HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to follow their policies to identify an emergency medical condition (EMC) for a potential psychiatric emergency and provide an appropriate triage process, for one patient (#5) of nine ED records reviewed for patients that presented to the ED with an emotional illness/psychiatric disturbance chief complaint from 03/31/24 through 10/03/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital's average monthly ED census over the past six months was 859.
Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance," dated 12/2021, showed the following:
- All individuals who present to the ED are provided with an appropriate MSE to determine if an EMC exists.
- The term EMC means a medical condition manifesting itself by acute symptoms including severe pain, psychiatric (relating to mental illness) disturbances and/or substance abuse.
- The MSE may range from an abbreviated examination that involved brief questioning by a qualified medical person to a complex process that involved performing ancillary studies and procedures.
- The MSE is an ongoing process and requires determination, within reasonable clinical confidence, that a medical emergency does or does not exist.
- The process requires continued monitoring and documentation and involves more than the initial triage process. The triage process does not constitute as a MSE and only determines the order in which individuals are screened.
- In the event a patient decided to voluntarily withdraw their request for examination, an appropriately trained individual from the ED staff must, offer the individual further medical examination and treatment that may be required to identify and stabilize an EMC; the patient must be educated of the risks of withdrawing their request for an MSE; and steps should be taken to secure the individuals informed written refusal of examination and/or treatment.

Review of the hospital's policy, "Management of the Emotionally Ill Patient," dated 08/20/24, showed the following:
- A patient who presented to the ED for a possible psychiatric emergency, should not be left unattended.
- A patient who has expressed suicidal ideation (SI, thoughts of causing one's own death) or who had attempted suicide, must be provided constant surveillance and attended to by a qualified staff member or law enforcement.
- The patient should be assessed for thoughts of suicide, paranoia (excessive suspiciousness without adequate cause), depression (extreme sadness that doesn't go away) and hallucinations (seeing or hearing things which are not there).
- A patient with a complaint of emotional illness, should not be discharged without a psychiatric screen that showed an absence of a mental health emergency and a medical screening that showed an absence of a physical health emergency.

Review of the hospital's policy, "Emergency Department Scope of Services," date 08/20/24, showed the following:
- An EMC is any condition that is a danger to the patient or unborn fetus or has increased the risk dysfunction or impairment to a body part or organ, if the patient is not treated in the near future. EMCs included but are not limited to, undiagnosed acute pain which has impaired normal functioning; pregnancy with contractions; substance abuse symptoms; and psychiatric disturbances. Psychiatric disturbances may include severe depression, SI or suicide attempt, dissociative state (feeling disconnected from yourself and the world around you), an inability to comprehend danger or care for themselves.
- When a patient arrived at the ED registration desk, the ED Registered Nurse (RN) is notified.
- If the patient's complaint was shortness of breath, chest pain, decreased level of consciousness (LOC, the state of being fully alert, aware, oriented, and responsive to the environment), bleeding or that of panic, ED RN or ED physician should be immediately notified by registration staff.
- The goal from patient arrival to be triaged, is as timely as possible or within 20 minutes.
- During the triage process, the ED RN completes an initial assessment and assigns an Emergency Severity Score Index (ESI, a numerical value one [most urgent] to five [least urgent] that shows priority of medical evaluations, as well as resources needed to treat patients).
- A patient who is in a high-risk situation such as a psychiatric patient, a patient at risk of harm to self or others, or who is in severe pain and or distress, will be assigned an ESI level two.
- Any patient identified as at risk of harm to self or others, should be provided a one to one (1:1, continuous visual contact with close physical proximity) sitter.
- If all ED patient care areas were occupied by other patients and a patient presented with a condition that threatened life or limb, the ED RN and/ or the ED physician were responsible to relocate stable patient to make room for the unstable patient.

Review of the hospital's policy, "Emergency Room Registration," dated 12/14/21, showed the following:
- When a patient presented to the ED, the ED registration clerk obtained the patient's date of birth (DOB), legal name and chief complaint.
- The patient will be asked to review, initial, and sign the consent to treat.
- Once all the required information is entered, the patient is then asked to have a seat in the waiting room.
- If the patient's stated chief complaint was shortness of breath, chest pain, decreased LOC, bleeding, HI/ SI, or that of panic, the ED clinical staff should be immediately alerted about the patient. If there were no clinical staff located at the nursing station, the ED registration clerk should go find a clinical staff member to be notified of the emergent patient.
- An ED registration clerk should meet a patient, who has arrived via ambulance or by police escort, at the door to complete the registration process.



Please refer to 2406 for further details.

Based on interview, record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#5) of 27 Emergency Department (ED) records reviewed from 03/31/24 through 10/03/24. The hospital failed to follow their policies to identify an emergency medical condition (EMC) for a potential psychiatric emergency and provide an appropriate triage process, for one patient (#5) of nine ED records reviewed for patients that presented to the ED with an emotional illness/psychiatric disturbance chief complaint from 03/31/24 through 10/03/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital's average monthly ED census over the past six months was 859.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance," dated 12/2021, showed the following:
- All individuals who present to the ED are provided with an appropriate MSE to determine if an EMC exists.
- The term EMC means a medical condition manifesting itself by acute symptoms including severe pain, psychiatric (relating to mental illness) disturbances and/or substance abuse.
- The triage process does not constitute as a MSE and only determines the order in which individuals are screened.
- In the event a patient decided to voluntarily withdraw their request for examination, an appropriately trained individual from the ED staff must, offer the individual further medical examination and treatment that may be required to identify and stabilize an EMC; the patient must be educated of the risks of withdrawing their request for an MSE; and steps should be taken to secure the individuals informed written refusal of examination and/or treatment.

Review of the hospital's policy, "Management of the Emotionally Ill Patient," dated 08/20/24, showed the following:
- A patient who presented to the ED for a possible psychiatric emergency, should not be left unattended.
- A patient who has expressed suicidal ideation (SI, thoughts of causing one's own death) or who had attempted suicide, must be provided constant surveillance and attended to by a qualified staff member or law enforcement.
- A patient with a complaint of emotional illness, should not be discharged without a psychiatric screen that showed an absence of a mental health emergency and a medical screening that showed an absence of a physical health emergency.

Review of the hospital's policy, "Emergency Department Scope of Services," date 08/20/24, showed the following:
- An EMC is any condition that is a danger to the patient or unborn fetus or has increased the risk dysfunction or impairment to a body part or organ, if the patient is not treated in the near future. EMCs included but are not limited to, undiagnosed acute pain which has impaired normal functioning; pregnancy with contractions; substance abuse symptoms; and psychiatric disturbances. Psychiatric disturbances may include severe depression, SI or suicide attempt, dissociative state (feeling disconnected from yourself and the world around you), an inability to comprehend danger or care for themselves.
- When a patient arrived at the ED registration desk, the ED Registered Nurse (RN) is notified.
- If the patient's complaint was shortness of breath, chest pain, decreased level of consciousness (LOC, the state of being fully alert, aware, oriented, and responsive to the environment), bleeding or that of panic, ED RN or ED physician should be immediately notified by registration staff.
- The goal from patient arrival to be triaged, is as timely as possible or within 20 minutes.
- During the triage process, the ED RN completes an initial assessment and assigns an Emergency Severity Score Index (ESI, a numerical value one [most urgent] to five [least urgent] that shows priority of medical evaluations, as well as resources needed to treat patients).
- A patient who is in a high-risk situation such as a psychiatric patient, a patient at risk of harm to self or others, or who is in severe pain and or distress, will be assigned an ESI level two.
- Any patient identified as at risk of harm to self or others, should be provided a one to one (1:1, continuous visual contact with close physical proximity) sitter.
- If all ED patient care areas were occupied by other patients and a patient presented with a condition that threatened life or limb, the ED RN and/or the ED physician were responsible to relocate a stable patient to make room for the unstable patient.

Review of the hospital's policy, "Emergency Room Registration," dated 12/14/21, showed the following:
- When a patient presented to the ED, the ED registration clerk obtained the patient's date of birth (DOB), legal name and chief complaint.
- The patient will be asked to review, initial, and sign the consent to treat.
- Once all the required information is entered, the patient is then asked to have a seat in the waiting room.
- If the patient's stated chief complaint was shortness of breath, chest pain, decreased LOC, bleeding, HI/SI, or that of panic, the ED clinical staff should be immediately alerted about the patient. If there were no clinical staff located at the nursing station, the ED registration clerk should go find a clinical staff member to be notified of the emergent patient.

Upon presentation to the ED registration desk, the registration clerk, not clinical staff, determine the immediacy of their assessment. Patients are either placed in the waiting room or they are seen by the clinical staff.

Review of Patient #5's medical record, dated 06/18/24, showed:
- At 10:07 PM, she presented to the ED with police and her chief complaint was entered as self-harm/ psychiatric evaluation.
- Staff N, ED Clerk, wrote on the Consent For Treatment form, "Patient was brought in as a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others), refused to sign" in the patient signature line.
- At 11:50 PM, Staff P, RN, documented that the patient left without being seen with a police officer (PO), daughter and family.
- There was no additional documentation provided.

Although requested, there was no police report available for Patient #5 on 06/18/24 since Patient #5 was escorted by family to the ED.

During an interview on 10/02/24 at 8:30 AM, Staff J, RN, stated that the ED does not have a dedicated triage nurse. Patients were triaged when they were brought back to be placed in a room. Suicidal patients would be given an ESI of two, during the triage process. A patient with an ESI of two should not be placed in the waiting room. The ED RN should be notified of the patient with SI by ED registration when they entered the ED. When the ED rooms were full and a patient with SI presented, they worked to clear a room to get that patient into an ED room as soon as possible. The patient with SI, was monitored every 15 minutes to make sure they did not leave or self-harm, were placed in paper scrubs and searched for high-risk items.

During an interview on 10/02/24 at 9:15 AM, Staff H, Chief Nursing Officer (CNO), stated that the ED registration clerks have been instructed to enter the patient's stated chief complaint on arrival. When a patient with SI presents to the ED, the patient would be registered and the ED RN should be alerted by registration staff of the patient if they need to be seen immediately. When a patient with SI was brought into the ED by law enforcement, the patient would be placed directly into a room. Psychiatric patients were given an ESI of two so the entire department was alerted that a patient with a possible psychiatric emergency was in the department. Ideally patients were seen by someone within 20 minutes of arrival. There were times when psychiatric patients eloped (when a patient makes an intentional, unauthorized departure from a medical facility), but she believed there were safety measures in place in the ED to prevent elopement. When a patient left before they were triaged, nursing staff should attempt to stop the patient. Ideally, they had the patient sign the refusal of services form before they left.
During an interview on 10/02/24 at 10:35 AM, Staff L, ED Clerk, stated that his job was to get information about why the patient presented to the ED upon their arrival. After they got the information, they put it on a log and created an encounter for the patient. If police brought a patient into the ED with SI or homicidal ideation (HI, thoughts or attempts to cause another's death) they knew to skip the registration desk and enter through the ambulance doors.
During an interview on 10/02/24 at 10:45 AM, Staff M, ED Clerk, stated that if a patient presented to the ED with a chief complaint of self-harm, she would immediately go and tell a nurse. If the ED was not busy, she would take the patient straight back to a room. She tried to keep SI and HI patients out of the waiting room. If a patient there for self-harm decided to leave before being seen by a nurse or physician, she would apologize to the patient about the wait time and then complete an event report.
During an interview on 10/02/24 at 11:30 AM, Staff N, ED Clerk, stated that Patient #5 was brought in by her family through the main ED entrance. Patient #5 did not want to provide any information for registration and she was placed in the ED waiting room with the PO and family that came in with her. She noticed that the patient was walking out of the ED on the camera and thought to herself, "Why is this patient leaving?" Normally when a patient was brought in by police, they were supposed to be directly placed into a room.

During an interview on 10/02/24 at 2:51 PM, Staff O, PO, stated that she received a call about an intoxicated person (Patient #5) that was having an argument with her son and who reported she had been cutting herself. It was reported that Patient #5 stated to her son, "Well, I might as well die then." The patient's daughter drove Patient #5 to the ED. She followed the patient and her daughter in her police car. When they arrived at the ED, registration told them that there would be a several hour wait time. The patient was not assessed by any staff and sat in the waiting room. After 45 minutes to an hour of waiting, the patient wanted to leave to go home and smoke. The patient was told by registration she was free to go. Staff O made it a point to tell registration why the patient was there just to make sure.

During an interview on 10/03/24 at 9:30 AM, Staff P, RN stated that she was unable to remember Patient #5 and without any documentation, could not say if she laid eyes on her while she was in the ED on 06/18/24. Whenever law enforcement brought a patient, with SI or possible SI, into the ED, they bring them into the ED through the ambulance bay and complete the required paperwork which included an affidavit. Local law enforcement were usually good about getting the required paperwork completed. Since law enforcement did not fill out the paperwork they do for patients with SI, she questioned if the patient had SI when they presented to the ED. Registration entered the patient's chief complaint and registered the patient. If the patient's chief complaint was something that needed to go straight back, registration would bring the paperwork to the ED RN and notified them of the patient's chief complaint. In the event a patient with SI presented to the ED and there were no rooms available, the patient may be sat in the waiting room with law enforcement. The law enforcement officer was allowed to be responsible for close observation while the patient waited in the waiting room. ED registration would make the call to sit the patient in the waiting room with law enforcement to observe them if the ED RN was not notified of the patient. If the law enforcement officer had to leave the hospital or was not able stay to observe the patient while in the waiting room, the law enforcement officer would have to notify ED registration. The ED nurses would need to be made aware of the situation, by registration, so they could work on getting the patient to the back so they could be closely observed. There were times when a BHU technician or a house supervisor could be pulled to sit with the patient in the ED waiting room, but the ED RN would have to be aware of the situation to coordinate resources for the patient to be observed while in the waiting room. Patients do not get triaged until they were taken back to their room. The goal to get a patient with SI triaged is within 20 to 30 minutes of arrival. If the ED RNs were not informed by registration that there was a patient with SI in the waiting room that could make the triage wait time longer.




41474