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Based on medical record review, document review and staff interviews, the acute care hospital's administrative staff failed to ensure the Emergency Department (ED) staff followed the hospital's policy which required the hospital staff to provide an appropriate medical screening exam for 1 of 20 reviewed patients (Patient #1) who presented to the ED and requested an emergency medical screening examination. Failure to provide an appropriate medical screening exam placed all patients who presented for an emergency medical examination at risk for deterioration or death from an emergency medical condition. The acute care hospital administrative staff identified an average of 4,487 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of the policy "EMTALA: The Treatment and Transfer of Individuals Who Request Emergency Medical Services", effective 02/2021, revealed in part:

"This policy applies to all individuals seeking or needing an examination or treatment for emergency medical services who come to the Hospital's dedicated emergency department."

"The Hospital will provide an appropriate medical screening examination within the capability of the Hospital's dedicated emergency department, including ancillary services routinely available to the dedicated emergency department, to determine whether or not an emergency medical condition exists. An 'Emergency medical condition' is defined as 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."

"The Hospital will provide an individual with an emergency medical condition such further medical examination and treatment as required to stabilize the emergency medical condition, within the capability of the Hospital."

"'Medical screening examination' means the screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist. Triage is not considered a medical screening examination."

"If the Hospital offers examination and treatment and informs the individual or the person acting on the individual's behalf of the risks and benefits to the individual of the examination and treatment, but the individual or person acting on the individual's behalf does not consent to the examination and treatment, the Hospital shall take all reasonable steps to have the individual or the person acting on the individual's behalf, sign a "Refusal to Permit Medical Examination and Treatment for Emergency Medical Condition"...The medical record shall contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual; the risks/benefits of the examination and/or treatment; the reasons for refusal; and if the individual refused to sign [the form], the steps taken to secure the written informed refusal. Hospital personnel involved with the individual's care, or personnel witnessing the individual requesting to leave, for example registrar personnel, triage nurse, or personnel made aware that the individual left the emergency department may complete the forms."


2. Review of Patient #1's medical record revealed the following:

a. Patient #1's face sheet indicated the registration staff documented that on 10/25/21 at 5:36 AM, Patient #1 was admitted to the ED with a psychiatric problem.

b. On 10/25/21 at 5:51 AM RN A documented Patient #1 was discharged from the ED. RN A noted the patient discharge disposition was "registered in error".

c. On 10/25/21 at 10:49 AM, RN A documented the encounter with Patient #1 that took place at 5:50 AM (RN A's documentation was done approximately 5 hours later, after Patient #1 had committed suicide and RN A had spoken with hospital administration).

According to RN A's late entry note, Patient #1 presented to the ED, asked for a face mask, asked the staff if they were at the emergency department (ED), and if the hospital provided psychiatric services. RN A replied yes, and asked how they could assist Patient #1. Patient #1 then indicated that they wanted to wait until they got back home, they did not need to check in, and they were good to go. RN A did not feel comfortable allowing Patient #1 to walk away without further assessment, so RN A asked Patient #1 to accompany them to ED Triage Room #1. RN A shut the Triage Room 1 door to assess patient and provide privacy.

Patient #1 indicated they came to hospital because they felt they needed a medication adjustment. Patient #1 said they "... take medications for the things that I hear sometimes". Patient #1 indicated they heard a buzzing sometimes but the things Patient #1 heard did not tell Patient #1 to hurt themselves. Patient #1 felt like they just needed to sleep for a few hours, since they had been awake longer than normal. RN A screened Patient #1 for suicide risk using "CCSR" (meaning C-SSRS, Columbia-Suicide Severity Rating Scale) and asked Patient #1 if they were suicidal or having suicidal ideations which Patient #1 denied more than once. Patient #1 denied any attempt at suicide in the past or any current plan to commit suicide.

RN asked Patient #1 if they were sure they did not want to be seen by an ED provider and talk to psychiatric services. Patient #1 stated, "No I don't, I am good to go. I appreiciate [sic] you guys talking to me".

RN A then asked Patient #1 to wait while RN A got a list of local shelters, churches, clinics, and mental health services to share with Patient #1. RN A and Patient #1 exited Triage Room 1, RN A went to the back of the ED and asked the Unit Secretary and 3 Emergency Department physicians (each able to determine if Patient #1 was experiencing a psychiatric emergency medical condition) if they knew where a different hospital's mental health crisis service information sheet was located. RN A shared this information with Patient #1 and Patient #1 left the ED.

d. RN A did not request any of the 3 physicians present while Patient #1 was in the ED to examine Patient #1. RN A did not ask a physician to explain to Patient #1 the medical risks of refusing to be examined by an ED provider. RN A did not explain to Patient #1 the medical risks of refusing to be examined by an ED provider. RN A did not ask Patient #1 to sign a form acknowledging the medical risks of leaving the ED without being seen.

3. Review of ED coverage for 10/25/21 revealed 3 physicians were available to provide a medical screening evaluation for patients who presented to the ED with psychiatric concerns or to explain the medical benefits of a medical screening examination or the medical risks of refusal.

4. Review of the ED call coverage for 10/25/21 revealed that a service providing remote psychiatric evaluations was available to evaluate patients who presented to the ED with psychiatric concerns.

5. During an interview on 11/1/21 at 4:00 PM, RN A verified they were sitting at the triage desk with Patient Access Representative B when Patient #1 approached them, asked for a mask, and asked if they offered any psychiatric services. RN A stated she replied yes and referred Patient #1 to the registration staff to get checked in but about halfway through the registration process Patient #1 changed their mind and said they would wait until they got back home to talk to someone.

RN A stated she wanted to ask a few questions before Patient #1 left so she took Patient #1 to Triage Room 1 and pulled the door shut for privacy. RN A said she asked multiple screening questions, Patient #1 declined to be seen in the ED and they exited the triage room. RN A wanted to share additional resources with Patient #1 and asked Patient #1 to wait while she gathered some additional resources for Patient #1. At one point, RN A walked into the back of the ED and asked some staff members (a unit secretary and three physicians) if they knew where the handout for Hospital A's crisis center was located, but those staff members were unable to help. RN shared the information with Patient #1 and Patient #1 left the ED.

RN confirmed that they are not qualified to perform a medical screening examination. RN A said they didn't chart any of the encounter because Patient #1 did not want to check in and did not want to stay in the ED, and RN A did not do a full triage.

RN A had asked Patient Access Representative B the best way to document Patient #1's discharge disposition since they didn't stay and RN A did not do a full triage. RN A said Patient Access Representative B told them to chart Patient #1 as "registered in error." RN A later got a call after Patient #1 committed suicide. RN A's director called RN A later in the morning and asked RN A to review the situation with Patient #1. RN A's director then asked RN A to come in and chart the additional information RN A provided verbally to the director.

RN A further indicated that they would have asked one of the ED providers to talk to Patient #1 if Patient #1 had said they were suicidal. RN A would have also pushed Patient #1 to stay had that been the case, but explained that even if someone says they are suicidal, the ED staff cannot make the patient stay without a court order. RN A did not ask Patient #1 to sign any forms related to leaving the ED without being seen because RN A was unsure how to document Patient #1's discharge disposition, since Patient #1 would have probably walked away and left about a minute or two into the registration process.

6. During an interview on 11/2/21 at 7:00 AM, Patient Access Representative B recalled Patient #1 came to the triage desk and asked if the hospital offered psychiatric help. RN A answered yes and then directed Patient #1 to Patient Access Representative B, who went through the normal process of registration including the patient's first and last name, social security number, and birth date. Patient Access Representative B listed the reason for visit as "psychiatric".

Patient Access Representative B was about to print off a wrist band and registration sheet when Patient #1 stopped them and asked if it was okay if they went back home? Patient #1 was told that was fine, they can't force anyone to stay. RN A then asked Patient #1 if they could ask some personal questions and went with Patient #1 to the triage room. After about 5 minutes, RN A came out of the room and started to compile a list of local resources. Patient Access Representative B also recalled RN A was emphasizing Hospital A's services, because they had more outpatient services. RN A wrote a few options on a piece of paper and sat with Patient #1 in the lobby and went over it with them for about 5 minutes. Patient #1 seemed appreciative, was super nice, and then Patient #1 left the ED.

Patient Access Representative B said they were fairly new to their role and were unsure of what to do in this circumstance. Patient #1 was in their software that listed all ED patients including those waiting to be seen. Patient Access Representative B did not think Patient #1 should be in the system which would show them as in the ED and needing to be seen. RN A asked if they should put Patient #1 in as "registered in error" and since Patient Access Representative B was new, they said it was okay.

Please refer to A-2406 for additional information.

Based on medical record review, document review and staff interviews, the acute care hospital's administrative staff failed to ensure the Emergency Department (ED) staff followed the hospital's policy which required the hospital staff to provide an appropriate medical screening exam for 1 of 20 reviewed patients (Patient #1) who presented to the ED. Failure to provide an appropriate medical screening exam placed all patients who presented for an emergency medical screening at risk for deterioration or death from an emergency medical condition. The acute care hospital administrative staff identified an average of 4,487 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #1's medical record revealed the following:

a. The registration staff documented on Patient #1's face sheet that on 10/25/21 at 5:36 AM, Patient #1 was admitted to the ED with a psychiatric problem.

b. On 10/25/21 at 5:51 AM RN A documented Patient #1 was discharged from the ED. RN A noted the patient discharge disposition was "registered in error".

c. On 10/25/21 at 10:49 AM, RN A documented the encounter with Patient #1 that took place at 5:50 AM (RN A's documentation was done approximately 5 hours later, after Patient #1 had committed suicide and RN A had spoken with hospital Risk Management):

i. Patient #1 asked for a face mask, and asked if this was the ED and if they provided psychiatric services. RN A replied yes, and asked how they could assist. Patient #1 then stated that they wanted to wait until they got back home, they did not need to check in, and they were good to go. RN A asked Patient #1 to accompany them to ED Triage Room #1 because RN A did not feel comfortable allowing Patient #1 to walk away without further assessment. RN A shut the Triage Room 1 door to assess patient and provide privacy.

ii. Patient #1 indicated they came to hospital because they felt the needed a medication adjustment. Patient #1 said they "... take medications for the things that I hear sometimes". Patient #1 indicated they heard a buzzing sometimes but the things Patient #1 heard did not tell Patient #1 to hurt themselves. Patient #1 felt like they just needed to sleep for a few hours, since they had been awake longer than they normal. RN A asked the Patient #1 if they felt safe or if they felt Patient #1 was a danger to themself and Patient #1 denied being a danger to themself. RN A asked about any support system available to Patient #1, and Patient #1 indicated they could reach out to some friends for support.

iii. RN A continued to screen Patient #1 for suicide risk using "CCSR" (meaning C-SSRS, Columbia-Suicide Severity Rating Scale) and asked Patient #1 if they were suicidal or having suicidal ideations to which Patient #1 responded, "No I am not.". RN A asked Patient #1 if they were a danger to themself, to which Patient #1 responded, "I am not". RN A asked Patient #1 if they were having any suicidal thoughts or ideations to which Patient #1 responded, "No." Patient #1 denied ever attempting suicide in the past or having a current plan to commit suicide. Patient #1 said that they just needed to get some sleep and head back home to get everything sorted out with their medications. RN A again asked if Patient #1 had any intention to hurt themself or anyone else, and Patient #1 said, "No I don't. Really I am good." RN A noted Patient #1 was making appropriate eye contact, was calm, cooperative, smiling and interacting with RN A. Patient #1 was not aggressive and did not appear distressed.

iv. RN took basic vital signs which were within normal limits (RN A did not document any specific vital sign results) and asked Patient #1 if they were sure they did not want to be seen by an ED provider and talk to psychiatric services. Patient #1 stated, "No I don't, I am good to go. I appreiciate [sic] you guys talking to me". RN A did not obtain a list of Patient #1's medications, the frequency Patient #1 took their medications, or if Patient #1 was compliant with taking their medications.

v. RN A then asked Patient #1 to wait while RN A got a list of local shelters, churches, clinics, and mental health services to share with Patient #1. RN A and Patient #1 exited Triage Room 1. RN A went to the back of the ED and asked the Unit Secretary and 3 Emergency Department physicians (each able to determine if Patient #1 was experiencing a psychiatric emergency medical condition) if they knew where a different hospital's mental health crisis service information sheet was located. RN A could not locate the printed sheet, so RN A entered the triage desk again, utilized Google to write down the number for a mobile crisis center, crisis observation center, and a 24/7 crisis team number. RN A also wrote down the address for the other hospital's cricis center. RN A sat in the triage area with Patient #1 and read the list of outpatient walk-in services that were available anytime and informed Patient #1 of the multitude of area hospitals. RN A told Patient #1 to come back to this ED at any point, services were available 24/7, 365 days a year. RN A asked Patient #1 if they were sure they wanted to leave, and stressed to Patient #1 that they would be happy to help them here. Patient #1 replied that they appreciated the resources and would look into them. RN A asked Patient #1 if they had any other needs and Patient #1 replied no, thank you. RN A then got Patient #1 a glass of water, told them to take care of themself. Patient #1 said thank you, appreciated it, and Patient #1 left the ED.

vi. RN A then asked Patient Access Representative B if they thought RN A should register Patient #1 "in error" for disposition since Patient #1 did not want to be seen and did not want to finish the registration process. RN A revealed they were directed by Patient Access Representative B to enter Patient #1's as "registered in error".


d. The medical record lacked documentation that RN A requested any of the 3 physicians present while Patient #1 was in the ED to examine Patient #1, or RN A requested to have a physician explain to Patient #1 the risks of refusing an examined by an ED provider. RN A did not ask Patient #1to sign a form acknowledging the risks of leaving the ED without being seen by an ED provider and the record lacks documentation that Patient #1 refused to sign the form.

3. Review of ED coverage for 10/25/21 revealed 3 physicians were available to provide a medical screening evaluation for patients who presented to the ED with psychiatric concerns.

4. Review of the ED call coverage for 10/25/21 revealed Integrated Telehealth Partners (ITP -- a service that provides remote psychiatric evaluation) was available to evaluate patients who presented to the ED with psychiatric concerns.

5. During an interview on 11/1/21 at 4:00 PM, RN A verified they were sitting at the triage desk with Patient Access Representative B when Patient #1 approached them and asked if they offered any psychiatric services. RN A replied yes and referred Patient #1 to the registration staff to get checked in. RN A recalled that Patient #1 pulled out their drivers license and was unsure if Patient #1 had an insurance card. Patient Access Representative B was about halfway through the registration process when Patient #1 changed their mind and Patient #1 indicated they would wait until they got back home to talk to someone.

Since Patient #1 asked RN A about the hospital's psychiatric services and the hospital's ability to provide care for patients with psychiatric conditions, RN A requested that Patient #1 would allow RN A to ask Patient #1 a few questions before Patient #1 left the hospital. RN A informed Patient #1 they had the right to leave the hospital and RN A could not force Patient #1 to stay at the hospital, but RN A encouraged Patient #1 to talk to RN A about Patient #1's concerns before Patient #1 decided to leave the hospital.

RN A took Patient #1 to Triage Room 1 and pulled the door shut for privacy. They both sat down and RN A asked Patient #1 what type of psychiatric services Patient #1 was seeking. Patient #1 replied that they were looking for a medication adjustment and sometimes Patient #1 heard a buzzing sound. RN A started asking additional screening questions: Any thoughts of suicide? Any thoughts of danger to self or others? Patient #1 replied no. RN A asked about a support system, could Patient #1 pick up the phone and call anyone? Patient #1 said yes, they were from another state and would just rather go back there. RN A again asked if felt they were a danger to self, and asked if they had ever tried to commit suicide in the past. RN A took Patient #1's blood pressure, heart rate and pulse oximetry (a measure of oxygenation in the blood) but RN A did not do a full triage assessment, since Patient #1 didn't want to check in to the ED. RN A told Patient #1 about the hospital's services and Patient #1 still declined. RN A recalled that at that point they exited the triage room and RN A asked Patient #1 to wait so RN A could get some resources for them. RN A gathered some information about Hospital A's crisis center which has a walk in clinic, RN A explained to Patient #1 that it is a good resource for people who need a medication adjustment or to talk to a therapist. At one point, RN A indicated they walked into the back and asked some staff members if they knew where the handout for Hospital A's crisis center was located, but those staff members were unable to help. RN A used their phone to pull up phone numbers and then wrote down phone numbers for the Des Moines Police Department, a mobile crisis, and the number for Hospital A.

RN A recalled Patient #1 then was siting in a chair in the waiting room. RN A noted that Patient #1 did not appear to be distressed, was making eye contact, and smiling. RN A shared with Patient #1 the information from RN A's phone and the papers with the phone numbers of the other resources. RN A reiterated that the hospital's emergency department was available 24/7, 365 days a year. RN A got Patient #1 a cup of ice water, Patient #1 said "thank you" and left the ED. RN A thought they were in the triage room with Patient #1 for about 5-7 minutes.

RN A explained that the normal registration process included asking for an ID, an insurance card, and then once a patient was registered, the patient was taken into a room for triage. RN A confirmed that Patient #1 wasn't registered but RN A did do some triage. Patient #1 said they didn't want to check in, just kind of thought they wanted to go home. The registration staff had already scanned Patient #1's license into the system and RN A asked if Patient #1 would be willing to talk to RN A really fast before Patient #1 walked away. RN A did not want Patient #1 to leave the ED without knowing other available services in the area.

RN confirmed that they are not qualified to perform a medical screening examination. RN A said they didn't chart any of the encounter because Patient #1 did not want to check in and did not want to stay in the ED, and RN A did not do a full triage assessment. RN A asked Patient #1 if RN A could just a least share with them the psychiatric services available in the area. RN A wanted to provide Patient #1 with a list of Hospital A's mental health services since Hospital A provided outpatient services such as access to a therapist or getting psychiatric medications adjusted (despite the hospital having 3 physicians in the Emergency Department who could have assessed Patient #1 and potentially ordered medication changes to Patient #1's medications).

RN A had asked Patient Access Representative B the best way to document Patient #1's discharge disposition since they didn't stay and RN A did not do a full triage. RN said Patient Access Representative B told them to chart Patient #1 as "registered in error." RN A later got a call after Patient #1 committed suicide. RN A's director called RN A later in the morning and asked RN A to review the situation with Patient #1. RN A's director then asked RN A to come in and chart the additional information RN A provided verbally to the director.

RN A further indicated that they would have asked one of the ED providers to talk to Patient #1 if Patient #1 had said they were suicidal. RN A would have also pushed Patient #1 to stay had that been the case, but explained that even if someone says they are suicidal they cannot make them stay without a court order. RN A did not ask Patient #1 to sign any forms related to leaving the ED without being seen because RN A was unsure how to document Patient #1's discharge disposition since Patient #1 would have probably walked away and left about a minute or two into the registration process.

6. During an interview on 11/2/21 at 7:00 AM, Patient Access Representative B recalled Patient #1 came to the triage desk and asked if the hospital offered psychiatric help. RN A answered yes and then directed Patient #1 to Patient Access Representative B, who went through the normal process of registration including the patient's first and last name, social security number, and birth date. Patient Access Representative B listed the reason for visit as "psychiatric". Patient Access Representative B was about to print off a wrist band and registration sheet when Patient #1 stopped them and asked if it was okay if they went back home? Patient #1 was told that was fine, they can't force anyone to stay. RN A then asked Patient #1 if they could ask some personal questions and went with Patient #1 to the triage room. After about 5 minutes, RN A came out of the room and started to compile a list of local resources. Patient Access Representative B also recalled RN A was emphasizing Hospital A's services, because they had more outpatient services. RN A wrote a few options on a piece of paper and sat with Patient #1 in the lobby and went over it with them for about 5 minutes. Patient #1 seemed appreciative, was super nice, and then Patient #1 left the ED.

Patient Access Representative B said they were fairly new to their role and were unsure of what to do in this circumstance. Patient #1 was in their software that listed all ED patients including those waiting to be seen. Patient Access Representative B did not think Patient #1 should be in the system which would show them as in the ED and needing to be seen. RN A asked if they should put Patient #1 in as "registered in error" and since Patient Access Representative B was new, they said it was okay.


7. Review of video footage from the hospital's security cameras revealed that Patient #1 presented to the hospital's emergency department at 5:33 AM on 10/25/21. Patient #1 left the ED triage desk at approximately 5:42 AM walked to the hospital's chapel at approximately 5:50 AM. Patient #1 walked into the men's bathroom at approximately 5:53 AM.

8. During an interview on 11/1/21 at 3:00 PM, RN C recalled that sometime after 7:00 AM they were on their way to dialyze a patient when they were stopped in front of the men's bathroom and told there was a person in the bathroom who needed help. RN C went into the bathroom and witnessed Patient #1 lying on the floor and called for additional help.

9. During an interview on 11/2/21 at 4:00 PM, Physician H stated they went to the men's bathroom after hearing the call for assistance. Upon assessing Patient #1, Physician H determined Patient #1 was deceased.

10. During an interview on 11/2/21 at 3:15 PM, the ED Director indicated that the normal registration process includes Patient Access staff obtain a patient's ID, confirmed the date of birth, and asked if they have been seen at this hospital before if they do not locate that patient in their system. After that, the nurse will take the patient into a triage room and ask questions. If there is not a nurse at the desk and a patient has an immediate need, staff will go get a nurse.

The ED Director acknowledged that the ED staff should not have listed Patient #1's discharge disposition as "registered in error." The ED Director revealed that RN A indicated the primary reason that was done was to avoid Patient #1 receiving any ED charges, since Patient #1 was adamant they did not want to be seen in the ED. The ED Director acknowledged that RN A did not understand the need to have an accurate record of the patient's registration and encounter. RN A's main concern was that Patient #1 did not get charged.

The ED Director revealed that they looked up Patient #1 after Patient #1 committed suicide in the hospital, saw the disposition, and then called RN A and asked about the situation, which RN A remembered fully. RN A inquired why the ED Director was asking, and after learning what happened, the ED Director indicated RN A wanted to come back to the hospital and talk to Risk Management and the police. Risk Management had RN A put a note in the record knowing it would be a late entry, as an addendum to the chart. The ED Director acknowledged that RN A did not have Patient #1 fill out the form for patients who leave the ED without being seen because RN A said Patient #1 was registered in error.