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Based on interview and record review, the facility (Hospital A) failed to ensure a completed medical screening examination (MSE- an assessment by a medical provider to determine whether an individual has a emergency psychiatric or medical condition) was conducted for one of 20 sampled patients (Patient 1). PT 1 was brought to the facility's Emergency Department (ED) by California Highway Patrol Officer (CHPO) on 3/9/2023 at 2:02 AM for Suicidal Ideations (SI-thoughts to hurt self) and was found walking on the freeway. This failure had the potential to adversely affect Patient 1's health and safety.

Findings:

Review of the Emergency Department (ED) Log indicated, Patient 1 was transported to the Hospital A's ED by CHPO on 3/9/2023 at 2:02 AM. Patient 1 was discharged on 3/9/2023 at 2:39 AM and transported by CHPO to Hospital B.

Review of Patient 1's Hospital A demographic sheet indicated, Patient 1's presented to the ED with symptoms of psychiatric emergency (an adult who had a mental health crisis and was involuntarily detained 72 hours for danger to self and others).

Review of Patient 1's Hospital A ED History Note, dated 3/9/2023 at 2:23 AM, indicated, Patient 1 had SI. MD 1 informed Patient 1 and CHPO that he was unable to place patient on a 5150 hold (a 72 hour involuntarily hold for danger to self and others) as Hospital A was not a Psychiatric Emergency facility. Per MD 1 indicated, Patient 1 will not be seen at the ED as a patient.

Review of the Hospital B Emergency Provider Notes, dated 3/09/2023 at 2:48 AM, indicated CHPO stated Patient 1 verbalized SI and homicidal ideations (HI-to hurt others) on the highway and at Hospital A. Patient 1 was found in the middle of the freeway and was placed on a 5150 hold by CHPO, for danger to self and others.

Review of the Hospital B Detained Advisement document, dated 3/9/2023 at 2:50 AM indicated Patient 1 was placed on a 5150 hold for walking on the freeway and verbalized statements of hurting himself and others.

During an interview with Hospital's A's ED Medical Doctor MD 1 on 4/11/2023 at 2:09 PM, MD 1 stated he did not do a complete MSE for Patient 1. MD 1 also stated he should have ordered blood tests (Monitor levels of various compounds in the blood), Acetaminophen levels (Monitor levels of acetaminophen in the blood), urine toxicology (Monitor for intentional overdose or drug dependency) tests and did not assess or document heart and lung sounds, for Patient 1.

During an interview with Hospital A's ED Medical Director (EDMD) on 4/11/2023 at 3:42 PM, EDMD stated, MD 1 should have done a complete MSE for Patient 1. The EDMD also stated that MD 1 should have placed Patient 1 on a hold for 24 hours, for danger to self or others.

During a concurrent interview and record review with the ED Nursing Director (EDND) on 4/12/2023 at 10:07 AM, EDND stated, vital signs were not completed or documented by the ED nursing staff for Patient 1.

During an interview with the ED Registered Nurse (RN 3) on 4/12/2023 at 8:53 AM, RN 3 stated, he did not complete Patient 1's vital signs.

Review of Hospital A's Medical Staff Bylaws, Rules and Regulations, dated 2/8/2023 indicated,"For all patients presenting to the facility's emergency room, a licensed physician will perform the MSE."

The Hospital A's policy and procedure, titled "Emergency Medical Treatment and Active Labor Act (EMTALA),"dated 8/2021, indicated, "A medical screening examination shall be offered to any individual presenting for examination or treatment of a medical condition. The scope of the examination shall be tailored to the presenting complaint and the medical history of the patient. The process may range from a simple examination (such as a brief history and physical to a complex examination that may include laboratory tests)..."

Based on interview and record review, Hospital A failed to ensure Hospital B had available space to treat and agreed to accept, one of 20 sampled patients (Patient 1), was brought to the facility's Emergency Department by California Highway Patrol Officer on 3/9/2023 at 2:02 AM for Suicidal Ideations after being found walking on the freeway. In addition, Hospital A failed to transfer Patient 1's medical records to Hospital B. These failures had the potential to adversely affect Patient 1's health and safety.

Findings:

Review of the Emergency Department (ED) Log indicated, Patient 1 was transported to the Hospital A's ED by CHPO on 3/9/2023 at 2:02 AM. Patient 1 was discharged on 3/9/2023 at 2:39 AM and transported by CHPO to Hospital B.

Review of Patient 1's Hospital A demographic sheet indicated, Patient 1's presented to the ED with symptoms of psychiatric emergency (an adult who had a mental health crisis and was involuntarily detained 72 hours for danger to self and others).

Review of Patient 1's Hospital A ED History Note, dated 3/9/2023 at 2:23 AM, indicated, Patient 1 had SI. MD 1 informed Patient 1 and CHPO that he was unable to place patient on a 5150 hold (a 72 hour involuntarily hold for danger to self and others) as Hospital A was not a Psychiatric Emergency facility. Per MD 1 indicated, Patient 1 will not be seen at the ED as a patient.

Review of the Hospital B Emergency Provider Notes, dated 3/09/2023 at 2:48 AM, indicated CHPO stated Patient 1 verbalized SI and Homicidal ideations (HI-to hurt others) on the highway and at Hospital A. Patient 1 was found in the middle of the freeway and was placed on a 5150 hold by CHPO, for danger to self and others.

Review of the Hospital B Detained Advisement document, dated 3/9/2023 at 2:50 AM indicated Patient 1 was placed on a 5150 hold for walking on the freeway and verbalized statements of hurting himself and others.

During an interview with the MD 1 on 4/11/2023 at 2:09 PM, MD 1 stated, he did not notify Hospital B's physician regarding Patient 1's emergency psychiatric condition, to ensure Hospital B's physician agreed to accept Patient 1 prior to transferring him to Hospital B. MD 1 stated, "I made a mistake."

During a concurrent interview and record review with the ED Nursing Director (EDND) on 4/12/2023 at 10:07 AM, EDND stated, Patient 1's medical records were not send to Hospital B.

During an interview with the Social Worker (SW) on 4/12/2023 at 3:09 PM, SW stated, when transferring a patient with an emergency psychiatric condition, the patient must be stabilized first and the patient will be placed at the receiving hospital if they have available space and accepted by the receiving hospital.

Hospital A's policy and procedure, titled "Emergency Medical Treatment and Active Labor Act (EMTALA),"dated 8/2021, indicated, "A patient with an unstable emergency medical condition shall be transferred only if the facility complies with the following standards, the receiving hospital has available space and qualified personnel for treatment of the patient; and the receiving hospital and physician has agreed to accept the patient and to provide appropriate medical treatment. The facility sent to the receiving facility medical records or copies available at the time of transfer related to the emergency condition of the patient..."