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Based on medical record review, document review, and staff interview the critical access hospital (CAH) failed to follow their Emergency Medical Treatment and Labor Act (EMTALA) policy regarding stabilization and/or transfer of patients having an emergency medical condition (EMC) for 1 (Patient #3) of 20 patients selected from the ED log for review for the past six months from October 2015 to March 2016. The facility discharged Patient #3 even though the patient remained agitated, had rambling thoughts, and thoughts of harming himself.



Findings include:


- Patient #3's medical record reviewed on 3/9/2016 at 11:15 AM revealed the patient presented to the CAH's Emergency Department (ED) on 1/23/16 at 2:35 PM for "Suicidal Ideation" (thoughts of suicide). ED Physician Staff A's History and Physical at 2:48 PM indicated Patient #3 had been released from the mental hospital two days prior on 1/21/16 with a diagnosis of bipolar disorder and prescribed medications including alprazolam (Xanax--a medication used to treat anxiety and panic disorders) and ambien (a medication used to treat sleeping problems). The qualified mental health provider (QMHP) licensed professional counselor Staff D presented to the ED on 1/23/16 at 4:35 pm and after performing her screening recommended that patient #3 needed inpatient psychiatric services and completed paperwork to place the patient on an involuntary hold. The CAH made several unsuccessful attempts to transfer patient #3 to an inpatient psychiatric facility. The initial plan of care for the patient after the unsuccessful attempts to transfer the patient was to place the patient in observation status until a psychiatric bed became available. Patient #3's behaviors escalated and the CAH staff agreed to have the police officers arrest him and take him to jail. The CAH's ED Physician Staff B/the QMHP LPC Staff D/or other CAH staff failed to provide any further examination or stabilizing treatment for patient #3's EMC and they allowed an unstable patient with an EMC to discharge to Law Enforcement officers.


- The hospital's policy "EMTALA Screening, Stabilization, and Transfer Policy" reviewed on 3/9/2016 at 8:00 PM directed, " ...It is the policy of the hospital to comply with all applicable laws and regulations relating to the provision of emergency services and transfer of patients, including requirements as defined in the Emergency Medical Treatment and Active Labor Act (EMTALA) ...An Emergency Medical Condition (EMC): is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe chest pain, psychiatric disturbances and/or symptoms of drug abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual in serious jeopardy, b. Serious impairment to bodily functions, c. Serious dysfunction of any bodily organ or part ...With respect to psychiatric conditions; a. The individual is assessed to have a psychiatric condition for which inpatient psychiatric care is medically indicated ...the individual is expressing suicidal or homicidal thoughts or gestures and is determined to be dangerous to self or others ... Stabilize means that the treating physician or authorized qualified medical personnel, attending to the individual in the emergency department or hospital has determined with reasonable clinical confidence that the EMC has been resolved.

- Policy titled "Treatment and Referral of Emotionally Ill or Chemically Dependent Patients "reviewed on 3/14/2016 at 2:45 PM directed "...(the CAH) does not have the capabilities to provide inpatient psychiatric or substance abuse treatment services. Patients presenting to (the CAH's) emergency department (ED) with symptoms of psychiatric or substance abuse conditions will be provided a medical screening exam (MSE) to determine whether an emergency medical condition (EMC) exists, in accordance with the EMTALA policy .... And ... Mental Health Center AA provides on call professional services for patients in need of psychiatric or substance abuse assistance, and may be requested to assist in providing a MSE to determine whether a " Psychiatric or Substance Abuse EMC " exists. If such an EMC exists, then it is the policy of (the CAH) to provide stabilizing treatment until the EMC is " Stabilized, " or if (the CAH) does not have the capabilities to stabilize such EMC, to effect an appropriate transfer of the patient to another facility for further stabilizing treatment in accordance with the EMTALA Policy.

- The hospital's policy "Assessing Individuals with Psychiatric Conditions in the Emergency Department" reviewed on 3/9/2016 at 8:10 PM directed "...If a psychiatric EMC exists, (the CAH) will provide treatment to stabilize the psychiatric EMC or if (the CAH) does not have the capabilities to stabilize the psychiatric EMC (the CAH) will effect an "Appropriate Transfer" of the individual to another facility for further stabilizing treatment in accordance with the EMTALA Screening, Stabilization, and Transfer Policy..."

Refer to C - 2407 for further details

Based on record review and staff interview, the facility failed to provide further examination or stabilizing treatment within their capabilities for one patient (Patient #3) with an emergency (psychiatric) medical condition out of twenty patients reviewed. The facility discharged Patient #3 from the Emergency Department (ED) to law enforcement officers in an unstable condition.

Findings included:

- The CAH/Hospital database worksheet updated on 3/9/16 showed the CAH had a dedicated emergency department and provided emergency psychiatric services.
- Patient #3's medical record reviewed on 3/9/2016 at 11:15 AM revealed the patient presented to the CAH's Emergency Department (ED) on 1/23/16 at 2:35 PM for "Suicidal Ideation" (thoughts of suicide). The ED Physician Staff A's History and Physical at 2:48 PM indicated Patient #3 had been released from a mental hospital two days prior on 1/21/16 with a diagnosis of bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and prescribed medications including alprazolam (Xanax--a medication used to treat anxiety and panic disorders) and Ambien (a medication used to treat sleeping problems).

- Documentation of Nurses' notes showed patient 3's behavior became increasingly more agitated and erratic as time passed:

At 4:10 pm RN Staff J documented "Patient went into the stock room and retrieved clothes...Patient Agitated. Emergency medical technician (EMT) Staff M in room with patient. Security called to sit with patient".

At 5:52pm RN Staff J documented "Patient standing in doorway of room. Stating he is going to get clothes and leave. The QMHP (qualified mental health provider) Licensed Professional Counselor Staff D and EMT Staff M in with patient."

At 5:53pm RN Staff J documented "Patient stating he is not going to another facility. States is not suicidal and stating he is going to leave. Continues to speak with the QMHP and Nursing staff. Patient agitated."

At 6:05 pm RN Staff F documented "Trying to get pt (patient) to stay in room. Pt states "were you here when I overdosed on 9000 mg (milligrams) of Seroquel (antipsychotic medication used to treat bipolar disorder? ...Pt stated 'you should have let me die then'."

At 6:09 pm RN Staff E documented "Pt had a Xanax on the counter. Went in to introduce myself and pt was seen snorting a crushed Xanax. ED Physician Staff A and B agreed that involuntary admission was necessary. Police department contacted. Officer on the way."

At 6:15 pm RN Staff E documented "Pt is standing in doorway with officers at side. Pt has aggressive behavior. Pt asking officer how quick he could take him down."

At 7:52 pm RN Staff E documented "Mental health in to talk with pt regarding involuntary admission. Pt cusses at mental health worker. Pt states, 'I'm going to try to hang myself at this hospital too.' Pt shortly after says he is not a suicide threat. This nurse just walked out of room. Officer still at bedside."

At 9:45 pm RN Staff E documented ...Pt requesting another Xanax, 'so I can snort it'."

At 10:34pm RN Staff E documented "CNO (Chief Nursing Officer) contacted regarding status of pt admission. Pt needs to be 1:1 observation. Calling in male aid to sit with pt. Clinical Resource Nurse (CRN) Staff N notified. Security officers also made aware of pt agitation and the need for a security guard to possibly sit with pt.

At 10:45 pm RN Staff E documented "Pt up in room and not following directions. Officer threatening handcuffs. This nurse stepped out of room for safety reasons."

At 11:00 pm RN Staff E documented "Still attempting to de-escalate the situation. Called CRN Staff N that 1:1 with an aid is not safe. Looking to see if officer has the ability to stay and sit with pt."

At 11:07 pm RN Staff E documented "Pt having confrontation with officer. he is not following commands. Officer is threatening to place pt in handcuffs. Pt asking officer to slam head in to the ground and break his nose."

At 11:14 pm RN Staff E documented "Still attempting to de-escalate the situation. Officer called in backup. Officer closed door. Security officer and officer at bedside."

At 11:23 pm RN Staff E documented "Officers are unable to sit with pt in the hospital due to staffing issues. Officer is going to contact chief regarding placing pt under arrest due to disorderly conduct."

At 11:27 pm RN Staff E documented "Officer is waiting to hear back from chief. He states that they may not be of any assistance to us. Pt is medically stable and Mental health can't provide a place to stay, so they would send him home. Officers made aware that pt will absolutely not be able to go home. Pt talking about shooting himself in the head at this moment. "I will blow my brains out with a gun. I need my meds and need to be sent home'."

At 11:29 pm RN Staff E documented "Pt talking about suicide by shooting himself at this time. Three officers and EMT Staff N at bedside."

At 11:31 pm RN Staff E documented "Pt is wanting to go to his room. Educated pt that we can not take him to a room because of a safety issues. Pt is a threat to himself and to staff."

At 11:37 pm RN Staff E documented "Contacting QMHP. officer on the phone with her regarding a disorderly conduct situation earlier where pt told her and this nurse to "_ _ _ _" off. Officer states he needs something stating the pt is medically cleared to be taken. ED Physician staff B notified. Will call CNO."

At 11:45 pm RN Staff E documented "Pt in room with officers. Contacting CNO prior to officers taking pt". Pt placed in handcuffs. Belonging sent with officer. Pt escorted out of the ED with three officers at side.


- Mental Health Notes reviewed on 3/9/2016 at 1:05 PM revealed the QMHP documented patient #3 "was found to be a current and potential danger to himself. It was recommended he be hospitalized involuntarily because he was not capable of making an informed decision " and "it is recommended this patient have eyes on for his stay including bathroom visits. He should not have access to his phone. He is a high risk for suicide and precautions should be taken." Qualified Mental Health Professional (QMHP) Staff D indicated on the "Application for Emergency Admission (for observation and treatment)" form that patient #3 is believed to be a mentally ill person subject to involuntary commitment for care and treatment.

- After several attempts to transfer patient #3 on 1/23/16, the QMHP was notified an inpatient psychiatric bed would be available in 2 days (on 1/25/16) at the state psychiatric hospital located about 80 miles away.

- ED Physician Staff B documented the patient's initial plan of care on 1/23/16 at 10:35 pm ...He (patient #3) will be placed in observation status. Physician Staff B's documentation on 1/23/16 at 11:39pm revealed the patient had become "belligerent verbally abusive threatening there is no security here to watch patient one on one he is under arrest and will go to jail he is medically stable." There was no evidence in the medical record that ED Physician Staff B provided patient #3 with any further examination or stabilizing treatment prior to discharge. Physician Staff B's documentation in the medical record indicated patient #3's condition at the time of discharge (11:45 pm) was "Guarded".

- ED Physician Staff B interviewed 3/10/2016 between 9:00 AM and 9:30 AM acknowledged when they documented the patient was medically stable in the medical record they did not conclude that the patient was psychiatrically stable. Staff B indicated an individual presenting to the ED with acute psychiatric symptoms has an emergency medical condition (EMC) that needs to be stabilized prior to discharge or transferred to an appropriate facility. Staff B acknowledged Patient #3 was in fact not stable for discharge at the time they were arrested and allowed to leave with the police officers.

- QMHP Staff D interviewed on 3/10/2016 between 10:25 AM and 10:55 AM stated patient #3 was not safe for discharge. She had left the facility around 10:30 pm that night after Physician Staff B made the decision to place patient #3 in observation until the inpatient psychiatric bed became available two days later. Staff D revealed a police officer called her after that and asked if the patient had been aggressive toward him/her. Staff D stated patient #3 had been and was informed they were arresting the patient for disorderly conduct and taking him to jail. Staff D reported patient #3 needed to be in a safe environment and felt the observation unit may have given him the opportunity to self-harm or harm others. Staff D indicated they didn't feel this was a bad decision.

- Registered Nurse Staff I (Current ED Director) interviewed on 3/11/2016 between 8:30 AM and 9:30 AM revealed the RN staff has Mental Health patient packets with a checklist to help them care for this patient population. A document within the packet titled "Behavior Health Patient Discharge Criteria "directs"...1. Primary nurse caring for the patient...will notify the administrator on call prior to discharge home. 2. Administrator on-call will query the primary nurse...to ensure documentation supports "stable for discharge". 3. If documentation does not support "stable for discharge" the primary nurse will be directed to communicate the need for further documentation to the ED physician... Questions include: Has mental health consult been completed? Does the provider agree with recommendation? Does the documentation support safe discharge? If provider does not agree with mental health recommendation, is clinical resoning apparent in the medical record? RN Staff I confirmed that the record did not show that the Administrator requested additional documentation to support that the patient was stable for discharge or that RN staff E communicated the need for additional documentation to ensure patient #3 was stable for discharge to ED physician staff B.

- RN Staff E interviewed on 3/10/16 at am acknowledged they did not feel jail is a safe disposition for a patient with an EMC that has not been stabilized and Patient #3 was not psychiatrically stable at the time they left with police.

- Administrative (CNO) Staff G interviewed on 3/10/2016 between 11:15 AM and 12:00 PM indicated they were called by RN Staff E while Patient #3 was being seen in the ED. Staff G acknowledged they agreed with the plan of care to admit Patient #3 to observation until a mental health facility bed became available. Staff G indicated later in the evening RN Staff E notified them in the change of plan to have Patient #3 arrested and taken to jail. Staff E indicated they agreed with this plan after receiving report the patient was combative and failed to follow direction by the police officers in the ED. Staff G acknowledged they had been informed the patient was medically cleared but knew the patient's psychiatric EMC had not been stabilized. Staff G admitted "technically no, he (patient #3) should not have been discharged" before his EMC was resolved or until he could transfer for further care and treatment.

Administrative (Risk Manager) Staff H interviewed on 3/9/2016 at 3:00 PM indicated they were notified of patient #3's status in the ED. Staff H revealed they did not have the resources to provide psychiatric treatment and were concerned with how to keep the patient and the CAH's staff safe. Staff H stated local law enforcement officers were requested and were here for a time but they were unable to commit to staying with the patient until an appropriate transfer could be arranged. Staff H reported the patient continued to confront the officers who made the decision to arrest the patient and advised Physician Staff B to document in the patient's medical record that patient #3 was verbally abusive and threatening and that he was medically stable. Staff H acknowledged a patient with a psychiatric condition like this has an emergency medical condition and patient #3's psychiatric symptoms were not stabilized prior to discharge.