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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 regarding not performing an appropriate medical screening examination (MSE) for one (1) of twenty one (21) sampled patients, Patient #21, on 10/06/2021.

Refer to the findings in tag A-2406.

Based on interview, record review, Medical Staff Rules and Regulations, Emergency Medical Services (EMS) report, police traffic report, 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 determine if there was an emergency medical condition that required treatment and stabilization before discharge, for one (1) of twenty-one (21) sampled patients, Patient #21.

The findings include:

Patient #21 presented to the Emergency Department (ED), on 10/05/2021 at 11:08 AM, with the complaint of suicidal ideations and hallucinations. The patient was assessed and placed in
Room 16, the safe room. Patient #21 was determined not to have an acute, emergent condition due to his/her recent discharge (earlier on 10/05/2021) from the inpatient Behavioral Health Unit of the facility. Patient #21 was determined to be stable for discharge to self (not a threat to self or others) on 10/05/2021 at 2:30 PM.

Patient #21 again presented to the ED (second visit), on 10/05/2021 at 4:50 PM, via Emergency Medical Services (EMS), with the complaint of suicidal ideations. Patient #21 requested to be re-admitted or to be transferred to another facility for inpatient treatment. Per the Behavior Assessment Coordinator (BAC), Patient #21 did not have a psychiatric evaluation completed because he/she was noncommunicative, would not answer questions, and the psychiatric elements to be evaluated were "unable to assess." Patient #1 was placed in a room with one-to-one (1:1) care and monitored while waiting for psychiatry to assess on the morning of 10/06/2021; however, the morning of 10/06/2021, psychiatry did not come to reassess, but still determined the patient was stable for discharge. Patient #21 was discharged, on 10/06/2021 at 11:46 AM, without receiving an additional psychiatric evaluation or MSE, as planned by the ED provider.

Patient #21 again presented to the ED, on 10/06/2021 at 12:27 PM, via EMS. The EMS run sheet, dated 10/06/2021, reported the patient had walked out into traffic, in front of the facility, and was struck by a moving vehicle.

Review of the facility's policy titled, "EMTALA", review date 08/14/2021, revealed the facility ensured that individuals seeking examination or treatment subject to the Emergency Medical Treatment and Active Labor Act (EMTALA) would receive: (1) a Medical Screening Examination (MSE) by a physician or other Qualified Medical Personnel (QMP) to determine whether the individual had an Emergency Medical Condition (EMC): and, if so (2) stabilizing treatment or an appropriate transfer to another facility. Continued review revealed EMTALA applied when an individual came to a Dedicated Emergency Department (DED), including an off-campus DED, and requested examination or treatment for a medical condition. Further review of the policy revealed the hospital's EMTALA obligation ended, or EMTALA did not apply when: (1) a physician or other QMP had performed the MSE and determined the individual did not have an EMC; (2) an individual's EMC had been stabilized; or (3) an individual had been admitted as an inpatient.

Further review of the facility's "EMTALA" policy revealed an individual had an EMC if his/her medical condition manifested 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. Additional review revealed, with respect to a psychiatric patient, the individual's EMC was considered stabilized when a physician determined the individual would not harm him/herself or others.

Review of the facility's Medical Staff Rules and Regulations General Practices Guidelines, Admission and Discharge of Patients, revised 10/01/2019, Approved by the Board of Directors, on 10/09/2019, revealed, in Section H, for the protection of the patient, the medical and nursing staff, and the hospital, the following principle was to be met in the care of the potentially suicidal and/or dangerous patient: any patient known or suspected to be suicidal in intent shall be admitted, if possible, to the Behavioral Health Center of the hospital. In addition, the policy stated, in Section I, that all psychiatric patients admitted to the Behavioral Health Center must be admitted by a Psychiatrist or their Advanced Practice Clinician.

Review of Patient #21's medical record revealed the hospital originally admitted the patient, on 09/28/2021, through the Emergency Department (ED) to the Behavioral Health Unit with diagnoses which included Persistent Mood (Affective) Disorder and Suicide Ideation. Patient #21's other diagnoses included Bipolar 2 Disorder, Psychosis, Chronic Post-Traumatic Stress Disorder (PTSD), and Generalized Anxiety Disorder. Continued record review revealed the physician documented Patient #21's chief complaint was having panic attacks and feeling scared. Further documentation revealed Patient #21 was depressed, staying in bed, and being unable to drive due to being scared. Continued review revealed documentation that Patient #21 was quoted as saying he/she was going to take all their medications and commit suicide.

Review of Patient #21's Discharge Summary from the Behavioral Health Unit, dated 10/05/2021, revealed Patient #21 had denied suicidal ideation. Documentation revealed Patient #21 was depressed and having high anxiety, racing thoughts, and panic attacks. Continued review revealed medication changes were done for Depression and PTSD. The provider documented Patient #21 was given information regarding Alcoholics Anonymous and Narcotics Anonymous related to Patient #21's concerns about relapsing on "Crack".

1. Review of Patient #21's medical record of the Emergency Department (ED) first visit, dated 10/05/2021, revealed Patient #21 arrived in the ED at 11:08 AM on 10/05/2021. Continued review revealed, in the ED Triage Note, dated 10/05/2021 at 11:30 AM, Patient #21 was just discharged from the Behavioral Health Unit and sent home in a cab, but the patient asked the cab driver to take him/her back to the hospital. Further review of the Triage Note revealed Patient #21 was answering questions with a delay or not at all, but the patient finally stated he/she was "scared" at home when asked multiple times why he/she was at the ED to be seen. When the Triage Nurse, Registered Nurse (RN) #1, asked if Patient #21 was suicidal, the patient answered "yes" but denied a plan. According to the Triage Note, Patient #21 denied homicidal ideation (HI) but stated he/she did see, hear, and smell things that were not there, but the patient would not expand on what specifically. Further review of the Triage Note revealed, when Patient #21 was asked about wishing he/she were dead, had thoughts of killing self, and thinking about how to kill self, Patient #21 was documented as answering "yes" to all questions. The Triage Nurse documented Patient #21's acuity level as emergent.

Continued review of Patient #21's first ED visit, on 10/05/2021, in the Psychiatric Notes, dated 10/05/2021 at 1:44 PM, revealed the Psychiatrist documented Patient #21 did not know the reason why he/she returned to the hospital, but later during the interview or face-to-face meeting with the Psychiatrist, stated he/she was feeling anxious about returning home. Further review revealed the Psychiatrist documented Patient #21 denied any suicidal or homicidal ideations, denied any plans, and denied any auditory and visual hallucinations. In addition, further review revealed the Psychiatrist documented Patient #21 did not meet criteria for admission to the psychiatric unit and could be discharged from the ED to his/her home. Further review of Patient #21's first ED visit record revealed the patient was discharged at 2:30 PM on 10/05/2021.

Interview with Registered Nurse (RN) #1, on 10/27/2021 at 2:10 PM, revealed she was the triage nurse when Patient #21 came in into the Emergency Department (ED) after being discharged from inpatient Behavioral Health. RN #1 stated she remembered Patient #21 stating he/she was scared and felt suicidal but did not talk about a plan.

Interview with Patient #21's nurse (RN #3), on 10/28/2021 at 8:30 AM, revealed the patient had been discharged earlier that day and given a cab voucher to go home, but Patient #21 told the cab driver he/she needed to come back. RN #3 stated she asked Patient #21 if he/she was having any suicidal ideations, homicidal ideations, and/or any hallucinations. RN #3 stated Patient #21 denied all. RN #3 stated the Behavior Assessment Coordinator (BAC) was with Patient #21 in the ED and stated she was going to contact the Psychiatrist to come and talk with Patient #21. RN #3 stated the Psychiatrist had a face-to-face meeting with Patient #21, and the Psychiatrist told her the patient had been given time and resources, and there was no reason to re-admit the patient. Per RN #3, the Psychiatrist told Patient #21 he/she needed to follow-up with outpatient therapy. RN #3 stated Patient #21 mentioned going to another psychiatric hospital to the Psychiatrist, but then the Psychiatrist told the patient that he/she did not want to go there. RN #3 stated she called Patient #21's parent to come and get the patient, but the parent was not able to come. RN #3 stated she attempted to call a friend of Patient #21's that lived in the same housing community, but he/she was also not able to come and get the patient. RN #3 stated she then discharged Patient #21 home via a cab.

Interview with the BAC, on 10/28/2021 at 10:00 AM, revealed she received a call whenever there was a psychiatric patient in the ED, and she did an assessment on them. The BAC stated when she received a call regarding Patient #21, she knew the name from the Behavioral Health inpatient unit, and earlier that day (10/05/2021), Patient #21 had not wanted to be discharged and leave the inpatient Behavioral Health unit. The BAC stated she called the Psychiatrist to let him know Patient #21's chief complaint, on coming to the ED was Anxiety. The BAC stated she saw the patient with the Psychiatrist. The BAC stated the Psychiatrist asked Patient #21 why he/she returned to the facility, via the ED. The BAC stated Patient #21 stared at the Psychiatrist. She stated the Psychiatrist kept asking the patient what the problem was. The BAC stated, when the Psychiatrist asked Patient #21 if he/she had HI/SI and/or was hearing voices, Patient #21 stated no, and that he/she was anxious about going home. The Psychiatrist told Patient #21 he/she needed to go home, take his/her medications, and follow through with the plan for outpatient therapy.

Interview with the Psychiatrist, on 10/28/2021 at 9:30 AM, revealed when he was notified Patient #21 had returned to the ED after discharge, he went to the ED to talk with the patient. The Psychiatrist stated when he entered the patient's room, Patient #21 was sitting on the bed. The Psychiatrist stated he told Patient #21 he came here to help him/her and needed to talk about what was going on. The Psychiatrist stated Patient #21's response was he/she did not want to go home but denied SI and HI. The Psychiatrist stated he told the patient he/she needed to use the social network to get involved. He stated the patient lived in social housing and needed to make friends, go to the library, and increase social interactions with others. The Psychiatrist stated he told Patient #21 to have a bus pick him/her up and take to social functions. The Psychiatrist stated he tried to address the patient's loneliness and inform the patient about community resources available. Then, the Psychiatrist reported Patient #21 stated, "OK, I can go home."

2. Interview with the Community Support Person (CSP) at Patient #21's housing community, on 10/25/2021 at 2:00 PM, revealed she was in her office when another resident of the community came in and told her something was wrong with Patient #21. The CSP stated Patient #21 was crying hysterically and would not enter the building to go to his/her apartment. When the CSP asked Patient #21 what was wrong, the CSP stated Patient #21 told her that he/she did not want to be alive anymore. The CSP stated she called EMS due to Patient #21 having suicidal ideations. The CSP stated a Police Officer (PO) arrived prior to the ambulance, and Patient #1 had asked the PO to "shoot" him/her.

Post-exit interview with the PO, on 10/29/2021 at 1:30 PM, revealed he had arrived prior to Emergency Medical Services (EMS) and found Patient #21 crying and upset. The PO stated he asked Patient #21 how he could help him/her. The PO stated Patient #21 then formed a "gun" with his/her hand and with the action of his/her finger, fired the "gun" into his/her head. The PO stated he told Patient #21 he was not going to do that but would make sure he/she got somewhere to get the help he/she needed.

Review of the Emergency Medical Services (EMS) Patient Care Record, Incident #13971, dated 10/05/2021, revealed EMS arrived at Patient #21's side at 4:20 PM, and he/she was transported to the facility due to suicidal ideations (SI). The record stated EMS transferred Patient #21's care to ED staff at 4:40 PM. The EMS record stated when he/she was asked about SI, Patient #21 stated he/she wanted to kill self but refused to give any other information. Continued review revealed the patient was transported via ambulance due to the need for constant monitoring because of SI.

Review of Patient #21's second ED visit medical record, dated 10/05/2021 at 4:50 PM (arrival time), revealed the Chief Complaint was Suicidal and contained the comment "Patient was discharged from hospital this morning, checked back in for Suicidal Ideations without plans, was discharged approximately two (2) hours ago but has returned with Suicidal ideations, denies plan but will not answer any further questions."

Continued review of Patient #21's second ED visit, on 10/05/2021 at 4:50 PM (arrival time), in the History of Present Illness (HPI) by ED Physician #1, dated 10/05/2021 at 4:58 PM, revealed Patient #21 did not say he/she was suicidal but was basically scared to go home. ED Physician #1 documented Patient #21 would talk to him only a little bit. ED Physician #1 stated Patient #21 did not tell him that he/she was actively suicidal, but he/she really would not talk much to him. Continued review of Patient #21's chart, another note by ED Physician #1, dated 10/05/2021 at 5:11 PM, revealed the patient was anxious and depressed, had involuntary mouth movements (tardive dyskinesia), and of his/her own volition, was noncommunicative and uncooperative. Further review revealed ED Physician #1, on 10/05/2021 at 6:00 PM, under Management Options documented his discussion with the attending Psychiatrist. ED Physician #1 stated the Psychiatrist did not want to readmit Patient #21 to the psychiatric unit, and the patient did not meet admission criteria to the geriatric psychiatric facility. ED Physician #1 stated he discussed with the Psychiatrist that perhaps he could see Patient #21 on the morning of 10/06/2021 for re-evaluation to see if he/she was still clear to go home, from a psychiatric standpoint. In addition, ED Physician #1 stated he was concerned about sending Patient #21 home based on Patient #21 coming back to the ED twice, on 10/05/2021, and his conversation with Patient #21's mother, who had not seen the patient since her inpatient psychiatric admission, but felt Patient #21 was a danger to self before the inpatient admission. ED Physician #1 documented Patient #21 should be watched overnight so placement could be found and a better plan for discharge could be determined. Further review revealed he documented there was a case management consult and a psychiatric consult to re-evaluate Patient #21 on the morning of 10/06/2021.

Continued review of Patient #21's second ED visit record, in the BAC's Note, dated 10/05/2021 at 5:49 PM, revealed the patient would not talk with the BAC, so the Columbia-Suicide Severity Rating Scale (C-SSRS), could not be completed. (According to the website,
https://suicidepreventionlifeline.org, the C-SSRS was a questionnaire used for suicide assessment, with the National Institute for Mental Health support. Per the website, the Risk Assessment version was intended for clinical practice and was intended to establish a person's immediate risk of suicide and was used in the acute care setting.) Further review of the BAC's Note revealed a psychiatric assessment, with the elements of SI, HI, delusions, hallucinations, risk of harm to self, trauma history, anxiety, depression, level of function outside of the hospital decreased, and family history of mental illness or suicide attempts were "UTA", meaning unable to assess. Review of the BAC's ED Notes for Patient #21's Intake Assessment, on 10/05/2021, no time listed, revealed it was signed, on 10/05/2021 at 6:18 PM, by the BAC. The Intake Assessment revealed the BAC called the Psychiatrist who stated Patient #21 did not meet criteria for an inpatient psychiatric admission. The BAC stated the Psychiatrist told her that Patient #21 just did not want to go home, and he/she wanted to have the SW talk with him/her about placement. The BAC stated ED Physician #1 told her Patient #21 could remain in the ED until the morning (10/06/2021), when the SW could see the patient.

Interview with RN #3, on 10/28/2021 at 8:30 AM, revealed when Patient #21 returned to the ED on 10/05/2021 at 4:50 PM, RN #3 asked the patient why he/she was back, and the patient stated he/she was scared to go home. RN #3 stated when the patient was asked questions regarding suicidal ideations, homicidal ideations, or hallucinations, Patient #21 denied all. RN #3 stated she told ED Physician #1 the patient was scared to go home. RN #3 stated ED Physician #1 told the patient RN #3 needed to get social services involved with Patient #21 to look for placement in an assisted living facility (ALF), a group home, or a personal care home. RN #3 stated the patient told all physicians that he/she was scared to go home; however, provided no further explanation.

Interview with the Psychiatrist, on 10/28/2021 at 9:30 AM, revealed the Psychiatrist was already at home, on 10/05/2021, when the ED called and stated Patient #21 was back in the ED. The Psychiatrist stated he was told the patient did not have SI, but he/she did not want to go home. The Psychiatrist stated it was late in the day, and the patient needed to see the social worker and get some resources in the morning. The Psychiatrist stated he personally saw the patient earlier in the day, on 10/05/2021, and the patient denied SI and HI, but was lonely and feeling anxious to be home alone. The Psychiatrist stated the EMC had been resolved, and it had been resolved when Patient #21 was discharged from the inpatient unit. The Psychiatrist stated Patient #21 denied SI and HI while in the ED. The Psychiatrist stated when someone remained with SI after five (5) to seven (7) days, the patient was then transferred to the state psychiatric hospital. The Psychiatrist stated Patient #21 had no SI from five (5) days prior to discharge from the Behavioral Health Unit. The Psychiatrist stated Patient #21 still had anxiety but no SI. The Psychiatrist stated ED Physician #1 called regarding a transfer of Patient #21 to a nursing home. The Psychiatrist stated Patient #21 did not meet criteria to be admitted to a nursing home. The Psychiatrist stated he told ED Physician #1 that Patient #21 needed a social network. The Psychiatrist stated when Patient #21 was discharged on 10/05/2021 from the inpatient unit, he/she had no SI thoughts. The Psychiatrist stated even when he spoke with Patient #21, face-to-face, on 10/05/2021, during the first ED visit, he/she did not have any SI thoughts.

Interview with ED Physician #1, on 10/28/2021 at 9:45 AM, revealed Patient #21 had been seen by other physicians in the ED. ED Physician #1 stated Patient #21 came back after he/she had just left. ED Physician #1 stated Patient #21 was not SI, HI, or psychotic. ED Physician #1 stated Patient #21 did not want to go home. ED Physician #1 stated he evaluated Patient #21 three (3) to four (4) times. ED Physician #1 stated at first Patient #21 would not talk to him, and he/she just did not want to go home. ED Physician #1 stated he called Psychiatry (PSY)to see what was going on with Patient #21. ED Physician #1 stated Patient #21 had a formal Psychiatry consult on the chart, and he was able to talk to the Psychiatrist personally. ED Physician #1 stated the Psychiatrist stated Patient #21 did not meet criteria for admission to the PSY unit. ED Physician #1 stated he decided to keep Patient #21 overnight and get the social worker involved in the morning.

Interview with the BAC, on 10/28/2021 at 10:00 AM, revealed she was in the ED when Patient #21 returned from his/her housing community, for the second ED visit. The BAC stated Patient #21 was placed back in the safe room, Room 16, on 10/05/2021 at 4:50 PM. The BAC stated she notified the Psychiatrist of Patient #21's return and then got Patient #21 settled in. The BAC stated ED Physician #1 was evaluating Patient #21. The BAC explained to ED Physician #1 what all had happened during Patient #21's first visit to the ED. According to the BAC, Patient #21 told ED Physician #1 he/she did not want to go home. The BAC stated ED Physician #1 decided to keep Patient #21 overnight and let the SW see the patient in the morning.

Interview with Constant Observation Companion (COC) #2, on 10/28/2021 at 2:05 PM, revealed she was with Patient #21 from 10/05/2021 at 5:45 PM until 6:00 AM on 10/06/2021. COC #2 stated Patient #21 would not really talk to her, unless the patient wanted something to eat or drink, or to go to the bathroom. COC #2 stated the patient would not respond when asked if he/she was safe or felt suicidal.

Interview with COC #3, on 10/28/2021 at 1:55 PM, revealed she sat with Patient #21 beginning on 10/06/2021 at 5:45 AM. COC #3 stated Patient #21 was not really talking, just answering yes and no questions. COC #3 stated when asked if the patient felt safe, or felt suicidal, Patient #21 would respond with either a nod, yes, or shake his/her head no.

Continued review of Patient #21's ED record for the second ED visit, on 10/05/2021 at 4:50 PM, in ED Physician #3's notes, dated 10/05/2021 at 10:00 PM, revealed she took over the care of Patient #21 from ED Physician #1. She stated Patient #21 was not forthcoming with questioning, and he/she wished to sleep. In addition, ED Physician #3 stated the plan for Patient #21 was to involve the Psychiatrist regarding re-evaluation of the patient and to involve the SW to see if there were any other discharge options. ED Physician #3 signed out to ED Physician #2, on 10/06/2021 at 6:30 AM and documented she discussed Patient #21's anticipated plan for psychiatric re-evaluation on 10/06/2021, as was discussed with her when she took over care of Patient #21 from ED Physician #1.

Continued review of Patient #21's ED record for the second ED visit, on 10/05/2021 at 4:50 PM, in ED Physician #2's notes, dated 10/06/2021 at 6:52 AM, revealed ED Physician #2 received the patient from ED Physician #3. Continued review revealed ED Physician #2 stated the plan this morning was for Patient #21 to have a psychiatric evaluation. He stated the primary ED physician did not feel he could adequately evaluate Patient #21 because the patient had stated he/she was suicidal and would not further participate with their evaluation. On 10/06/2021 at 10:55 AM, per ED Physician #2's notes, he stated Patient #21 had been evaluated by the SW, who had attempted to find alternate placement but was unsuccessful. He stated Psychiatry again stated Patient #21 should be discharged and did not feel the patient was appropriate for inpatient admission or transfer to another facility (ED Physician #2 did not document how he was in contact with the Psychiatrist). Further review revealed documentation that Patient #21 did acknowledge to staff he/she was apprehensive about going home by self. Continued review of ED Physician #2's notes, on 10/06/2021 at 11:41 AM, revealed at this point, the facility felt they had exhausted all options and documented Patient #21 was still apprehensive but was agreeable to going home. ED Physician #2 stated, in the note, Patient #21 was given a cab voucher and discharged to the waiting room to wait for the cab ride home.

However, there was no documentation in Patient #21's second ED record that he/she received a psychiatric re-evaluation on the morning of 10/06/2021, which was the plan, as documented by ED Physician #1, ED Physician #2, and ED Physician #3.

Interview with ED Physician #2, on 10/28/2021 at 7:45 AM, revealed he came into the ED at 6:00 AM the morning of 10/06/2021. ED Physician #2 stated both psychiatry and Social Services had already come in to assess several times and evaluate Patient #21, on 10/05/2021. ED Physician #2 stated it seemed Patient #21's main concern was he/she was anxious about going home alone. ED Physician #2 stated Psychiatry did not feel Patient #21 needed to be admitted to inpatient Psychiatry and was stable to be discharged. ED Physician #2 stated Patient #21 would not talk very much. ED Physician #2 stated he did not have any concerns regarding Patient #21's safety. ED Physician #2 stated what had been conveyed to him was that the main issue was Patient #21 did not want to go home alone and did not seem to be a danger to him/herself or to anyone. ED Physician #2 believed Patient #21's Emergency Medical Condition (EMC) had been resolved. ED Physician #2 stated in retrospect, there was nothing present in the record nor his/her actions to suggest the ultimate outcome which occurred. ED Physician #2 stated Psychiatry had evaluated Patient #21 several times, on 10/05/2021, and the patient denied SI to them. ED Physician #2 stated when he told the patient they had exhausted everything they could do in the ED, he stated the patient stated, "OK, I will go home then", and got up and started to put on his/her shoes. ED Physician #2 stated Patient #21 did not voice SI to him, but he also stated he did not ask since Psychiatry had assessed and cleared the patient, on 10/05/2021.

3. Review of the Kentucky Uniform Police Traffic Collision Report, Master File #72679549, revealed an incident occurred at 11:58 AM on 10/06/2021. It was documented Patient #21 ran out into traffic and ran into a trailer being pulled by a truck, outside of the facility.

Record review of Patient #21's medical record for admission to the ED, on 10/06/2021 at 12:27 PM, after walking out into traffic and being struck by a vehicle revealed Patient #21's chief complaint was obvious right elbow injury. After exams, additional diagnoses included Closed Fracture of Right Humerus, Closed Fracture of Right Elbow, Closed Head Injury, Blunt Trauma to Chest, Blunt Abdominal Trauma, and Closed Fracture of Pelvis. Patient #21 was transferred to Facility #2 due to the severity of his/her injuries, on 10/06/2021 at 2:38 PM, where the patient expired, on 10/15/2021 at 2:43 AM.

Interview with the ED Medical Director, on 10/28/2021 at 2:15 PM, revealed Patient #21 had a thorough assessment including a medical screening exam, vital signs, and labs, to make a recommendation for discharge. The ED Medical Director stated, from his understanding, Patient #21 was discharged from the inpatient Behavioral Health Unit, and then brought to the ED. The ED Medical Director stated Patient #21 was seen and evaluated by several Medical Providers, on 10/05/2021, who all agreed the patient needed to go home and re-admission for an inpatient stay was not necessary.

The patient was not reevaluated by the psychiatrist on the morning of 10/06/2021 and was not stabilized prior to discharge.