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Based on policy review, medical record review, video review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking medical treatment for an emergency medical condition (EMC) received an appropriate and ongoing medical screening examination (MSE), monitoring and treatment for 1 of 20 (Patient #1) sampled patients.

The findings included:

Refer to A2406.

Based on policy review, medical record review, video review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking medical treatment for an emergency medical condition (EMC) were provided an appropriate and ongoing medical screening examination (MSE), monitoring and treatment for 1 of 20 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital's "Emergency Medical Treatment and Active Labor (EMTALA)" policy revealed, "Emergency Medical Condition [EMC] means...A medical condition manifesting itself by acute symptoms of sufficient severity [including severe pain, psychiatric disturbances and/or symptoms of substance abuse] such that the absence of immediate medical attention could reasonably be expected to result in...Placing the health of the individual...in serious jeopardy...With respect to an individual with psychiatric symptoms...That the individual is expressing suicidal or homicidal thoughts or gestures and is determined to be a danger to self or others...Medical Screening Examination [MSE] is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists...The MSE is an ongoing process, and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized, admitted to inpatient care, or appropriately transferred...EMTALA Requirements...Provide an appropriate medical screening examination by a qualified medical professional, within the capability of the hospital's emergency department, to determine whether or not an emergency medical condition exists...Note that an MSE is not an isolated event but it is an on-going process. Thus, the medical record must reflect continued monitoring according to the patient's needs and must continue until the patient is stabilized, discharged, admitted or appropriately transferred"

2. Review of the hospital's "Suicide Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Setting" policy revealed, "All adolescent and adult patients...who present for care and services will be screened for suicide ideation and behavior using the Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale [C-SSRS]...Based on the severity and immediacy of suicide risk assessed using the Columbia Protocol, patient safety measures and interventions will be implemented as a means to keep patients from inflicting harm to self...High level of risk > Initiate 1:1 Continuous observation RN (Registered Nurse) to assess and complete Safe Room Checklist...RN to notify MD (Medical Doctor) and MD to order Mental Health Professional face to face consult before leaves the area/unit..."

3. Review of the hospital's "TRIAGE ASSESSMENT OF PATIENTS BY EMERGENCY SEVERITY INDEX (ESI)" policy revealed, "...Triage will involve a rapid, directed patient assessment which provides an assignment of an acuity level for each patient arriving in the unit...The assessment should include subjective and objective data appropriate to the presenting signs and symptoms to determine acuity level...B. High risk situation? Or confused/Lethargic/Disoriented? Or Severe Pain/Distress...2..."

4. Review of the hospital's "Pain Management Program Policy" revealed, "...Pain will be assessed on initial assessment. An on-going reassessment of pain is performed on a regular basis utilizing appropriate, reliable, and valid pain assessment tools...Patient-specific pain management outcomes will be established and if not achieved will elicit a review and modification of the pain management plan..."

5. Medical record review for Patient #1 revealed the patient was an insured 23 year old male and arrived to the Hospital's ED on 8/30/2021 at 11:59 AM in a private vehicle. The patient's chief complaint was chest pain, abdominal pain, back pain, and plans to shoot himself in the head. Patient #1 also complained of a wound to the left buttock due to history of surgery after necrotizing fasciitis (a serious bacterial infection that destroys tissue under the skin). The wound on the left buttock had fluid coming out of it.

A triage assessment performed by Registered Nurse (RN) #1 began at 12:02 PM on 8/30/2021. RN #1 assigned Patient #1 an acuity level of 2. RN #1 documented Patient #1's pain level as a 7, on a scale of 0-10 with 10 being the most severe. Patient #1's vital signs were the following: Blood Pressure- 119/73, Pulse Rate- 132, Temperature- 99.6 degrees Fahrenheit, oxygen saturation- 100 percent (%) on room air. RN #1 documented Patient #1's Columbia Suicide C-SSRS scale as a 7, high risk for suicide.

An Electrocardiogram (EKG) was performed on Patient #1 at 12:07 PM on 8/30/2021 that revealed Sinus Tachycardia (fast, but steady heart rate). Suicide precautions were ordered at this time.

Review of Patient #1's room assignment log revealed Patient #1 remained in the triage room after triage was completed. Patient #1's mother was in the room with the patient.

There was no documentation Patient #1 received a medical screening examination by a qualified medical provider (QMP) , further assessment, examination, monitoring, or treatment related to Patient #1's pain, fast heart rate and oozing wound. There was no documentation suicide precautions were initiated due to Patient #1's high risk for suicide.

At 4:11 PM on 8/30/2021 RN #1 found Patient #1 was no longer in the triage room. RN #1 did not find Patient #1 in the waiting room of the ED, breezeway of the hospital, or outside the hospital. RN #1 then attempted to call Patient #1 and his Mother, with no answer to the call. At 4:16 PM RN #1 contacted the sheriff's department of the county Patient #1 lived, and requested deputies respond to Patient #1's address and bring him back to the hospital.

Review of the hospital's security video footage of the ED on 8/30/2021 beginning at 12:02 PM revealed Patient #1 was seen leaving the ED at 2:54 PM. Patient #1 is seen returning to the ED on 8/30/2021 at 5:44 PM, escorted by a law enforcement officer.

Patient #1 received a MSE on 8/30/2021 beginning at 5:54 PM. Patient #1 had laboratory testing and a Computerized Tomography (CT) scan of the abdomen and pelvis. Patient #1 was admitted to the hospital as an inpatient on 8/30/2021 at 11:58 PM with diagnoses that included Colitis, Fistula, Gastrointestinal (GI) Bleed, Suicidal Ideations, and Ulcerative Colitis.

In a telephone interview on 9/13/2021 at 9:30 AM, RN #1 stated Patient #1 was suicidal with a plan to put a gun to his head and shoot himself. RN #1 stated she kept Patient #1 in the triage room, with his Mother present. When RN #1 went to move Patient #1 to an ED room, she found he and his Mother were gone. RN #1 verified she searched for the patient, called his phone and his Mother's phone, then called the Sheriff's Department. RN #1 was asked if Patient #1 received anything for pain before eloping from the ED. RN #1 stated she couldn't remember. RN #1 stated she felt that Patient #1 was safe in the triage room since his Mother was with him, due to the ED was very busy that day.

The hospital failed to provide an appropriate and ongoing MSE by a qualified medical provider, and failed to appropriately monitor and observe, related to suicide thoughts with a plan before Patient #1 eloped from the ED at 2:54 PM on 8/30/2021. The patient received no stabilizing treatment prior to eloping from the hospital's ED.