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Based on interview and document review, the facility failed to follow the existing policy for determination of transfer for suicidal patients, and failed to provide a policy for safe discharge for the patient who had voiced mental instability (verbalization of suicidal thoughts with a plan), for 1 of 1 patient (#1 who was not transferred to a higher level of care) from May until August 2018, four months.


This deficient practice had the likelihood to effect all patients of the facilities Emergency Department.


Findings included.


On the morning of 8/13/2018, in the conference room the medical record for patient #1 (Pt/pt) was reviewed with the assistance of the Director of the Emergency Department, staff #2.

5/2/2018 at 10:50 AM, pt #1 was a 32 year old male patient who presented to the Emergency Department (ED) accompanied by his mother with an unstable medical condition. PT #2 was seen in the ED and admitted to the in-patient unit with a diagnosis of Hyperosmolar nonketotic hyperglycemia. Pt #1 verbalized he did not want to be admitted but was convinced to stay as his blood sugar was above 600 deciliters (dl), (normal is 70-110). Pt #1's blood pressure was low and his pulse and respirations were elevated.

Interview with the admitting Registered Nurse (RN) #4, indicated that upon admission to the in-patient unit, pt #1 and his mother entered into a volatile altercation in the pt's hospital room.
The pt began screaming for the nurse and cursing his mother demanding she be removed from his room and that he was just going to kill himself. After the pt's mother left his room the patient ambulated to the nurses station demanding to leave. He signed documents, indicating he left Against Medical Advice (AMA) and walked out of the building. The RN notified the sheriffs department the patient was acting erratic, threatened suicide and had left the hospital AMA. Per RN #4, She over heard pt #1 was returned to the hospital emergency department (ED) after pt #1 yelled at the officer stating, "If you take me back to the hospital, I'll blow my F****** brains out", while she was on the phone with the Deputy Sheriff.

The Sheriffs Deputy, who intercepted pt #1 walking off the hospital grounds, was not available for interview. However, the County's Sheriff was interviewed and confirmed pt #1 voiced suicide by fire arm. He reported pt #1 was returned to the ED under an Emergency Detention Warrant (EDW).

Review of the Psychiatric observation sheet indicated pt #1 arrived back in the ED, via police escort at 5:15 PM. Pt #1 was initially socializing and calm. At 6:00 PM he was refusing to cooperate and yelling at the nursing staff, and a police officer was "at the bedside". At 8:26 he ran out of the building but returned in 5 minutes. He slept the remainder of the night. He awoke at 5:50 and was calm.

Further review of the medical record (MR) indicated the local mental health authority worker interviewed pt #1 on 5/3/2018 at 6:55 AM and the encounter was recorded as lasting until 7:30 AM. The Mental Health intake signed her credentials as QMHPCS.

On 8/20/2018 at 11:00 AM, a telephone interview with The Director of the Community Mental Health Services, clarified The crisis intervention staff member who evaluated Pt #1 was a Masters prepared Social Worker. Her credentials QMHPCS indicated Qualified Mental Health Practice Community Services.

Review of the documented intake revealed pt #1 told the QMHPCS, "only out of frustration he stated would shoot himself". "He denies any suicidal /homicidal ideation's at the time of the screening. For the most appropriate least restrictive environment hospitalization is not recommended. THIS IS A FALSE ALARM."

Further interview with the Director of the Community Mental Health Services confirmed the "This is a false Alarm", was used for internal guidance and should not be written on the crisis evaluation from. She confirmed this could be misleading to hospital staff.


Physician #6 was interviewed and he confirmed pt #1 was admitted to the in-patient department for an elevated blood sugar of greater than 600 dl. He confirmed the patient needed to be stabilized medically before discharge was recommended. Physician #6 also confirmed pt #1 was brought back into the ED by police escort and left almost immediately but came back of his own choosing within 3-5 minutes. He indicated his behavior was angry and erratic. Physician #1 confirmed his shift ended prior to pt #1 discharge from the hospital and he released care of pt #1 to the on-coming ED physician. He stated the community mental health authority was called to send someone to conduct a face to face evaluation of pt #1.

Physician #6 was asked if he relied on the mental health authority to be provide the psychiatric diagnosis for ED pt. He reported he took their evaluation seriously and he could not think of a time when he had disagreed with the evaluation, however, he was not on duty at the time pt #1 was discharged. Physician #6's final notation was, "1:30 (AM) Repeat bedside blood glucose is 332 (Normal is 70-110) will treat with regular insulin; Patient is stable for transfer"

Pt #1 was discharge by the on-coming ED Physician #7. The documentation included the following:

"07:50 (AM) MHMR (Mental Health Mental Retardation) here to assess patient; He reports he is not Suicidal and does not wish to harm himself; He will be seen as out patient for psychiatric services."

"Final diagnostic impression Feeling Suicidal, Hyperglycemia".

Telephone interview with physician #7, on 8/17/2018, confirmed he had placed the admission diagnosis in as the discharge diagnosis. He verbalized, he felt Mr. Roberts was not suicidal at the time of discharge but his documentation did not reflect that.


On 8/20/2018 at 11:00 AM, a telephone interview with the Mental Health Authority worker #11, confirmed she had spoken with ED staff RN #10 and ED Physician #7 and neither voiced any concern to her regarding Pt #1 being suicidal at the time of the evaluation.

PT #1 was driven to his automobile by the County Sheriff. Interview with the Sheriff indicated he spent 15 minutes talking with pt #1 who professed no desire to commit suicide. Later in the day pt #1 was found on the side of a county road in his pickup truck. He had taken a firearm from his father's home and died of a self inflected gun shot wound to the head.


Policies for the ED related to the evaluation and care of mental health patients were reviewed. Policy #1207 "Care and Evaluation of the Psychiatric Patient, Guidelines for commitment to a Mental Health Facility" addressed mental health patient's who were evaluated in need of transfer to a psychiatric in-patient hospital setting.

"Criteria for Implementing The Protocol,
Suicide attempt
Suicidal ideation (Pt #1 voiced suicidal ideation with a plan).
Homicide attempt
Homicidal ideation
Need for medical clearance for a referral to a psychiatric facility
Psychotic behavior (for example-auditory or visual hallucinations".

The facility had not followed its policy for suicidal patients. Interview with the Administrator and ED director confirmed they relied on the mental health authority for the recommendation to be able to transfer a mental health patient to a facility.

The policy provided no guidance to the physician requiring documentation of physical/mental stability prior to discharge from the hospital. No other policy for mental health evaluation and treatment was provided.

Interview with the ED Director confirmed the hospital did not have a process where by the physician staff consistently documented their evaluation of a mental health patient who had presented with crisis behavior (voiced suicide with a plan) prior to discharge. There was no policy requiring the physician document an evaluation for any mental health patient prior to discharge unless they were transferred.