HospitalInspections.org

Based on policy review, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20(l) and §489.24.

Findings included:

1. The hospital failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 7 of 11 sampled patients. (Patients #1, #3, #7, #8, #9, #11 and #13)

~cross refer to §489.24(a) & §489.24(c), Appropriate Medical Screening Exam - Tag A2406

Based on policy and procedure review, medical record reviews, emergency department logs, and staff interviews, the hospital failed to maintain medical and other records related to individuals who were discharged from the hospital for 7 of 11 sampled patients. (Patient #1, #3, #7, #8, #9, #11 and #13)

Findings included:

Review of a hospital policy titled, "Record Entries, Quantitative", effective on 03/16/2020 revealed, "PURPOSE: To provide a framework for...staff to adhere to regulations and standards as required by...(State) laws, rules, and regulations in relation to quantitative medical record entry timeliness requirements...POLICY...This requirement is viewed as an indicator of quality services...PROCEDURES: I...II...Attachment I indicates documentation requirements pertaining to this policy...Psychiatric Assessment. 24 hours dictated. 10 days to sign..."

Review of a hospital policy titled, "Medical Records" effective 05/21/2021 revealed, "...POLICY: Each patient who is evaluated...has a record written in sufficient detail and organized to identify the patient, support the diagnosis...Significant clinical information pertaining to the patient is incorporated in the medical record...I. Record Content...records include at least the following: A. Identification data, including patient's name, address, date of birth, next of kin, name of any legally authorized representative, and hospital number; (if not obtainable, the reason is entered in the record)...III. Patient records are kept confidential, secure...authenticated, legible and complete...VI...The practitioner must separately date and time their signature authenticating an entry...Documentation Instructions...Addressing Omissions...1. Every entry in the medical record must include a complete date-month, day and year. 2. Every entry must have a time associated with it.

1. Review on 05/10/2022 of the hospital's Electronic Arrival Log revealed Patient #7 was not listed. Review of a Handwritten Arrival Log of patients presenting to the hospital in 2022 revealed Patient #7, a 49-year-old female arrived at the hospital on 02/03/2022 at 1115. The Log failed to reveal Patient #7's chief complaint and had no medical record number assigned. Review of an email written by MD (Medical Doctor) #1 and sent to the ACMO (Assistant Chief Medical Officer) on 02/03/2022 at 1227 revealed, "I saw (Patient #7) today at 1130 outside of Admissions. She was accompanied by (Therapist)...and (Guardian). (Patient #7) is currently residing at (Homeless Shelter)...well-groomed and dressed appropriately for the weather. She stated several times, 'I am not going in there. You will have to drag me in there. I do not need to be in the hospital. I need an apartment. They need to find me an apartment.' She turned to (Therapist) and (Guardian) and said to them, 'You lied to me, you said you were taking me to look at an apartment!'

Review of the hospital's medical records failed to reveal a record had been created for Patient #7 and the MD #1's email failed to reveal the time Patient #7, her therapist and guardian departed the hospital campus. Review revealed no medical record number or complete medical record was available for Patient #7.

2. Review on 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #8 was not listed. Review of a Handwritten Arrival Log of patients presenting to the hospital in 2022 revealed Patient #8, a 17-year-old female who arrived at the hospital on 02/07/2022 at 1627. The Log failed to reveal Patient #8's chief complaint. The document failed to reveal a medical record number for Patient #8 or her departure time from the hospital campus. Review revealed no medical record number or complete medical record was available for Patient #8.

3. Review on 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #9 was not listed. Review of a Handwritten Arrival Log of patients presenting to the hospital in 2022 revealed Patient #9, an 82-year-old female who arrived at the hospital on 03/29/2022 at 1410. The Handwritten Arrival Log revealed Patient #9 had a history of Dementia and Bipolar disorder, but failed to reveal an assigned medical record number. The Log further revealed Patient #9 had a recent history of picking at bugs and talking at deceased husband." Review revealed no medical record number or complete medical record was available for Patient #9.

4. Review on 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #11, who arrived at the hospital on 09/21/2021 at 1527 as a "Volunteer walk-in from (Nearby County)...outpatient appt process started, taken to shelter by (named hospital's police department). The Electronic Admissions Log failed to reveal Patient #11's date of birth, age or an assigned medical record number. Review revealed no medical record number or complete medical record was available for Patient #11.

5. Review on 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #13 was not listed. Review of a Handwritten Arrival Log of patients presenting to the hospital in 2022 revealed Patient #13, a male of unknown age arrived at the hospital on 03/15/2022 at 0415. The Handwritten Arrival Log failed to reveal Patient #13's last name, date of birth, chief complaint or an assigned medical record number. Review of the document failed to reveal his departure time from the hospital campus. Review revealed no medical record number or complete medical record was available for Patient #13.

6. Review on 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #1 was not listed. Review of a handwritten Arrival Log of patients presenting to the hospital in 2021 revealed Patient #1 presented to the Admission Unit with a guardian on 05/17/2021. Review of a typed note revealed a name and approximate time seen. Note review revealed the last name of a physician handwritten at the top. Review revealed no medical record number or complete medical record was available for Patient #1.

7. Review of 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #3 was not listed. Review of handwritten and typed document revealed Patient #3 arrived to the Admission Unit on 08/18/2021 at 1900. Review revealed no medical record number or complete medical record was available for Patient #3.

Interview on 05/10/2022 at 1221 with the ACMO revealed "We are obligated to see every patient that arrives on hospital property. We have to evaluate them for an EMC (Emergency Medical Condition)." The ACMO revealed that the psychiatry providers dictated an evaluation note for every patient who presented to the admission/intake area. Interview further revealed that when patients did not meet admission criteria, the provider completed a denial supplement; which stated the reason why they were denied. Follow-up interview on 05/11/2022 at 0958 revealed that some walk-in patients did not have a medical record created due to system errors, but when that occurred the provider typed a note and sent a copy to the ACMO through the hospital's secured messenger system.

Interview on 05/10/2022 at 1234 with Registered Nurse (RN) #3 revealed once it was determined that a patient was seeking admission, the RN went out to talk to them and bring them inside. RN #3 revealed the patients who met criteria for admission had a medical record created for the psychiatrist to document their evaluation in. Interview revealed that patients who did not meet criteria for admission were given back their belongings, changed back into their clothes and provided with resources and instructions for follow-up care. Interview revealed a medical record number was not created for every patient who presented to the admissions/intake unit.

Interview on 05/11/2022 at 0920 with admissions HCT (Healthcare Technician) #4 revealed he usually listened in while patients were being assessed by the provider and tried to gather enough information to create a MRN (medical record number). HCT #4 stated that patients who did not meet criteria for admission or changed their minds were kept on the handwritten log and a MRN was not always generated.

Interview on 05/11/2022 at 0956 with MD #1 revealed a MRN was not always created for walk-in patients because there was not always enough information provided to do so.

Interview on 05/11/2022 at 1105 with the HIM (Health Information Management) Director revealed that patients who came in for an evaluation, but were not admitted were not always given a Medical Record Number (MRN). Interview revealed the hospital's current system required a patient's full name, date of birth, preliminary diagnosis, county of residence, MCO name and number and several other pieces of data that walk-in patients were often unable to provide at the time of presentation. Interview revealed the hospital's current system was not user friendly and required a lot of information in order to create a MRN.

Interview on 05/12/2022 at 1157 with the CEO and CMO revealed that with COVID, "they were seeing some patients outside. The CMO stated, "They did all the essentials, but sometimes they weren't able to get all of their information. Interview revealed that some patients presented to the admissions/intake area for other reasons such as to ask for information or get resources and might not have made it to the log, but I think we captured everyone that came in. The CEO stated, "We are working on a better process." Interview revealed the hospital's process for creating MRN's on walk-in patients was flawed and needed to be improved.

In summary, the hospital's Electronic Arrival and Handwritten Arrival Logs revealed a total of 11 patients that walked-in to the hospital over the past year and were denied admission. Review of several typed and handwritten notes by various psychiatrists revealed Patients #1, #3, #7, #8, #9, #11 and #13 were evaluated by hospital psychiatrists upon arrival to the hospital but no MRN was created for these 7 walk-in patients. Review of the Electronic Arrival Logs revealed 4 of the 6 walk-in patients (#7, #8, #9 and #13), were missing from the log and later found on a one page hand written log with missing data. Further investigation revealed the hospital did not have one centralized log with all presenting patients. Given the hospital's current practices and system limitations, providers are unable to dictate properly signed and dated notes into the system. Interviews revealed the process of keeping a handwritten log in the admissions unit has changed over time and is not always used, therefore, determining an accurate number of patients who visited the admissions area in the past year was not able to be verified. Based on the above findings, the hospital failed to create and maintain complete and proper medical records for all patients arriving at the hospital seeking care.

Based on policy and procedure review, medical record reviews, emergency department logs, staff and physician interviews, the hospital failed to maintain a central log on each individual who came to the Dedicated Emergency Department (DED), seeking assistance for 7 of 11 sampled walk-in patients. (Patient #1, #3, #7, #8 and #9, #11 and #13)

Findings included:

Review of a hospital policy titled, "EMTALA Compliance and Reporting of Suspected Violations" effective on 11/18/2020 revealed, "...B. The admitting services of Hospital maintains a central log of each individual who comes seeking assistance..."

1. Review on 05/10/2022 of the hospital's Electronic Arrival Log revealed Patient #7 was not listed. Review of a Handwritten Arrival Log of patients presenting to the hospital in 2022 revealed Patient #7, a 49-year-old female arrived at the hospital on 02/03/2022 at 1115. The Log failed to reveal Patient #7's chief complaint and had no medical record number assigned. Review revealed no medical record number was generated for Patient #7 and therefore her visit to the hospital was not captured on the Electronic Arrival Log.

2. Review on 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #8 was not listed. Review of a Handwritten Arrival Log of patients presenting to the hospital in 2022 revealed Patient #8, a 17-year-old female who arrived at the hospital on 02/07/2022 at 1627. The Log failed to reveal Patient #8's chief complaint or an assigned medical record number. Review revealed Patient #8's hospital visit was not captured on the Electronic Arrival Log.

3. Review on 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #9 was not listed. Review of a Handwritten Arrival Log of patients presenting to the hospital in 2022 revealed Patient #9, an 82-year-old female who arrived at the hospital on 03/29/2022 at 1410. The Handwritten Arrival Log revealed Patient #9 had a history of Dementia and Bipolar disorder, but failed to reveal an assigned medical record number. The Log further revealed Patient #9 had a recent history of picking at bugs and talking at deceased husband." Review revealed no medical record number was generated for Patient #9 and therefore her visit to the hospital was not captured on the Electronic Arrival Log.

4. Review on 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #11, who arrived at the hospital on 09/21/2021 at 1527 as a "Volunteer walk-in from (Nearby County)...outpatient appt process started, taken to shelter by (named hospital's police department). The Electronic Log failed to reveal Patient #11's date of birth, age or an assigned medical record number. Review revealed no medical record number was generated for Patient #9 and the Electronic Arrival Log failed to capture his age and departure time.

5. Review on 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #13 was not listed. Review of a Handwritten Arrival Log of patients presenting to the hospital in 2022 revealed Patient #13, a male of unknown age arrived at the hospital on 03/15/2022 at 0415. The Handwritten Arrival Log failed to reveal Patient #13's last name, date of birth, chief complaint or an assigned medical record number. Review of the document failed to reveal a medical record number for Patient #13 was generated and therefore his visit to the hospital was not captured on the Electronic Arrival Log.

6. Review on 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #1 was not listed. Review of a handwritten Arrival Log of patients presenting to the hospital in 2021 revealed Patient #1 presented to the Admission Unit with a guardian on 05/17/2021. Review revealed no medical record number was generated for Patient #1 and therefore his visit to the hospital was not captured on the Electronic Arrival Log.

7. Review of 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #3 was not listed. Review of handwritten and typed document revealed Patient #3 arrived to the Admission Unit on 08/18/2021 at 1900. Review revealed no medical record number was generated for Patient #3 and therefore her visit to the hospital was not captured on the Electronic Arrival Log.

Interview on 05/11/2022 at 1105 with the HIM (Health Information Management) Director revealed that patients who came in for an evaluation, but denied admission were not always given a Medical Record Number (MRN). Interview revealed the hospital's current system required a patient's full name, date of birth, preliminary diagnosis, county of residence, MCO name and number and several other pieces of data that walk-in patients were often unable to provide at the time of presentation. Interview revealed the central log (electronic arrival log) only included patients who had a MRN, so those walk-in patients who did not have a MRN generated did not show up on the log.

Interview on 05/12/2022 at 1157 with the CEO and CMO revealed that with COVID, "they were seeing some patients outside. The CMO stated, "They did all the essentials, but sometimes they weren't able to get all of their information. Interview revealed that some patients presented to the admissions/intake area for other reasons such as to ask for information or get resources and might not have made it to the log, but I think we captured everyone that came in. The CEO stated, "We are working on a better process." Interview revealed the hospital's process for creating MRN's on walk-in patients was flawed and needed to be improved.

In summary, the hospital's Electronic Arrival Logs and Handwritten Arrival Logs revealed a total of 11 patients that walked-in to the hospital over the past year and were denied admission. Medical record reviews revealed no MRN was created for these 7 walk-in patients. Review of the Electronic Arrival Logs revealed 4 of the 6 walk-in patients (#7, #8, #9 and #13), were missing from the log and later found on a one-page handwritten log with missing data. Given the hospital's current practices and system limitations, providers are unable to dictate properly signed and dated notes into the system. Interviews revealed the process of keeping a handwritten log in the admissions unit has changed over time and is not always used, therefore, determining an accurate number of patients who visited the admissions area in the past year was not able to be verified. Based on the above findings, the hospital failed to maintain complete central log for all patients arriving at the hospital seeking care.

Based on policy and procedure review, medical record reviews, emergency department logs, staff and physician interviews, the hospital failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) for 7 of 11 walk-in patient records reviewed. (Patient #1, #3, #7, #8, #9, #11 and #13).

Findings included:

Review of the hospital policy titled, "Leaving Hospital Against Medical Advice" effective 09/18/2019, revealed, "...POLICY: Only voluntarily admitted patients may be given a discharge against medical advice. If a voluntary patient is a minor or is adjudicated incompetent, the legally responsible person (LRP) can initiate the request for discharge...PROCEDURE: Upon request for discharge by the patient or legally responsible person, staff will: A. Obtain request for discharge...B. Explain form to patient/LRP including the following: 1. Patient may be detained for a period not to exceed 72 hours after signing form. 2. The attending physician may legally extend the 72 hour period if he/she feels the patient is a danger to self or others by petitioning the court for involuntary commitment of the patient. C. Discuss with the patient/LRP the benefits of remaining in treatment, as well as the possible outcome of stopping or delaying treatment. If the patient/LRP continues to request discharge then: 1. Witness patient/LRP signature on the request form, accurately documenting date and time. 2. Notify attending physician of patient's request for discharge as soon as possible...3. Notify the patient's social worker and place discharge request in the patient's medical record. 4. The attending physician must thoroughly document in the patient's medical record that the attending physician explained to the patient/LRP the benefits...as well as the possible outcome..."

Review of the hospital policy titled, "EMTALA Compliance and Reporting of Suspected Violations" effective 11/18/2020 revealed "Medical Screening Examination...it may be a brief history and physical examination, or it can be more extensive...depending upon the presenting symptoms and the hospital's capabilities...A. If an individual comes to the hospital and requests an examination, or a request is made on the individual's behalf...Hospital provides an appropriate medical screening examination, within its capability, to determine whether or not an emergency medical condition exists...D. All individuals who have an emergency medical condition on hospital grounds are served within the capabilities and resources available throughout the hospital, regardless of ability to pay. K. The physician completes the Evaluation for Admission, and admission denial supplement (last page of the Psychiatric Assessment). L. If the individual is denied admission, and is medically stable, no further treatment or documentation (other than the above) is required by the physician..."

1. Review on 05/10/2022 of the hospital's Electronic Arrival Log revealed Patient #7 was not listed. Review of a Handwritten Arrival Log of patients presenting to the hospital in 2022 revealed Patient #7, a 49-year-old female arrived at the hospital on 02/03/2022 at 1115. The Log failed to reveal Patient #7's chief complaint and had no medical record number assigned. Review of an email written by MD (Medical Doctor) #1 and sent to the ACMO (Assistant Chief Medical Officer) on 02/03/2022 at 1227 revealed, "I saw (Patient #7) today at 1130 outside of Admissions. She was accompanied by (Therapist)...and (Guardian). (Patient #7) is currently residing at (Homeless Shelter)...well-groomed and dressed appropriately for the weather. She stated several times, 'I am not going in there. You will have to drag me in there. I do not need to be in the hospital. I need an apartment. They need to find me an apartment.' She turned to (Therapist) and (Guardian) and said to them, 'You lied to me, you said you were taking me to look at an apartment!' She denied SI [suicidal ideations], HI [homicidal ideations], AVH [audio-visual hallucinations], SIB [self-injurious behavior]. She was linear and organized and voiced no delusions and was not responding to internal stimuli. She has access to her medications. She does not have access to a gun. (Therapist) stated, 'She needs a place to stay other than where she is staying. I asked if she had called the MCO [managed care organization - group of healthcare providers for behavioral health services and some community based long term care services)...She is not aggressive or self-injurious.' I explained... (Patient #7) did not meet commitment criteria, that we could not put hands on her to bring her in, that we do not admit people for placement purposes...(Patient #7) refused to get out of the car and I was talking only to (Therapist)..." Review of the hospital's medical records failed to reveal a record had been created for Patient #7 and therefore a denial supplement was not completed. Review of MD #1's email failed to reveal the time Patient #7, her therapist and guardian departed the hospital campus. Review further failed to reveal a thorough medical evaluation that included a physical exam and vital signs was performed on Patient #7.

Interview on 05/10/2022 at 1221 with the ACMO revealed that during the pandemic, it was sometimes faster for their providers to put on PPE (personal protective equipment - mask, gown, gloves, eye protection) and go outside to evaluate patients than it was to have patients come inside. Follow-up interview on 05/12/2022 at 0856 revealed, Patient #7 would not walk into the hospital. The ACMO stated that the hospital initiated IVC paperwork on any patient deemed dangerous to themselves or others, but otherwise was not able to force patients to come inside the hospital for an evaluation or admission. Interview revealed denials were usually discussed with the ACMO or the CMO. The ACMO stated that she spoke with MD #1 about Patient #7 and agreed that she did not meet admission criteria. Interview revealed a physical assessment and vital signs were only performed for patients who met admission criteria or exhibited outward signs of an emergent medical condition such as withdrawal symptoms.

Interview on 05/11/2022 at 0920 with admissions HCT (Healthcare Technician) #4 revealed he remembered Patient #7 and was on duty when she presented to the hospital on 02/03/2022. HCT #4 stated that patients who did not meet criteria for admission or changed their minds were kept on the handwritten log. HCT #4 stated that he recalled Patient #7 was in the car and one of her representatives rang the doorbell and told him, "We have a patient here to be admitted." HCT #4 stated that he did not see Patient #7 up close and was not able to tell what she looked like or how she appeared.

Interview on 05/11/2022 at 0956 with MD #1 revealed she remembered Patient #7. MD #1 stated that Patient #7 refused to come inside. Interview revealed Patient #7 was brought to the facility by her guardian and therapist and was outside arguing with the two ladies at first. MD #1 stated that Patient #7 did not want to be there and said "They lied to me. What is this place? It's a hospital". Interview revealed MD #1 performed a mental status exam and risk assessment on Patient #7. MD #1 stated that the guardian and therapist wanted to talk to her, but she told them that she needed to talk to the patient first. MD #1 talked to Patient #7 until "she told me she was not talking to me anymore and went to the car." MD #1 stated that after her conversation with Patient #7, she did not feel she needed to assess her further because she had already determined that she did not have an Emergency Medical Condition that needed to be treated. MD #1 stated, "She was not having an acute psychiatric or medical emergency. The patient was well-dressed, well-groomed and dressed appropriately for the weather. She had no suicidal ideations or homicidal ideations. Her speech was normal, and thoughts were linear. She had no audio/visual hallucinations. She was not responding to internal stimuli." MD #1 stated that she always spoke to patients directly and didn't just go by what the guardian said. Interview revealed the delusions described by the guardian were not told to her directly by Patient #7 and nor were they observed.

Interview on 05/12/2022 at 1157 with the CMO revealed that with COVID, "they [psychiatrists] were seeing some patients outside. The CMO stated, "They did all the essentials, but sometimes they weren't able to get all of their information. Interview revealed the caseworker for Patient #7 "called me and wanted her admitted." The CMO stated that he spoke with the ACMO who had communicated with MD #1 and the ACMO agreed that Patient #7 did not need to be admitted.

2. Review on 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #8 was not listed. Review of a Handwritten Arrival Log of patients presenting to the hospital in 2022 revealed Patient #8, a 17-year-old female who arrived at the hospital on 02/07/2022 at 1627. The Log failed to reveal Patient #8's chief complaint or an assigned medical record number. Review of an unsigned and undated typed note revealed, "(Patient #8...This evening (2/7/22), I was called by the admissions office to see patient, who was accompanied by her mother. On evaluation, the patient reported worsening depression, hopelessness, and some anhedonia. She had also had some increased urges to self-injure. At the same time, she was future oriented and forward thinking and able to spontaneously describe using several positive coping skills. She was convincingly without active suicidal ideation. She had no plan or intent. She did not evidence any psychotic disorganization of thought or other psychotic symptoms. Her community supports included a psychotherapist, as well as an equine therapist [specialist that uses horses to promote mental health). After a lengthy discussion with the patient and her mother...the patient's mother decided the best option would be for the patient to return home and follow-up with her therapist the next day. The patient was able to convincingly assure me that she could maintain her own safety until seen again by a therapist the following day. Her mother took her home." Record review failed to reveal documentation that the attending psychiatrist explained to Patient #8's mother the possible outcome/risk of delaying treatment and taking Patient #8 home. Review revealed a medical record number was not generated for Patient #8 and therefore a denial supplement was not completed. Review further failed to reveal a thorough medical evaluation that included a physical exam and vital signs was performed on Patient #8.

Request for interview on 05/12/2022 with MD #6 (evaluated Patient #8) revealed he no longer worked at the hospital and was unavailable.

3. Review on 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #9 was not listed. Review of a Handwritten Arrival Log of patients presenting to the hospital in 2022 revealed Patient #9, an 82-year-old female who arrived at the hospital on 03/29/2022 at 1410. The Handwritten Arrival Log revealed Patient #9 had a history of Dementia and Bipolar disorder, but failed to reveal an assigned medical record number. Review of an unsigned typed note revealed, "(Patient #9) March 29, 2022 @ 1410, I was called down to the admission office to see a woman who was driven to the hospital by her adult daughter looking for help. The woman identifying herself as...said that she had brought her mother, (Patient #9) to the hospital for medication adjustments...(Daughter) reports that (Patient #9) had been in her usual state of mind until last Monday or Tuesday...when (Patient #9) began talking about her deceased daughter, husband and was speaking in English and refusing to speak to the family in Spanish, which she normally did...she was concerned because (Patient #9) lived alone behind her deceased daughter's husband...denied that (Patient #9) had been violent, wandering, setting fires or had any weapons...self injurious...reported that since (Patient #9) had gotten out of rehab, she had been receiving home health, physical therapy and hospice/palliative care...(Daughter) ... seemed to perseverate [repeat, go back over] that (Patient #9's) medications were not right...in the process of getting a new provider. (Daughter) handed me past hospital records, that indicated...Major Neurocognitive disorder and had been discharged from (named outside hospital) that day...said (Patient #9) was at baseline, there was nothing more they could do for her...She was first treated for psychiatric issues at the age of 14. Her past psychiatric treatment includes ECT [electroconvulsive therapy - brief stimulation of the brain using a mild electrical current, used to treat severe major depression or bipolar disorder that has not responded to other treatments] and multiple medications...During the evaluation, (Patient #9) appeared to be well-nourished and well-developed. She was clean and neatly dressed. She sat in the front of her daughter's car engaged in self-dialogue in both English and Spanish. She acknowledged me when I spoke to her directly but was non-sensical. She was not oriented to time or situation...She did not have any tremor, psychomotor agitation or retardation. Her speech was soft and rapid. (Patient #9's) family was advised to have her seen in the community for medication adjustments. They had taken her to (Community Mental Health Service) but left without an appointment and were 'mad' at her primary care physician. They were encouraged to reach out to him despite this since he was best positioned to determine if (Patient #9) was at her baseline and could coordinate her care as needed...They were advised that (Patient #9) did not meet the level of dangerousness for admission and that her needs would be addressed in the community. They said that they were able to stay with her at home and supervise her." Review revealed Patient #9 did not have a medical record number generated and therefore a denial supplement was not completed. Review failed to reveal a thorough medical evaluation that included a physical exam and vital signs was performed on Patient #9.

Interview on 05/12/2022 at 1508 with MD #5 revealed the physician was called by the CNA's when a patient walked in. MD #5 stated they evaluated any patient for an emergency medical condition that would bring them into the hospital. Interview revealed, that the most significant part of the evaluation was whether the patient was dangerous to themselves or others.

4. Review on 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #11, who arrived at the hospital on 09/21/2021 at 1527 as a "Volunteer walk-in from (Nearby County)...outpatient appt process started, taken to shelter by (named hospital's police department). The Electronic Admissions Log failed to reveal Patient #11's date of birth, age or an assigned medical record number. Review of an undated handwritten note that was signed by MD (Medical Doctor) #1 revealed, "Nearly 30's white male, walk-up on 09/21 presented alone. He was unkempt [untidy appearance] and malodorous [foul smelling]. He had an ankle monitor on. He was loud and cursing when I spoke with him. He stated that he had smoked meth [methamphetamine - controlled substance that affects the nervous system and can cause delirium or psychosis] several hours ago in the parking lot of (named hospital). His speech was linear and organized. He was able to give his name and the correct date. He was fully oriented. He denied SI [suicidal ideation] or HI [homicidal ideation]. He was mildly agitated...He stated that he wanted to be given some Percocet [narcotic pain medicine] and Xanax [treats anxiety]. When I told him that we could not do that, he did curse me. He denied he had any mental health issues or treatment. I told him that I would go and get some resources for him to call mental health or for substance abuse treatment. When I came back out, someone had called the police and I saw him being driven off the property in a police car." Review revealed a medical record number was not generated for Patient #11 and therefore a denial supplement was not completed. Review failed to reveal a thorough medical evaluation that included a physical exam and vital signs was performed on Patient #11.

Interview on 05/11/2022 at 0956 with MD #1 revealed she vaguely remembered Patient #11. Interview revealed that Patient #11 presented to the hospital for the purpose of obtaining a prescription for pain medication. MD #1 stated that after speaking with Patient #11, she determined that he did not have an Emergency Medical Condition. MD #1 stated that she told Patient #11 she was unable to prescribe narcotics to him and offered him some resources for substance abuse. Interview revealed that when MD #1 went inside to get the information, she returned to find Patient #11 driving away in the back of a police vehicle.

5. Review on 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #13 was not listed. Review of a Handwritten Arrival Log of patients presenting to the hospital in 2022 revealed Patient #13, a male of unknown age arrived at the hospital on 03/15/2022 at 0415. The Handwritten Arrival Log failed to reveal Patient #13's last name, date of birth, chief complaint or an assigned medical record number. Review of an undated typed note signed by "Dr. (first initial)" [MD #2] revealed, "Note from 03/15/22 about a walk-in (Patient #13 - first name only). Pt [patient] came from (Nearby City) via Uber [Car Service - similar to a taxi] to (City where hospital is located), wanting help for emotional distress. He was evaluated outside of the admissions office. He initially complained that, 'I may lose control.' When asked what it means to him, he said initially that he might hurt someone and then he said, 'I am lying.' Upon further evaluation he denied SI/HI (suicidal ideations/homicidal ideations). He had a place to live and no known access to guns. Stress: working for (Coffee shop), lives with BF [boyfriend] of 4 yrs. [years], who he has a tumultuous relationship with and who uses drugs at times...Pt reported some weight loss, but denies hopelessness, helplessness or anhedonia [inability to feel pleasure]. He remained in control, displayed no dangerousness and expressed frustration with his relationship. Disposition: Pt did not meet criteria for state admission and did not voluntarily walk-in or give his last name. He is having a tele-psych visit [virtual psychiatry appointment] with (Psychiatrist). Review of the document failed to reveal a medical record number for Patient #13 and therefore a denial supplement was not completed. Patient #13s departure time from the hospital campus was not available. Review failed to reveal a thorough medical evaluation that included a physical exam and vital signs was performed on Patient #13.

Request for interview on 05/12/2022 with MD #2 (evaluated Patient #11) revealed she retired and was unavailable.

6. Review on 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #1 was not listed. Review of a handwritten Arrival Log of patients presenting to the hospital in 2021 revealed Patient #1 presented to the Admission Unit with a guardian on 05/17/2021. Review of a typed note revealed a name and approximate time seen. Note review revealed the last name of a physician handwritten at the top. The typed note revealed "[Name of Patient #1] (seen 5/17/2021 around 2245) Earlier this evening, I was called by the admission office to see a....male who presented with his [family member]/guardian....The guardian said that [Patient #1] was functioning at the level of a 2-3 year old and was supposed to be placed in a care home the next day but that he (the guardian) had begun to feel concerned that [Patient #1] would become physically aggressive in the home with the care provider who was an elderly man. I asked the guardian if [Patient #1] had had any recent aggression and he answered, 'no'. He said that his major concern was about future acting out....Since October, [Patient #1 had had 3 episodes of aggression in the home, but none had been recent...reported (Patient #1) had not had any acute changes in his behavior or aggression....I informed the guardian that [Patient #1] did not presently meet criteria for admission, that he should take [the patient] home and continue with the plant [sic, plan] to take him to the care facility the next day. I let him know that he could have [Patient #1] seen by [organization initials] for an evaluation for medication changes. ..." Review of the documents presented also revealed handwritten notes, one of which was dated 5/17/2021 at 10:45, related to Patient #1. Identifying information including the patient's name, address, guardian, medications, and a number, possibly a social security number were listed on the notes. Review failed to revealed a medical record number was not generated for Patient #1 and therefore a denial supplement was not completed. Review failed to reveal a thorough medical evaluation that included a physical exam and vital signs was performed on Patient #13.

Review of the documents presented also revealed a handwritten note, dated 5/17/2021 at 10:45. At the top of the note was a first and last name. The first name was different from the name listed in the body of the handwritten document or the typed document. At the bottom of the second page of the handwritten note was identifying information including the patient's name, address, guardian, medications, and a number, possibly a social security number. There was no physician signature on the handwritten document. There was a third handwritten page as well with identifying information, medications, and resources related to Patient #1. There was no medical record started for Patient #1 and no further evaluation documented on the patient who was brought to the Admission Unit as a walk-in by a guardian seeking care and services.

Interview with MD #5, on 05/12/2022 at 1508, revealed Patient #1 was brought to the Admission Unit at night by a man who claimed to be his guardian and his caretaker. Interview revealed the patient had some aggression in the past but none recently and was supposed to go to an Assisted Living Facility the next day. The guardian, per interview, was hesitant because of the potential for aggression. Interview revealed the patient was not verbal, was playing with a toy, neat, smiling, trying to engage and showing no signs or aggression. Interview revealed the patient did not have any criteria for admission. Interview revealed this was a state hospital not the specialty needed for IDD (intellectual and developmental disability). The physician indicated the guardian became irate that the patient could not access services he felt the patient deserved. MD #5 stated Patient #1 did not have a medical/psychiatric emergency, the last aggression had been months before, there was a safe plan for placement, and a case manager in place. MD #5 stated she always evaluated patients for an emergency medical condition and this patient did not have one.

7. Review of 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #3 was not listed. Review of handwritten and typed document revealed Patient #3 arrived to the Admission Unit on 08/18/2021 at 1900. Document review revealed "....This evening, I was called by the admissions office to see a female walk-up. She stated 'I can't handle anything right now.' She said that she could not work or do anything and had been living in her car. She said that her husband had been assaultive and that she had no extended family support. She denied having any mental illness besides ADHD and was last prescribed Adderall for it. She denied having a PCP or outpatient providers. She said she had recently been prescribed Celexa, 'but needs something that works ...schizophrenia, I need something for schizophrenia .... (Patient #3) denied a history of suicide attempts, access to weapons, guns and suicide abuse. She was awake, alert and oriented with fair grooming and hygiene. She was dressed in street clothes and appeared to be well-nourished. She did not have any psychomotor abnormalities and had a normal gait. She denied auditory and visual hallucinations and denied suicidal and homicidal ideations. Her memory and concentration appeared to be intact. I informed Ms. (Name) that she did not meet criteria admission and attempted to get her resources to follow up as an outpatient but she refused and walked away... ." Review revealed a medical record number was not generated for Patient #3 and therefore a denial supplement was not completed. Review failed to reveal a thorough medical evaluation that included a physical exam and vital signs was performed on Patient #3.

Interview on 05/10/2022 at 1221 with the ACMO (Assistant Chief Medical Officer) revealed "We are obligated to see every patient that arrives on hospital property. Interview revealed walk-in patients received the same mental status exam and risk screenings as a referral patient did. Follow-up interview on 05/12/2022 at 0856 revealed the hospital initiated IVC paperwork on any patient deemed dangerous to themselves or others, but otherwise was not able to force patients to come inside the hospital for an evaluation or admission. Interview revealed denials were usually discussed with the ACMO or the CMO. " Interview further revealed that when patients did not meet admission criteria, the provider completed a denial supplement; which stated the reason why they were denied. Follow-up interview on 05/11/2022 at 0958 revealed that some walk-in patients did not have a medical record created due to system errors, but when that occurred the provider typed a note and sent a copy to the ACMO through the hospital's secured messenger system. Interview revealed a physical assessment and vital signs were only performed for patients who met admission criteria or exhibited outward signs of an emergent medical condition such as withdrawal symptoms.

Interview on 05/10/2022 at 1234 with RN #3 revealed once it was determined that a patient was seeking admission, the RN went out to talk to them and bring them inside. RN #3 revealed the patients who met criteria for admission had a medical record created for the psychiatrist to document their evaluation in. Interview revealed that patients who did not meet criteria for admission were given back their belongings, changed back into their clothes and provided with resources and instructions for follow-up care. Interview revealed a physical assessment was only performed on patients who met the criteria for admission.

Interview on 05/12/2022 at 1157 with the CEO and CMO revealed that with COVID, "they were seeing some patients outside. The CMO stated, "They did all the essentials, but sometimes they weren't able to get all of their information. The CEO stated, "We are working on a better process." Interview revealed the hospital's process for evaluating walk-in patients was flawed and needed to be improved.

Interview on 05/12/2022 at 1508 with MD #5 revealed Patient #3 was a walk-in patient. Interview revealed the physician was called by the CNAs when a patient walked in. Interview revealed the CNAs would try to get identifying information from the patient and would ask what precipitating events led to the patient coming to the hospital. MD #5 stated the physician would see the patients, observe them, do a mental status evaluation, including evaluating their cognitive and mental status, whether the patient had a steady gait or any abnormal movements. MD #5 stated they evaluated any patient for an emergency medical condition that would bring them into the hospital. The most significant part of the evaluation was whether the patient was dangerous to themselves or others. Interview revealed that for Patient #3, the patient was asking for help and deserved help, but did not have an emergency medical condition that needed admission to the hospital. The physician stated she went inside to get resources for the patient and the patient would not wait. Interview revealed MD #5 did not believe the patient needed to be petitioned for IVC, so she was not going to put hands on the patient to get her to stay but offered resources which the patient declined. Interview revealed Patient #3 was stable and safe to leave.