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Based on document review and interview the hospital failed to comply with the EMTALA (Emergency Medical Treatment and Labor Act) requirements at 42 CFR §489.24(d)(1). One of 1 (Patient #1) patient reviewed was discharged home while experiencing an unspecified psychotic disorder (a psychiatric emergency) before being stabilized. Physician #13 discharged Patient #1 home against the recommendations of the attending psychiatrist on 4/08/2024.


Refer to Tag A2407

Based on record review and interview the facility failed to provide stabilizing treatment to 1 (Patient #1) of 1 patient reviewed who was experiencing a psychiatric emergency before discharging the patient home.

Medical record reviews were completed on 5/16/2024 after 10:00 AM with RN Staff #9, Emergency Room (ER) Director of Nurses (DON) Staff #4, and Chief Nursing Officer (CNO) Staff #2.


Findings:

Patient #1 was discharged against the psychiatrist's recommendation for inpatient care on 4/08/2024 at 9:16 PM. Patient #1 was then admitted to an acute care hospital ER, Facility #2 on 4/09/2024 at 11:55 AM for similar and worsening symptoms. This was within 14 hours of discharge from The University of Texas Health Science Center ER. Patient #1 was subsequently admitted to the Behavioral Health Hospital, Facility #4, for management and stabilization on 4/09/2024 at the recommendation of Facility #2's Psychiatrist.

Patient #1 was a 38-year-old female who arrived at the ER by private vehicle on 4/08/2024 at 5:02 PM accompanied by her mother. The chief complaint was "Psychiatric Evaluation".

A review of the triage note dated 4/08/2024 at 5:13 PM by Registered Nurse (RN) Staff #11 was as follows:

"Patient arrives to the ER with her mother via POV (by private vehicle). Patient's mother states that patient has not eaten x 1 week. Patient's mother states patient has not bathed for 2 weeks, patient states she bathed 2 days ago. Mother states that the boyfriend told her that the patient said the bathtub is poisoned so she refuses to use it. Mother states that the patient called the police on her a month ago because patient stated mom was putting [white stuff through the vents to poison me]. Mother states the patient has a history of Bipolar. Patient states she has been having auditory and visual hallucinations. Patient is an established patient with the Local Mental Health Authority, Facility #3. Patient states she does not wish to be dead but does not wish to keep going on the way it is now. Denies homicidal ideation (HI)".

Patient #1 was triaged with an acuity level of 3. The ER acuity level is a numerical scale (1-5) used to determine the immediate needs of a patient presenting to the ER. 1 being emergent or life-threatening and 5 being non-urgent.



A review of Physician #13's Emergency Medicine Note dated 4/08/2024 at 6:20 PM was as follows:

" ...Patient is a 38-year-old female with a history of anxiety disorder, bipolar disorder, depression, and methamphetamine use disorder who was brought in by her mother for concern of severe depression, stop eating and drinking for 1 week and stop bathing for the past 2 weeks. Patient reports having auditory and visual hallucinations, uncertain if commanding. Pt also admits to may be (sic) suicidal. A review of systems revealed that Patient #1 was positive for hallucinations and suicidal ideas ...Her mood is depressed, and her Affect is flat. Speech is delayed ..."


Further review of Physician #13's ER Course and Impression documentation dated 4/08/2024 was as follows:

"1910 (7:10 PM)-I took over care from Physician #12. Pt has hallucinations, acting strange, and is not bathing. H/o methamphetamine use. Needs urine test.

2108 (9:08 PM)-UDS (urine drug screen) positive for methamphetamines. Pt denies suicidal ideation (SI) or homicidal ideation (HI) to me. Pt feels safe but wants help with hearing voices and with drug use. Pt stable at this time and medically clear. No emergent criteria for admission at this time.

2110 (9:10 PM)- Pt hesitant to leave because she says her mom won't let her come back home. Pt does have a boyfriend that she could stay with she says ..."



During the medical record review, RN Staff #4 and #9 confirmed Patient #1's urine drug screen resulted positive for amphetamines and cannabinoids and that Patient #1 had a medication history of Adderall.


Further review of the medical record revealed Physician #13 ordered a Psychiatric Consultation for a Psychiatric Assessment on 4/08/2024.

Physician #14 consulted on Patient #1 on 4/08/2024 at 7:11 PM. A review of the Psychiatry Consult was as follows:

" ...The patient was brought in by her mother for depression, suicide, and bizarre like behavior. The patient states that she can eat and her stomach is upset. She states she thinks she is dying and she smells like death. The patient currently has chest pain with point tenderness. It is a stabbing sharp pain non radiating 10 out of 10 pain. It has been going on for the last 3 days and feels like a panic attack...
Patient #1 was seen in the ER on 1/13/2024 with a similar presentation.

Collateral information: (Patients mother)
She states that her daughter has not eaten in 4 days due to her stomach hurting. She has been hearing voices, telling her that people are poisoning her. She can't shower because there is blood and poison in the bathtub. She has called the police on her parents multiple times. She has not been taking her medications for a couple of days because she has been with her boyfriend. Her boyfriend just broke up with her and she could no longer stay with him. She would tell her mom that she wished she was dead and a week ago she took pills to overdose.
She had multiple hospitalizations here and a previous history of suicidality trying to overdose on pills ...

Mental Status Evaluation:
Appearance: disheveled
Behavior: psychomotor retardation
Speech: delayed and soft
Mood: not a great mood
Affect: blunted
Thought Process: blocked
Thought Content: suicidal ...


Assessment of Patient:
The patient's current condition appears to be similar to that of prior admission with underlying psychotic disorder exacerbated by concurrent methamphetamine use and medication non-adherence. The patient's acute risk of suicide is high due to her currently endorsing suicidal ideations and her chronic risk of suicide is high due to previous suicide behaviors. Diagnostic consideration, given to unspecified psychotic disorder, unspecified mood disorder, and Stimulant Use Disorder.

The patient would benefit from admission to an acute psychiatric unit for close monitoring for safety and adjustment of psychotropic medications. Overall not stable for discharge due to current suicidal ideation and bizarre behavior. Treatment plan was discussed with the patient and inpatient admission is appropriate at this time. Will defer medication initiation to primary excepting (sic) team.

The patient voiced understanding and agreed with the treatment plan. The psychiatric service will continue to follow the patient as necessary ...

Diagnostic Impressions:
Unspecified psychotic disorder
Unspecified mood disorder
Stimulant use disorder ..."


The attestation statement signed by Physician #15 (Attending Psychiatrist) was as follows:

"The patient's history, physical exam findings, pertinent ancillary data, assessment, and plan were discussed with the Resident Physician, and I agree with the details as documented by the Resident Physician in their note. Additionally, I personally examined this patient and I agree with the details as documented by the Resident Physician ..."

ER, DON Staff #4 confirmed Patient #1 was discharged home by Physician #13 on 4/08/2024 at 9:16 PM against the recommendation of Psychiatrist #14 and Psychiatrist #15.


An interview was conducted with the ER DON, Staff #4 on 5/15/2024 at 12:15 PM.

ER DON Staff #4 was asked why the patient was discharged after the psychiatrist made the recommendation for admission to stabilize the patient. ER, DON Staff #4 replied, "I don't know. The resident saw the patient, but the attending also saw the patient and agreed with the resident's assessment and plan. This patient has been here several times and had several inpatient stays for psych". ER, DON Staff #4 confirmed there was no documentation by Physician #13 as to why he did not agree with the psychiatrist and admit the patient. ER, DON Staff #4 was asked if there was bed availability on 4/08/2024 at the hospital and she confirmed there was availability for a new admission.

ER, DON Staff #4 was asked if the ER nurses or the ER Physicians have the behavioral health patients agree and sign a patient safety plan before discharge. ER, DON Staff #4 stated, "No they do not. Psychiatry may but the ER staff does not.".

A request for the ER Policies and discharge policy was made on 4/08/2024. ER DON Staff #4 confirmed there were no ER-specific policies, and the ER followed the same policies as inpatient services. Also, it was confirmed there was no discharge policy. ER, DON Staff #4 stated, "If there are specific discharge needs the staff calls Case Management. There is always someone on call in the case management department".

An interview was conducted with Physician #8 on 4/08/2024 at 1:00 PM. Physician #8 confirmed she was the Psychiatrist that was assigned to the ER. Physician #8 was asked if she was the attending psychiatrist for the residents. Physician #8 replied, "There is always an attending psychiatrist available for the residents. I am here Monday through Friday and I provide services for the ER. After hours there is always someone on call and the residents communicate with us on every patient that is seen. The residents are covering the ER 24/7 on a call rotation and the attending psychiatrist does the same. They are never left without someone to contact or to be there with them". Physician #8 was asked if the ER physician and the psychiatrist work together to determine the best outcome for the patient. Physician #8 stated, "Yes".

An interview was conducted with Physician #7, ER Physician, on 4/08/2024 at 2:10 PM. Physician #7 was asked if the Psychiatry Residents were consulted on patients who needed a psychiatric evaluation in the ER. Physician #7 stated, "They look at the board on the computer and see if there are patients that need to be evaluated by psych and they go and see them. Sometimes we will both go to the patient's room together and I will do the medical clearance and introduce the resident and they will continue with the psych assessment. Sometimes they just see the patient if the chief complaint is psychiatric evaluation needed". Physician #7 was asked if the ER physicians would discharge patients even when the consulting psychiatrist is recommending inpatient care. Physician #7 stated, "The ER doctor determines if the patient is clear for discharge or not".


The complainant alleged that she was told by the local mental health authority, Facility #3, to take the patient to the ER for an assessment, and when they did not admit the patient, she was told to take the patient to an acute care hospital ER, Facility #2.


A review of the call logs provided by the local mental health authority; Facility #3 was as follows:

" ...The Local Mental Health Authority, Facility #3 documented on 4/08/2024 at 4:42 PM that Patient #1's mother contacted the local mental health authority, Facility #3, and requested assistance for her daughter, Patient #1. She was advised to take the patient to the ER or she could call back on the morning of 4/09/2024 and have the client referred to the (Mental Health Clinic) MHC for assessment. A follow-up call was documented by Facility #3 at 6:04 PM. Patient #1 was in the ER at The University of Texas Health Science Center for an assessment at that time. An additional follow-up call was documented on 4/09/2024 at 10:37 AM and no information was provided to Facility #3 due to HIPPA. The call center, Facility #3, had the spelling of the patient's last name incorrect. On 4/10/2024 at 10:41 AM Facility #3 contacted the Social Worker at Facility #2, an acute care hospital and confirmed Patient #1 was treated in their ER and admitted to a psychiatric hospital, Facility #4 for in-patient Care on 4/10/2024.


A review of the medical record provided by the acute care hospital; Facility #2 dated 4/09/2024 revealed Patient #1 arrived a 11:55 AM noting the same chief complaints as the previous hospital. Patient #1 was examined through telehealth services by Psychiatry on 4/09/2024 at 3:10 PM.

A review of the telehealth services was as follows:

" ...HISTORY OF PRESENT ILLNESS: Patient presents ER today due to concern for possible needing psychiatric admission. Patient is a longstanding history of bipolar disorder, is on multiple medications for depression and family states that she is "like a zombie" that she does not take a shower, does not eat, is having hallucinations and paranoia. She sees people that are not there, sees blood in the shower so she will not take a shower for weeks, she states she is taking her medications. She denies any active suicidal ideation or homicidal ideation, however, does have a history of overdose as a suicide attempt in the distant past. She denies any major trauma, or other complaint. Pt UDS positive for Amphetamines and Cannabinoids. Pt endorses taking Adderall,(an amphetamine drug used to treat attention deficit disorder) Klonopin (a medication used to control panic attacks and seizures), Zyprexa (an antipsychotic medication). Per med list pt is on guanfacine (a medication used to treat ADHD), Klonopin, and also Restoril (a medication used to treat insomnia). Patient was seen via telehealth video conferencing in secure location. Pt is awake, alert, and oriented x 4. Pt states name and DOB. Pt also identified by staff/family at bedside. Pt is voluntary. Consult reason listed as "psychotic". Pt is having difficulty responding to questions. Pt is responding to stimuli, continues to move her hands and look around the room. Pt states she guesses she is depressed. Pt states she came to the hospital because she is hearing things. Pt states she is hearing things in the shower, cannot sleep, issues with her couch. Pt states the house is messed up and she cannot wear her clothes. Pt states that everyone else says it is not real. Pt states she lives with her parents. Pt states does not work or go to school. Pt states she does take medication. Pt states she takes Klonopin, Depakote, levothyroxine, and Zyprexa. Pt states she has been taking her medication prior to coming here. Pt states she is hearing the voices a lot. Pt states the voices are telling her to do things. Pt states "sorry for being rude". Pt states they tell her how to shower, how to sleep, everything and all day every day and it is very loud. Pt states the voices do not tell her to hurt herself or others. Pt states no SI or HI. Pt denies VH. Pt states she has been diagnosed with bipolar, anxiety, and schizophrenia. Pt then states has not been diagnosed with schizophrenia, but it seems she may have it. Pt endorses she has used etoh (alcohol). Pt states her medications have not been helping with her voices at all. Pt would like her meds looked at/adjusted ...


Disposition:
At this time, patient does present as gravely disabled. Recommend inpatient psych stay secondary to elevated risk factors, and a lack of meaningful protective factors. At this time, patient requires active treatment furnished directly by inpatient psychiatric facility personnel at levels of intensity and frequency exceeding what may be rendered in an outpatient setting. My recommendation is patient would benefit from inpatient psychiatric stay for stabilization and management once medically cleared.

The patient is not psychiatrically cleared. Patient would benefit from inpatient psychiatric placement for further treatment and evaluation once medically cleared to discharge ..."


The patient was transferred via ambulance to an inpatient Behavioral Health Hospital, Facility #4 on 4/09/2024 at 10:27 PM for inpatient behavioral health care.

Patient #1 was discharged home from The University of Texas Health Science Center, against the psychiatrist's recommendation for inpatient care on 4/08/2024 at 9:16 PM. Patient #1 was then admitted to an acute care hospital ER, Facility #2 on 4/09/2024 at 11:55 AM for similar and worsening symptoms. This was within 14 hours of discharge from The University of Texas Health Science Center ER. Patient #1 was subsequently admitted to the Behavioral Health Hospital, Facility #4, for management and stabilization on 4/09/2024 at the recommendation of the Psychiatrist.