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Based on record review and staff interviews it was determined the facility failed to comply with Section 484.24(a). The facility failed to provide an appropriate medical screening examination for one (1) of twenty (20) sampled patients (Patient #1) that was comprehensive enough to determine whether an emergency medical condition existed.

The facility also failed to comply with Section 484.24(d) by failing to provide further treatment to ensure the patient's condition was stabilized and his/her condition did not further deteriorate. On 04/19/16, Patient #1 presented at the Emergency Department with psychotic symptoms and homicidal ideation. The patient was discharged from the facility twenty-four (24) hours later. On 07/01/16, Patient #1 shot and killed his/her spouse and wounded a bystander who survived.

Cross Reference to: A-2406 - The facility failed to provide an appropriate medical screening examination to the extent necessary to determine if an emergency medical condition existed for Patient #1.

Cross Reference to: A-2407 - The facility failed to provide further medical examination and treatment necessary to stabilize the medical condition for Patient #1.

Based on staff interviews and record review it was determined the hospital failed to provide an appropriate medical screening examination for one (1) of twenty (20) sampled patients (Patient #1), who presented to the hospital with psychotic symptoms. Patient #1 presented to the Emergency Department (ED) on 04/19/16 with delusional and homicidal behaviors. The patient expressed the belief that this behavior was caused by a medication reaction. The hospital staff failed to fully screen the patient to determine the root cause of Patient #1's behavior.

The findings include:

Review of the Emergency Department record for Patient #1 revealed the patient presented to the ED on 04/19/16 at 11:42 AM. An initial screening by a Licensed Professional Counselor (LPC) described the patient's presenting symptoms of driving down a road the wrong way, screaming, yelling and expressing the belief that people were trying to kill him/her. The LPC documented the patient believed his/her behavior was caused by a medication reaction. The patient denied any past psychiatric history or treatment.

Review of Patient #1's medical record revealed on 04/19/16 at 12:22 PM, the ED Physician documented the patient was fearful, delusional and paranoid. The patient stated a similar event happened the previous year and he/she was concerned that his/her present symptoms were caused by a medication reaction.

Further review of the medical record revealed on 04/19/16 at 12:09 PM, Registered Nurse (RN) #6 documented while driving the wrong way down the street, Patient #1 had been screaming, honking the horn and blinking the lights. On 04/19/16 at 12:39 PM, the patient was given an intravenous injection of Lorazepam (antianxiety drug) after stating that he/she felt threatened and was screaming, "Don't kill [Patient #1's spouse]." On 04/19/16 at 4:40 PM, the patient stated, "We will be married 22 years in a couple of days. Too bad we won't make it till then." When asked by the staff what he/she meant, Patient #1 stated, "We'll be dead!" On 04/19/16 at 4:53 PM, Patient #1 became "violent" with staff and other patients. He/she (Patient #1) ran into the hallway and stated, "They killed (him/her)! They're going to kill you. I am not crazy! They are going to kill you too!" The patient was mechanically restrained in a restraint chair. On 04/19/16 at 5:50 PM, Patient #1 was given an intramuscular injection of Ziprasidone (antipsychotic drug). On 04/19/16 at 6:15 PM, the patient was removed from the restraint chair and returned to bed. The ED Physician completed the paperwork for Patient #1 to be evaluated by a local mental health professional for possible involuntary hospitalization to a regional state psychiatric hospital. However, when the mental health professional arrived, the evaluation could not be completed because the patient was sleeping. The mental health professional was again called at 2:38 AM, on 04/20/16. The ED staff was informed by the mental health professional that the evaluation could not be performed unless the ED Physician repeated the evaluation paperwork. Review of the Nursing and ED Physician Notes revealed the physician decided to wait for the hospital staff psychiatrist to evaluate the patient later that morning.

According to the document, "Psychiatric Consultation Evaluation" by an Advanced Practice Registered Nurse (APRN) dated 04/20/16 at 10:19 AM, the APRN documented the patient's symptoms prior to and following his/her arrival at the ED. The patient again stated similar symptoms occurred in the past related to a medication allergy. The APRN documented the patient to be alert and oriented. Patient #1 also denied any psychosis. After consultation with the staff psychiatrist, it was determined Patient #1 was not homicidal, suicidal or psychotic. Thus, it was decided the patient was not a candidate for voluntary or involuntary hospitalization. Arrangements were made for outpatient treatment and Patient #1 was discharged from the ED on 04/20/16 at 12:25 PM.

Interview was conducted with the LPC on 04/06/17 at 8:23 AM. The LPC stated on 04/19/16 he/she was the intake therapist for the ED. Part of his/her responsibilities as the intake therapist was to gather information from the patient and consult with the psychiatrist for possible inpatient hospitalization. The LPC stated Patient #1 was not appropriate for admission to the hospital's psychiatric unit because of his/her aggressive behavior. Further interview with the LPC revealed he/she left the hospital on 04/19/16 at approximately 11:30 PM and he/she did not know why Patient #1 was not transferred to the state psychiatric hospital.

Interview with the APRN, on 04/10/17 at 10:37 AM, revealed when he/she spoke with Patient #1, the patient was alert, oriented and did not exhibit any delusional or psychotic behaviors. The APRN conferred with the hospital psychiatrist, who decided Patient #1 did not meet inpatient criteria. The APRN stated Patient #1 was discharged after arrangements were made for outpatient treatment. Following these interviews, it could not be determined that the medical screening examinations fully explored the circumstances and details of the patient's reported past medication reactions. The interviews failed to verify that the practitioners attempted to independently verify Patient #1's statement that he/she had no previous psychiatric history or treatment. Review of the medical record documentation from these practitioners, as well as from the ED Physician, and other staff notes also failed to provide this information. The medical record documentation and staff interviews also failed to fully explain the patient's psychotic behavior prior to his/her arrival in the ED.

Review of an ED record dated 07/01/16, revealed Patient #1 was returned to the ED by law enforcement after shooting his/her spouse and another bystander. The ED Physician documented the patient's behaviors as combative and aggressive with disorganized thought processes and homicidal ideas. Further review revealed the patient stated he/she was "a child of God". On this occasion, the physician documented the patient had a psychiatric history that included hospitalization at a state hospital.

Based on staff interviews and record review it was determined the hospital failed to provide necessary stabilization treatment to a patient who was experiencing acute psychosis along with homicidal ideation. The facility failed to provide treatment to stabilize the patient to ensure these acute psychiatric symptoms would not deteriorate. This was found for one (1) of twenty (20) sampled patients (Patient #1).

The findings include:

Review of the Emergency Department (ED) record for Patient #1 revealed this person presented to the ED on 04/19/16 at 11:42 AM. An initial screening by a Licensed Professional Counselor (LPC) described the patient's presenting symptoms of driving down a road the wrong way, screaming, yelling and expressing the belief that people were trying to kill him/her. The LPC documented that the patient's belief (his/her behavior) was caused by a medication reaction. The patient denied any past psychiatric history or treatment.

Review of ED record Physician Notes, dated 04/19/16 at 12:22 PM, revealed the ED Physician documented the patient to be fearful, delusional and paranoid. The patient stated to the ED physician a similar event happened the previous year and he/she was concerned the symptoms were caused by a medication reaction.

Review of the ED record (Registered Nurse) note for 04/19/16 at 12:09 PM revealed Registered Nurse (RN) #6 documented while the patient was driving the wrong way down the street, the patient had been screaming, honking the horn and blinking the lights. On 04/19/16 at 12:39 PM, the patient was given an intravenous injection of Lorazepam (anti-anxiety drug) after stating he/she felt threatened and screaming, "Don't kill [patient's spouse]." On 04/19/16 at 4:40 PM, the patient stated, "We will be married 22 years in a couple of days. Too bad we won't make it till then." When asked by the staff what the patient meant, he/she stated "We'll be dead!" Further review revealed on 04/19/16 at 4:53 PM, Patient #1 became "violent" with staff and other patients, ran into the hallway and stated "They killed (him/her)! They're going to kill you. I am not crazy! They are going to kill you too!" The patient was mechanically restrained in a restraint chair and on 04/19/16 at 5:50 PM, was given an intramuscular injection of Ziprasidone (anti-psychotic drug). On 04/19/16 at 6:15 PM, the patient was removed from the restraint chair and returned to bed. The ED Physician completed the paperwork for Patient #1 to be evaluated by a local mental health professional for possible involuntary hospitalization to a regional state psychiatric hospital. However, when the mental health professional arrived the evaluation could not be completed because the patient was sleeping. The mental health professional was again called at 2:38 AM, on 04/20/16. The ED staff was informed by the mental health professional the evaluation could not be performed unless the ED Physician repeated the evaluation paperwork. Review of the Nursing and ED Physician Notes revealed the physician decided to wait for the hospital staff psychiatrist to evaluate the patient later that morning.

According to a document titled, "Psychiatric Consultation Evaluation" by an Advanced Practice Registered Nurse (APRN) dated 04/20/16 at 10:19 AM, the APRN documented the patient's symptoms prior to and following his/her arrival at the ED. The patient again stated similar symptoms occurred in the past related to a medication allergy. The APRN documented the patient to be alert and oriented. Patient #1 also denied any psychosis. After consultation with the staff psychiatrist it was determined Patient #1 was not homicidal, suicidal or psychotic. The psychiatrist decided the patient was not a candidate for voluntary or involuntary hospitalization. Arrangements were made for outpatient treatment and Patient #1 was discharged from the ED on 04/20/16 at 12:25 PM.

An interview was conducted with the LPC on 04/06/17 at 8:23 AM. The LPC stated on 04/19/16 he/she was the intake therapist for the ED. Part of her responsibilities was to gather information from the patient and consult with the psychiatrist for possible inpatient hospitalization. Patient #1 was not appropriate for admission to the hospital's psychiatric unit because of his/her aggressive behavior. The LPC stated he/she left the hospital on 04/19/16 at approximately 11:30 PM and he/she did not know why Patient #1 was not transferred to the state psychiatric hospital.

Interview with the APRN on 04/10/17 at 10:37 AM stated when he/she spoke with Patient #1 the patient was alert, oriented and did not exhibit any delusional or psychotic behavior. The APRN conferred with the hospital psychiatrist who decided Patient #1 did not meet inpatient criteria. The patient was discharged after making arrangements for outpatient treatment. Following these interviews, it could not be determined that, other then the administration of antipsychotic and antianxiety medications, the facility continued to provide stabilization treatment to ensure Patient #1's condition would not deteriorate following discharge. Although the medical record documented the severity of the patient's symptoms it failed to describe what interventions were taken to prevent further deterioration other then the one time dose of antipsychotic medication.

A subsequent ED record dated 07/01/16, revealed Patient #1 was returned to the ED by law enforcement after shooting his/her spouse and another bystander. The ED physician documented the patient as combative and aggressive with disorganized thought processes and homicidal ideas. The patient stated he/she was "a child of God." Further review of the medical record revealed the patient's symptoms were severe enough to warrant intravenous administration of Lorazepam (anti-anxiety drug), Haloperidol (anti-psychotic drug) and intramuscular injection of Ketamine (general anesthetic). The physician's final impression was 1.) Homicidal Ideation, 2.) Psychosis, unspecified psychosis type and 3.) Elevated serum creatinine.