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Based on document reviews and interviews, the facility failed to ensure that one patient (#1) out of 23 emergency department (ED) records reviewed received a complete medical screening exam (MSE), in order to determine whether or not an emergency medical/psychiatric condition (EMC) existed. The facility failed to ensure compliance with 42 CFR 489.24. Refer to citation at A-02406 for examples.


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Based on policy review, record review and interviews, the facility failed to ensure a complete medical screening examination (MSE) within the facility's capacity and capabilities to determine if an Emergency Medical Condition (EMC) existed for one patient (#1) out of 23 Emergency Department (ED) patient records reviewed. The main campus ED sees an average of 135 patients daily and the psychiatric campus sees an average of 20 unscheduled walk-in patients daily. The main campus census was 276 and the psychiatric campus census was 69.

Findings included:

1. The facility failed to ensure Patient #1 received a complete medical screening examination and failed to thoroughly assess the patient's homicidal thoughts during the psychiatric assessment to determine whether or not an emergency medical condition existed.

2. Record review of the Affidavit in Support of Application for Detention, Evaluation and Treatment/Rehabilitation - Admission for 96 Hours, not dated, showed the Life Coach documented that the patient became upset when a peer entered his apartment. He asked the other person to leave and told his Life Coach that he was feeling homicidal because that person had been bullying him. He stated that Columbine was about to happen again and that he wanted to torture two of the kids where he lived by shooting one of them repeatedly next to his head so he would lose all of his hearing. He also stated that he wanted to hurt another client with weapons. When asked if he had a gun he said he didn't but that he had plenty of weapons he could use.

3. Review of Patient #1's Behavioral Health Assessment showed the assessment was initiated 06/14/14 at 12:00 AM by Staff J, Mental Health Registered Nurse (MHRN). Patient #1 presented to the facility agitated and in handcuffs, accompanied by a police officer and his Life Coach (involves supporting clients in life skills and decision making) for assessment.

Further review for the Behavioral Assessment showed Staff J documented the following:
- During the assessment the Patient was very angry, calmed down and then became impatient and the assessor ended that assessment to be completed after the doctor was able to provide orders.
-Patient was on medication that he took daily but no notation of how many medications or what they were for.
- Unable to assess alcohol history, addictive behaviors or addictions treatment history and whether the patient felt safe where he lived.
There was no documentation of vital signs, medical or physical assessment or that the patient was adequately assessed and then reassessed regarding his homicidal behaviors at any time during the encounter.

4. During a telephone interview on 07/02/14 at 9:07 AM, Staff J, MHRN, Intake Assessor for Patient #1, stated that as an intake assessor her responsibility was to assess individuals for threats to themselves or others and the need for in-patient stay. She stated that Patient #1 came in with a police officer and was accompanied by his Life Coach staff member from the group home where he resided. The patient was handcuffed at the time of arrival. After a few minutes the patient seemed to calm down and the police officer left.

Staff J stated that she did not have admission criteria for the Psychiatric unit. She stated that once she had assessed the patient her responsibility was to contact the doctor, go over the assessment and the doctor made the decision to admit the patient based on her assessment.

During a telephone interview on 07/09/14 at 5:00 PM, Staff J stated that her typical assessment would include a temperature, blood pressure, heart rate, pulse, height and weight. She stated she would ask the patient if they had any medical problems, and past hospitalizations. She stated that typically medications were recorded but they did not make a list of medications unless the patient was admitted. She had no answer for why the vital signs, height and weight were not documented.

Staff J stated that the patient was angry and acting out toward his Life Coach, he broke the plastic frame covering a document on the wall in the intake office and threatened to urinate and spit on the floor. Staff J stated that she called for security presence and another staff member to assist with calming the patient. Staff J could not recall the timeframe of events.

Staff J stated that her Homicidal assessment of Patient #1 was based on information provided by the Life Coach and from the patient telling her he wanted his roommate out or he was going to kill him. She stated that she asked him if he had access to firearms because it was a question on the assessment but she did not ask him if he had access to other weapons and did not recall he had made a statement that he had access to other weapons.

5. During a telephone interview on 07/02/14 at 9:40 AM, Staff F, Psychiatrist, stated that he was the Psychiatrist on-call the evening of 06/13/14. He stated that based on the psychiatric assessment Patient #1 was socio-pathic (characterized by antisocial behavior) and that the suicidal/homicidal stuff and reference to Columbine and guns spoke to the patient's anger. He stated that the patient had no access to guns and that he backed off the ranting when he calmed down. He stated that the patient lived in a group home with a controlled environment because of his chronic mental condition and socio-pathic behavior.

Staff F stated that Staff J's assessment seemed to be accurate of the situation. He stated that at the time of his evaluation the patient had an anti-social disorder. He stated that his rational for not admitting the patient was because acute inpatient treatment was not appropriate for treatment of socio-pathic episodes.

During a telephone interview on 07/08/14 at 4:35 PM, Staff F stated that Patient #1 was a healthy 19 year old and would not have medical issues. He stated that he would expect vital signs to be checked and a few medical related questions documented in the record but the main focus would have been on the psychiatric issues. He stated that during the interval of time the patient was there he calmed down considerably, an indication the homicidal thoughts were due to his anti-social disorder.

Staff F stated that the fact that the patient was in an apartment based independent living situation instead of a group home would not have changed his decision to discharge the patient. He stated that the patient had no AXIS I (describes clinical symptoms that cause significant impairment) illness and did not meet criteria for admission to an acute psychiatric facility. He stated that if the group home could not handle the patient because he had assaulted his roommate then he should have been charged with assault and taken to jail.

6. During an interview on 06/30/14 at 2:15 PM, Staff H, Master of Social Work (MSW), Intake Coordinator, stated that unscheduled patients presenting to the Psychiatric facility should have a basic medical assessment including vital signs by a Registered Nurse (RN) and an RN or Social Worker (SW) assessed the patient's mental status. She stated that when a patient was identified as having a medical problem the House Supervisor was notified and the patient was transferred to the facility's dedicated emergency department to complete the medical screening examination and stabilizing treatment.








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