness was a major stressor for Patient #1.

Continued review of Patient #1's EPS Evaluation Note, dated 02/13/2021 at 11:10 AM, by Physician #2, revealed Patient #1 had considered jumping off bridges and buildings several times, self-rescued most often, and had not required medical care for prior attempts. Further review of the Mental Status Exam, in the Note, revealed Patient #1's concentration and attention was good, and he/she was oriented to person, place, and time; his/her mood/affect was irritable and dysthymic (persistent depressive disorder); he/she had no delusions and limited insight; his/her judgment was fair and advocated for self and knew how to obtain needed resources; and suicidal ideation was present, but chronic, with a chronic plan to jump from a bridge; and was future oriented.

Continued review of Patient #1's EPS Evaluation Note, dated 02/13/2021 at 11:10 AM, by Physician #2, of the Assessment and Plan, revealed the patient was intoxicated upon arrival to the ED/EPS; but he/she was interviewed when clinically sober. Per assessment, on interview, he/she was forthcoming, appeared irritated, stating no one ever helped him/her, despite naming numerous community resources in which he/she was currently involved and despite naming resources that were previously offered during numerous other hospitalizations for the same complaint at other facilities. Continued review of Physician #2's documentation revealed Patient #1 advocated for himself/herself throughout the interview and demonstrated the ability to find ways to meet his/her own needs and intended to continue to do so. Per the assessment, Patient #1 stated that having housing would make his/her life better, and he/she had been working with a resource center to obtain housing. Per the assessment, Patient #1 reported chronic suicidal ideation with chronic plans to jump off a bridge, had never done so, always self-rescued or was rescued when contemplating jumping. In addition, his/her most recent attempt occurred when intoxicated. Per the assessment, when sober, Patient #1 continued to voice suicide consistent with a chronic level of suicidal ideation but was notably future oriented for obtaining a hospital bed and was advocating for self appropriately. Per the assessment, he/she did not demonstrate dangerous behaviors during the time in EPS. However, per the assessment, when intoxicated, he/she might be at risk of engaging in dangerous behaviors, and previously the Note stated Patient #1 drank daily, to the point of passing out, but was not interested in treatment for substance abuse that would address the risk. Further, per the assessment, in Patient #1's current sober condition, he/she did not appear to represent a risk to himself/herself or others. Per the plan, Patient # 1 did not meet admission criteria and would be discharged with a resource packet and a recommendation that he/she return to the resource center to continue mental health care and substance abuse counseling. There was no documentation the facility contacted the outpatient resource center for follow-up with an immediate appointment. Patient #1's discharge instructions, signed by the patient, on 02/13/2021 at 10:55 AM, told the patient to contact the resource center in two (2) to three (3) days. The Note also revealed the findings had been discussed with the LCSW.

Review of the Emergency Psychiatry Evaluation, dated 02/13/2021 at 10:18 AM, signed by the Licensed Clinical Social Worker (LCSW) revealed Patient #1 was assessed as being at a low risk for suicide. The rationale for the low risk was that he/she had suicidal ideations while intoxicated, no history of prior attempts, and stated he/she was unable to bring self to follow through. According to the evaluation, Patient #1's suicidal ideation was situational, chronic, and vague. The diagnostic impression was alcohol-induced disorder with alcohol induced mood disorder.

2. Review of Patient #1's second visit, or first return visit, to EPS, on 02/13/2021 at 1:15 PM, revealed the ED Nursing Record assessed the acuity level of the visit as a three (3), which indicated urgent. It was documented Patient #1 was ambulatory and stated, after the previous discharge, less than three (3) hours ago, he/she went to a parking garage and tried to jump from seven (7) stories, but he/she could not do it. The patient stated he wanted to be locked away forever. In addition, the EPS Assessment, part of the Nursing Record, done by RN #1, revealed Patient #1 was asked several questions from the Columbia-Suicide Severity Rating Scale (CSSRS). Patient #1 answered "yes", he/she wished to be dead; "yes", he/she had suicidal thoughts; "yes", he/she had suicidal thoughts with a method; "yes", he/she had suicide intent with a specific plan; and "yes", he/she had suicide behavior. The record also revealed his/her level of observation for suicide prevention was "Line of Sight", and at 1:22 PM, a security hold was put in place.

Review of the EPS Evaluation Note, dated 02/13/2021 at 1:30 PM, by Physician #2, revealed Patient #1 returned to EPS within three (3) hours of discharge, continuing to voice SI. The Physician reported the patient once again considered jumping from a parking garage, but could not do it. Per the Note, Patient #1 was seeking hospitalization and asked to be "put in a nuthouse for a long time." The Note revealed the patient had not reviewed his/her discharge instructions from the first visit, which included outpatient treatment and resources information. In the Note, it was reported Patient #1 was once again resistant to solutions offered to address his/her chronic depressed mood and lacked insight into the effect of alcohol use on his/her mood and behavior. In addition, the Note documented the patient was future-oriented and advocating for his/her needs throughout the interview. In addition, this Note did not reveal it had been discussed with the LCSW.

Continued review of Patients #1's EPS Evaluation Note, dated 02/13/2021 at 1:30 PM, by Physician #2 for ROS documented "No physical complaints." The PE documented the patient was awake, alert, and in no acute distress. Review of the Assessment and Plan revealed Patient #1 presented again to EPS, within three (3) hours of the previous discharge with the same complaint. Per the Note, Patient #1 was seeking admission and hospitalization for a long time and was struggling with homelessness. Per the Note, the patient was chronically suicidal with a chronic plan to jump. Per the Note, Physician #2 revealed, even since the last evaluation, the morning of 02/13/2021, he/she had shown that while he/she did consider jumping from time-to-time, he/she quickly reconsidered or self-rescued. Physician #2 also documented, when the patient was intoxicated, he/she might engage in dangerous behaviors, and previously the Note stated Patient #1 drank daily, to the point of passing out, but was not interested in treatment for substance abuse that would address the risk. Per the Note, Physician #2 documented, in the patient's current sober condition, he/she did not represent a danger to self or others. Per the Note, the patient did not meet criteria for inpatient admission, and the team agreed that the patient be discharged with a recommendation that he/she return to the outpatient provider for mental health care and seek treatment for alcohol use. Patient #1 was discharged again, on 02/13/2021 at 2:25 PM.

Discharge instructions for this visit were signed as having been received, on 02/13/2021 at 2:20 PM, by Patient #1. However, the only instructions given for this visit were on Emergency Awareness and Preventive Care, which dealt with stroke, heart attack, and sepsis. Again, there was no communication with the patient's resource center that dealt with his/her mental health issues to get an immediate follow-up appointment.

3. Review of Patient #1's medical record for his/her second return or third visit to the facility, on 02/13/2021 at 8:04 PM, revealed he/she was brought in via ambulance after being found down and pulseless with a pool of blood around his/her face. It was documented that Patient #1 had received fifteen (15) minutes of pre-facility advanced cardiac life support (ACLS). No pulse was regained after three (3) rounds of cardiopulmonary resuscitation (CPR) in the ED, and the patient was pronounced dead at 8:09 PM. The record stated Patient #1 had gross facial trauma. Further review of the Death Notification revealed Patient #1's cause of death was traumatic brain injury with cardiac arrest.

Review of the EMS run sheet, dated 02/13/2021, Incident Number E21015269, revealed Patient #1 was found at the bottom level of a parking structure by passing bystanders. In addition, it stated due to the location of the patient at the base of an open area to the parking structure, the patient was a suspected long fall from the parking structure.

Interview with EPS RN #1, on 07/01/2021 at 10:40 AM, revealed she cared for Patient #1, on 02/13/2021, but was unable to remember specifics. RN #1 was the nurse that completed the EPS Assessment on the second visit with a presentation time of 1:15 PM. She stated she had been certified in psychiatric (psych) nursing and had twenty (20) years of psych experience. RN #1 stated the decision to admit or discharge patients was a collaborative effort between the provider and social worker. She stated the EPS RN role included making sure patients received and understood discharge instructions and making sure patients got any resource information they might need.

Interview with EPS RN #2, on 07/01/2021 at 11:00 AM, revealed he cared for Patient #1, on 02/13/2021, and remembered Patient #1 vaguely, nothing specific. He stated when a patient came to EPS, our goal was to keep them safe, with an evaluation and appropriate resources obtained.

Interview with the Licensed Clinical Social Worker (LCSW), on 07/01/2021 at 11:40 AM, revealed she worked exclusively in EPS. Requirements to work in EPS required her being a LCSW and receiving extra education and certification. Continued interview revealed she worked for an organization that provided mental health services in EPS. When asked how she decided a patient was ready for discharge, she stated a patient must meet all four (4) criteria for hospitalization, which included severe and persistent mental illness, must be at imminent risk for self-harm, previous hospitalizations must have been beneficial, and hospitalization should be the least restrictive treatment. When asked to explain the criteria, she stated many things were taken into account, such as: was the patient psychotic without a grasp of reality; history of SI attempts (prior to 02/13/2021, there were no documented, verbalized attempts by Patient #1), recent hospitalization, and if the hospital stay had benefited the patient, i.e. had the patient improved. Further interview revealed she was also present for Patient #1's second visit at 1:15 PM, and there were no changes from her assessment on the first visit. However, there was no documented evidence of the LCSW assessing Patient #1 during his second visit (first revisit) with an Emergency Psychiatry Evaluation, which specified risk of suicide and whether there was a plan.

Continued interview with Physician #1 (attending), on 07/01/2021 at 11:40 AM, revealed she worked exclusively in EPS and stated the admission criteria for both voluntary and involuntary admissions was based on the Kentucky Revised Statutes (KRS) Chapter 202 A Statutes, which was for an involuntary admission. She stated there were no specific criteria for a voluntary admission, which Patient #1 would have been. She stated the facility had many people that said things in the moment or out of distress, but when one did the actual evaluation, they might not present as a harm to themselves. Physician #1 stated it was hard to describe on paper the patient's body language and such, which could affect the interpretation of what the patient said.

Interview with Physician #2, on 07/01/2021 at 12:04 PM, revealed she remembered Patient #1. She was scheduled on-call for that shift in EPS. She stated Patient #1 came in, brought in by EMS from the bridge, and he/she had been thinking about jumping. She stated Patient #1 was assessed, and the patient did not appear to have the intent to end his/her life. Physician #2 stated she saw the patient again on the second visit, stating he/she had again thought about jumping but could not do it and requested hospitalization for a long time. Physician #2 stated the patient was dealing with stressors: homelessness, alcoholism, and being in an unfamiliar city. Physician #2 reported he/she wanted to be admitted to the hospital to have a place to stay. She stated the facility did not admit to psych areas for a place to stay. The interview with Physician #2 continued with her stating EPS used the four (4) KRS Chapter 202 A Statutes criteria for involuntary hospitalization for both voluntary and involuntary hospitalization. She stated these criteria were: mental illness (Patient #1 had been diagnosed with Persistent Depressive Disorder); the patient could stand to benefit from hospitalization (it was documented Patient #1 had previously stated that prior hospitalizations had not helped him/her); the hospital was the least restrictive treatment, and dangerousness to self (Patient #1 had chronic, not acute suicidal ideations) or others. Physician #2 stated if she had thought for one minute that he/she was a harm to himself/herself, she would not have discharged him/her either time.

Interview with the Executive Director of Quality and Safety (EDQS), on 07/02/2021 at 1:31 PM, revealed she was kept apprised of the investigation progress. She explained that the SWARM/Root Cause Analysis process was the process in which an event was discussed/analyzed for process and/or system improvements. She stated the facility did an investigation. Per interview with the EDQS, there was not a policy/process on voluntary admissions; and the Mental Health Exam drove both the involuntary/voluntary admission process, not the fact that someone came in court-ordered or walked in off the street, requesting to be admitted. She further stated the Root Cause Analysis was determined in the facility self-report Sentinel Event documentation.