HospitalInspections.org

Based on observation, interview and facility policy review, the facility failed to conspicuously post signage specifying the rights of individuals with respect to the Emergency Medical Treatment and Labor Act (EMTALA) in locations likely to be noticed by all individuals waiting for examination and treatment.

1. This included the waiting areas of the Emergency Department (ED), triage and the treatment areas of the ED.

2. A large movable banner was blocking the EMTALA signage at the entrance of the L & D unit and the two triage rooms did not have EMTALA signage.

These failures resulted in the potential for patients to not be informed of their rights to receive a medical screening examination or treatment for their emergent medical condition, including active labor.

Findings:

1. On 1/24/2023 at 10:11 a.m., a tour was conducted of the hospital ED. No postings or signage related to patient rights to examination, treatment, and Medicaid participation were observed in the patient registration area, the triage and patient waiting area, and the treatment areas.

During the tour conducted on 1/24/2023 at 10:17 a.m., the ED Director (EDD) confirmed that there were no EMTALA signs posted in the patient registration, patient waiting area, triage and treatment rooms.

During an additional observation and concurrent interview, tour conducted of trauma rooms on 1/24/2023 at 11:01 a.m., the Quality Nurse Consultant 1 (QNC 1) confirmed there were no EMTALA signs posted in the trauma treatment rooms.


2. On 1/24/2023 at 10 a.m., a tour was conducted of the hospital's labor and delivery (L&D) unit. A large movable banner was observed blocking the EMTALA signage at the entrance of the L & D unit. Additionally, no EMTALA signage was observed in the two L & D triage rooms.

During a concurrent observation and interview with the Labor and Delivery Manager (LDM) on 1/24/2023 at 10:20 a.m., LDM confirmed that the banner shouldn't have been placed in front of the EMTALA signage as she moved the banner to the right of the signage. She further confirmed that there was no signage in the two triage rooms.

Review of the hospital policy titled, "Emergency Medical Screening Examination, Treatment and Transfer (EMTALA)" dated 10/14/2020 and revised on 6/9/2021 indicated, "Signage: Conspicuous signs will be posted at the hospital entrances, Labor & Delivery, and Admitting Departments ...signage will specify the right of the individuals to examination and treatment for emergency medical conditions regardless of the ability to pay, and the rights of women in labor for health care services and whether the hospital participates in the Medicaid program ..."

The policy did not stipulate all applicable areas for the signage to be posted.

Citation Text for Tag 2406

Based on observation, interview, and record review [Hospital] Emergency Department (ED) failed to provide one of 27 patients (Patient 1) an ongoing medical screening exam (MSE) for an acutely ill, psychotic, patient on a 5150 (72-hour, involuntary detainment/ Hold of a patient who is danger to self (DTS), danger to others (DTO) and/or gravely disabled (GD), and are initiated by behavioral health professionals).

This failure to provide an ongoing MSE for changes in medical and mental status of Patient 1 resulted in two elopements (escaped the care of ED professionals) which led to the injuries and harm to himself, other patients and the community during a car theft and subsequent accident.

Findings:

On 1/25/2023 Patient 1's hospital security report, titled "Incident Report", and chart for admission to the ED on 9/25/2022 at 11:47 p.m. to his departure 9/25/2022 at 12:43 p.m., were received from Director Risk Manager, Patient Safety (DARLS). DARLS stated it was the "complete" chart. The record review indicated the following events:

On 9/25/2022 at 11:32 p.m., Patient 1, an adult black male was brought in by ambulance (BIBA) for an "Emergent (immediate response), ALS (Advance Life Support ambulance) for a "Behavioral/Psychiatric Crisis." Patient 1 had "hallucinations, visual [and] auditory [hearing], 'unsafe' feeling with history of schizophrenia (a lifelong mental disorder characterized by thoughts or experiences out of touch with reality, disorganized speech or behavior, hallucinations, and difficulty with concentration and memory)."

On 9/25/2022 at 12:02 a.m., ED "Events" indicated Patient 1 was placed in "Bed OH 47 [Orange Hallway gurney 47, next to automatic ED exit doors that had direct access to a hallway that exited to the hospital parking area]."

On 9/26/2022 at 12:16 a.m., "ED Care Timeline" indicated, ED physician (Medical Doctor [MD 1]), ordered a 1799 Hold (a 24- hour involuntary detainment/Hold of a patient who was DTS, DTO and/or gravely disabled [GD] initiated by medical professionals).

On 9/26/2022 at 12:16 a.m., "ED Care Timeline" indicated, Resident Physician in training, (MD 6) ordered Olanzapine (medication used to treat schizophrenia) and was given at 12:39 a.m. by the ED Registered Nurse (ED RN 7).

On 9/26/2022 at 12:47 a.m., ED Registered Nurse (ED RN 8) documented that "Patient 1 is on a 1799 (24- hour involuntary detainment/Hold of a patient who is danger to self (DTS), danger to others (DTO) and/or gravely disabled GD initiated by medical professionals) ED MD hold by meeting the following criteria Danger to Self [DTS] ...Safety of patient is a high priority ...behavior/mood calm and questionable judgment ...patient donned green paper scrubs [hospital psychiatric patients on Holds wear green scrubs]."

On 9/26/2022 at 2 :16 a.m., "ED Care Timeline" indicated, Patient 1 received a second dose of Olanzapine.

On 9/26/2022 at 3:08 a.m., the chart indicated that MD 6 evaluated Patient 1. MD 6 documented "emotional disturbance ...Auditory hallucinations, behavioral problems ...responding to internal stimuli ...slow response to questions, asks inappropriate questions ...medical concerns cough, chest pain abdominal pain, diagnosis 'schizophrenia' ...patient will include psychiatric consultation ...disposition pending psychiatry." The documentation indicated Patient 1 had no history of alcohol abuse, tobacco use or drug abuse. The chart indicated Patient 1 had a history of schizophrenia and "unknown if he takes his medications." The names of Patient 1's home medications were not located in the chart. There was no documentation of medical complaints of cough, chest pain, or abdominal pain were evaluated and treated.

On 9/26/2022 at 7:30 a.m., ED RN 7 documented Patient 1's "altered mental status: Hallucinations."

On 9/26/2022 at 9:34 a.m., ED physician (MD 5) documented that Patient 1 "presents with auditory hallucinations, Hx [medical history] schizophrenia ...Review of systems: unable to accurate obtain due to acute psychiatric presentation ....imp [impression] Psychosis, medication non-compliance ...5150 and medically cleared ....acute exacerbation of hallucinations." There was no documentation of medical complaints of cough, chest pain, or abdominal pain were evaluated and treated.

On 9/26/2022 at 10:25 a.m., ED RN 7 documented that Patient 1 "leapt over bed railing and attempted to run down CT [Computed tomography scan (CT), like Xrays, records images inside the body] hallway [outside ED]...security and EDT [emergency department technician] were able to detain pt [patient] ...cooperated in going back to his bed [hallway gurney OH-47] next to [ED] exit at CT main hallway...[RN] remained that he is on a mental health hold and that he cannot leave."

On 9/26/2022 at 10:41 a.m., ED "Events" indicated that Patient 1 was still in "Bed OH-47."

On 9/26/2022 at 10:41 a.m., the chart indicated Marriage Family Therapist (MFT), from the [Hospital] Behavioral Health (BH) Team, evaluated Patient 1. MFT documented Patient 1 was a "has a history of disruptive mood dysregulation, psychosis, and one known psychiatric hospitalization. No known substance abuse...He [Patient 1] reported to MD that he has been hearing voices for weeks...paranoia." MFT documented that Patient 1 was a "danger to others [and] gravely disabled adult." MFT indicated Patient 1 has a "psychotic disorder...DOES meet criteria for a 5150 [hold]." MFT completed the 5150-hold, "Application for Assessment, Evaluation and Crisis Intervention or Placement for Evaluation and Treatment" with recommendations that Patient 1 is referred to a an accepting LPS [LPS, Lanterman-Petris-Short Act is another name for 5150] Designated Inpatient Psychiatric Facility." The form indicated Patient 1 was to be transferred to a "5150 Designated Facility."

On 9/26/2022 at 11:00 a.m., ED RN 7 documented "pt leapt from bed and ran down CT hallway eastbound outside ER [ED]. Code elopement was paged...abrasions to LLE [left lower extremity] from event." ED RN 7 documented wound care.

On 9/26/2022, Patient 1's second elopement was chronicled in an event report written by hospital security staff. The "Incident Report" indicated, on Monday September 26th, 2022, around 10:59 [a.m.]," Patient 1 eloped a second time from the ED and "attempted to steal a member's vehicle." The report indicated security and the ED Tech "stopped" Patient 1, "pulled subject [Patient 1] out of the car...and assisted to the ground." The report documented that the event "resulted in a collision and injury to an elderly member...[who] suffered head and back injuries ...[member] taken immediately to the ER for evaluation and treatment." The report indicated Patient 1 was "taken into police custody...Criminal" for "theft" of an "auto."

On 9/26/2022 at 11:18 a.m., MFT wrote an "addendum" to the "Emergency Department Psychiatric Initial Consult". MFT documented, "after I informed MD [5], I was placing pt on hold, jumped into someone's vehicle and took off in our parking lot, crashing the car. Apparently, the car was running, and someone was helping an elderly lady get out of the vehicle. Will add DANGER TO OTHERS to the hold based on this." The documentation indicated MFT "informed" MD 5, Security, and nursing staff of Patient 1's psychiatric status and plan: "Patient not psychiatrically cleared for discharge...Patient meets criteria for Involuntary Commitment due to danger to others and grave disability." Plan was to transfer patient to "5150 Designated Facility."

On 9/26/2022 at 12:14 p.m., ED RN 1 documented "Wound injury care" for Patient 1.

There was no documentation in the chart that MD 5 evaluated Patient's medical or mental status after 9:34 a.m., or after the first or second elopement.

During an interview and record review on 1/25/2023 at 1:18 p.m., with Emergency Department (ED) Nurse Manager (EDNM) and ED RN 1, ED RN 1 stated she recalled caring for Patient 1 and shared in the care of Patient 1 with another ED nurse, (ED RN 7). ED RN 1 described Patient 1's location as OH-47, hallway gurney next to automatic ED exit doors. ED RN 1 stated that Patient 1 was "calm, quiet...sleeping." ED RN 1 stated that she "witnessed the first elopement" at 10:25 a.m. and indicated Patient 1 was "confused...escorted back to bed [hallway gurney OH-47]." ED RN 1 indicated that after the first elopement, that she asked for Patient 1 to be moved to the "Behavioral Health area," but it was "full." ED RN 1 stated that she saw Patient 1's elopements. ED RN 1 indicated when Patient 1 was returned to the ED by hospital security staff, that he had "abrasions." ED RN 1 acknowledged at 12:14 p.m. she provided Patient 1 with "Wound/Injury Care." ED RN 1 stated she "agreed with the [5150] Hold ...very large safety issues," and Patient 1 was a danger to self and others. ED RN 1 could not recall if MD 5 evaluated Patient 1 after the elopements.

During an interview and record review on 1/26/2023 at 11:21 a.m., with ED RN 6 and ED Nursing Director, (EDD), ED RN 6 acknowledged she was involved with Patient 1's care on 9/26/2022. ED RN 6 indicated during the second elopement Patient 1 "crashed car" and was returned to ED by hospital security. ED RN 6 stated Patient 1 was "cooperative...had no external signs of agitation...flattened affect...eyes moving back and forth...[behavior] not normal."

During an interview and record review on 1/25/2023 at 4:05 p.m. with ED MD 1, MD 1 reviewed Patient 1's chart. MD 1 acknowledged he provided care to Patient 1 from ED admission to 9/26/2022 6:00 a.m. MD 1 acknowledged MD 6 evaluated Patient 1 and he agreed with the history and physical. MD 1 stated that Patient 1 was "psychotic," "danger to self" and "gravely disabled," and he placed Patient 1 on 1799 Hold. MD 1 stated that he "medically cleared [Patient 1] sometime around 3:00 a.m." and "must be evaluated by BH [Behavioral Health team]." MD 1 reviewed the 9/26/2022 10:41 a.m. 5150 Hold authored and signed by MFT. MD 1 stated it was "appropriate" because Patient 1 was a "DTS, DTO". ED MD 1 indicated after Patient 1 eloped, and "had new medical issues or injuries, he should be reassessed" as continuation of the MSE. MD 1 indicated a "5150 is not discharged into the community, not stabilized to leave the ED ...patient transferred to acute psychiatric care facility."

During an interview, observation of video footage, and record review on 1/25/2023 at 1:08 p.m., with Security Manager (SM) and with DARLS, the events of Patient 1's elopements from the ED were reviewed. SM and DARLS stated the first "attempted" elopement from the ED to the hospital hallway occurred around 10:25 a.m. on 9/26/2022, and video footage was "not saved" and a security report was not written. SM and DARLS stated video footage and Incident Report reflected the events of Patient 1's second elopement starting "on 9/26/2022 10:59 a.m." SM narrated the video during video replay observation. At 10:59 a.m., SM identified Patient 1 "running down the hallway ... [called the] bowling alley ...security and additional staff following ...running through the old ambulance [automatic] doors ...exited outside ...jumps construction fencing ...headed to garage parking, towards medical building 2 .... [Patient 1] jumps into a car ...reverses it ...hits a car behind ...security remove him from the vehicle." SM confirmed the visuals of the video footage and security report that indicated several hospital staff were at the vehicle. Patient 1 was "pulled" from the vehicle and held him to the ground. The video ends. SM acknowledged the report reflected that an "elderly patient," was "still sitting inside the vehicle with her feet out, getting ready to get into a wheelchair "suffered head and back injuries". SM stated, at the time of the incident, Patient 1 was "always" on a "Hold" and "security advised to clear medically before jail."

During an interview and record review on 1/26/2023 at 1:23 p.m. with ED Medical Director (MD 3), MD 3 indicated he was not directly involved the with the care of Patient 1 but was familiar with the events and EMTALA (Emergency Medical Treatment and Labor Act requires hospitals with EDs to provide a medical screening examination to any individual who comes to the ED) requirements. Patient 1's records indicated that during the elopement he sustained injuries after being "pulled" from the vehicle and held to the ground. Record of injuries and wound care were documented by ED RN 1 and ED RN 7 at 11:00 a.m. and 12:14 p.m. MD 3 stated that the "nurse evaluated" Patient 1's new injuries and documented vital signs at 12:43 p.m. MD 3 indicated, even though Patient 1 sustained injuries after the elopements, a medical screening exam was not necessary because the "nursing exam was a summation of all events." ED MD 3 acknowledged, there was no documentation that MD 5 evaluated and completed a MSE after Patient 1 had a change in medical condition or mental status and sustained injuries after elopements at 10:25 a.m. and 11:03 a.m. MD 3 acknowledged there was no documented evidence that MD 5 evaluated Patient 1 after 9:40 a.m. on 9/26/2022. MD 3 stated it was "inferred a MSE occurred because [Patient 1] was stable."

An interview and record review with MD 5 was requested on 1/24/2023, 1/25/2023 and 1/26/2023, but DARLS informed the survey team, MD 5 was not available.

Policy and Procedure Record Review

Review of [Hospital] Policy and Procedures, "Emergency Medical Screening Examinations, treatment and Transfer- EMTALA," last revision 6/9/2021 Section titled "Medical Screening Examination (MSE)" indicated the MSE is a "process required to determine within a reasonable clinical confidence whether an emergency medical condition exists. It is an ongoing process, including monitoring of the patient until the patient is either stabilized or transferred ...The MSE will be provided by a qualified medical provider (QMP) ...QMP means categories of healthcare professionals designated in the Professional Staff Bylaws, Rules & Regulations to perform medical screening exams ...to provide medical treatment as necessary to assure, within reasonable medical probability, that no material deterioration to the condition is likely to result from or during the transfer ...Transfer means the movement, including discharge, of an individual outside a hospital's facilities."

Review of [Hospital] Policy and Procedures, "Basic Unit Care Standards for Emergency Services," last revision 7/8/2021, indicated "all Patients presenting to the ED will receive a medical screening exam (MSE) by a physician, physician assistant or nurse Practitioner ... Multidisciplinary resources (social services, discharge planner, behavioral health professionals) ... are contacted and utilized to meet Patient's needs ...This includes but not limited to ...psychiatric hospitals ...and jail."

Review of [Hospital], "Rules and Regulation of the Professional Staff", last revision 2021, section I-D indicated "appropriate service, whether available in the hospital or requiring outside referral, shall be offered to Patients based on their clinical needs, including patients who are mentally ill". Section I-H indicated an "appropriate medical screening examination ...shall be provided by qualified medical personnel ...include physician members of the professional staff ...emergency services and care shall be provided without regard to the patient's race, color, ethnicity ...physical or mental disability". Section II-A indicated "the attending Practitioner(s) shall be responsible to assure the medical record is complete. It indicated "a medical record is complete when its contents reflect the patient's condition on arrival, diagnosis, test results, therapy, condition, and inpatient progress ...Legal status of patients receiving Mental Health Services."

Review of [Hospital] Policy and Procedures, "Discharge - Multidisciplinary NCAL [sic] Regional Policy," last revision 10/18/2021, indicated "Special Discharge Planning Situations: Inpatient individuals with psychiatric symptoms and/or suicidal ideation or suicide attempt during the course of their admission should be referred to the Department of Psychiatry ...Re-assessment: if there was a change in the patient's physical/mental status, confirm that the Patient's discharge destination is still appropriate."

Review of [Hospital] Policy and Procedures, "Constant Observation by Sitter or Security Standby", last revision 3/5/2021, indicated "Involuntary Holds ...Probate Code 5150 a means by which someone who has a primary mental health disorder which makes him or her a danger to self, a danger to others, and/or gravely disabled (unable to provide for food clothing or shelter), can be transported to a designated psychiatric inpatient facility for evaluation and treatment for up to 72 hours against their will. [Hospital] is not a 5150 designated facility ...Criteria for use of Constant Observation ...highly impulsive with risk of injuries to self or others ...Elopement risk in patient without decision-making capacity ... confused/psychotic behaviors ...always Maintain a safe environment."

Review of [Hospital] Policy and Procedures, "Management of Behavioral Health Patients in the Emergency Department", last revision 4/2022, indicated the purpose of the policy was "to provide a safe and secure environment for all members, staff and visitors in the ED ...to describe the essential patient care and documentation requirements in the ED for Patients with psychiatric complaints and to provide them with a stable and secure environment ...To ensure all laws and regulations are followed ...At Risk patient: Any person who as a result of a mental disorder, presents a danger to him/herself. Or others ....and cannot be safely released from the Emergency Department (ED) and/or hospital. Patients who are risk have the potential to elope ...Elopement occurs when a patient leaves the Emergency Department (ED) and /or hospital without informing medical staff". Section 5.4 Stabilizing Treatment indicated "requires consultant in order to provide stabilizing treatment, an on-call physician will be contacted ...Once the emergency medical condition is stabilized, the individual may be admitted to the hospital for further care, be discharged, or be transferred to another facility."

Review of [Hospital] Policy and Procedures, "Suicide Screening and Management NCAL Regional Policy", last revision 11/2020, indicated "the process for the appropriate screening, assessment and ongoing evaluation and treatment of patients who are a danger to self, others or who are gravely disabled to ensure a safe environment ... At risk: any person who cannot be safely discharged from the hospital because of a mental disorder, presents a danger to themselves or others or the physician determines is gravely disabled. At risk patients have the potential to elope and include ... Patients without the capacity to make medical decisions ... Minimize elopement: Exits and elevators should not be easily accessible from where the patient is located."

The Booking/arrest report was provided by [Hospital] and [County] court case indicated, near 4 months after presenting to the ED for care, Patient 1 received court ordered psychiatric evaluation and was transfer to an inpatient psychiatric facility. The report indicated [case number] that Patient 1 was a "Pickup (Fresh Arrest) [at (Hospital) for] Felony...Carjacking and booked into the County Main Jail on 9/26/2022 at 3:18 p.m." Since a "subpoena" was required by the hospital for any information related to Patient 1's transfer or discharge, County Court case information for case number was obtained. It indicated the following: Patient 1 was in the Main Jail. On 9/28/2022 Patient 1 was arraigned. On 11/2/2022 court appointed a psychiatrist or licensed psychologist to examine the defendant. On 12/27/2022 doctors report determined "defendant found incompetent." On 1/12/2023 "defendant committed to state hospital." https://services.saccourt.ca.gov/PublicCaseAccess/Criminal/CaseDetails (accessed 1/27/2023).

Based on observation, interview, clinical record review and hospital policy review, the hospital failed to ensure stabilizing treatment and safety and security relevant to a psychiatric emergency medical condition (EMC) for 1 out of 27 sampled patients when a patient (Patient 1) was admitted on a psychiatric hold (where the patient cannot be safely released from the hospital as a result of being a danger to themselves, or a danger to others, or gravely disabled) and subsequently eloped (left the hospital without consent from medical staff) from the Emergency Department (ED) twice, and the second elopement resulted in attempted vehicle theft and endangerment to innocent bystanders.

This failure resulted in injury to Patient 27 and had the potential to cause additional serious harm and death to Patient 1 and people near or in the path of the stolen vehicle.

Findings:

A review of an EMS (Emergency Medical Services) report, dated 9/25/2022, indicated a 21-year-old male contacted EMS for reason of feeling "unsafe," and stated tenants of upstairs apartments were attempting to break into his home and threatening him with firearms. The EMS report revealed the patient indicated concerns with hallucinations, had a history of schizophrenia (a serious mental disorder involving hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning) , and was transported to the ED for behavioral/psychiatric crisis.

A review of Patient 1's clinical record revealed the following documents:

ED Arrival Information note, undated, indicated patient arrival time "9/25/2022 11:47 PM," and "Acuity [the severity of a patient's condition is assigned a number "1" through "5" where "1" is the most critical and "5" is the least critical]" listed as "2 Emergent."

A Section 1799.111 of the California Health and Safety Code (a 24-hour involuntary hold initiated by a physician where a patient cannot be safely released from the hospital because, in the opinion of the treating physician, the person, as a result of a mental disorder, presents a danger to himself or herself, or others, or is gravely disabled) initiated 9/26/22 at 12:43 a.m., signed by ED MD 1 (MD - Doctor of Medicine).

An ED Registered Nurse (RN) Behavioral Health Arrival Note, dated 9/26/2022 at 12:47 a.m., indicated upon arrival to ED the patient was placed on a 1799 hold for meeting the following criteria: "Danger to Self." The note further indicated the patient "was escorted to a safe and therapeutic environment per policy," and "Safety of patient is a high priority." The note further indicated, "Request for security Standby in the ED order signed by ED MD and copy provided to security staff observing the patient. Patient is in the line of sight of security staff. "

An ED Provider Note, dated 9/26/2022 at 3:08 a.m., indicated a medical screening evaluation was conducted and, "Presentation consistent with schizophrenia diagnosis. Evaluation of the patient will include a psychiatric consultation."

An "ED Nursing" note, dated 9/26/2022 at 10:24 a.m., indicated the patient "spontaneously leapt over bed railing and attempted to run down CT (Computed Tomography - a medical imaging technique used to obtain detailed internal images of the body) hallway towards main hospital." The note further indicated, "Security guard and EDT [Emergency Department Technician] were able to detain pt [patient] approximately 15 feet into hallway and he cooperated in going back to his bed. Pt was reminded that he is on a mental health hold and that he cannot leave."

Additional review of Patient 1's clinical record revealed an "Emergency Department Psychiatry Initial Consult" note, dated 9/26/2022 at 10:41 a.m. The note indicated the patient "...is psychotic. Not taking medications. Poor insight. He tried to elope before I spoke to him. Remains high risk if discharged. Am initiating a 5150 hold [a 72-hour involuntary psychiatric hold] for GD [Gravely Disabled]." The note further indicated, "**After I informed MD I was placing pt on a hold, he eloped, jumped into someone's vehicle and took off in it in our parking lot, crashing the car. Apparently the car was running and someone was helping an elderly lady get out of the vehicle. Will add DANGER TO OTHERS to the hold based on this."

Further review of the "Emergency Department Psychiatry Initial Consult" note, dated 9/26/2022 at 10:41 a.m., indicated the patient " ...DOES meet criteria for a 5150 application" for grave disability with the recommendation that patient is referred to an accepting designated inpatient psychiatric facility.

A review of Patient 27's clinical record revealed an ED Progress Addendum note, dated 9/26/2022 at 3:33 p.m. The note indicated, "Patient was the restrained front seat passenger sitting in a car when an escaped psych [sic] patient attempted to steal the car. Per patient's report, her caregiver was outside the car getting patient's wheelchair when the psych patient got into the driver's seat (door was open) and tried to drive away. Patient states that the driver backed into and side swiped 2 other cars." The same ED Progress note indicated Patient 27 was complaining of neck and shoulder pain at the time of assessment.

An interview was conducted with Emergency Department Technician (EDT) on 10/7/2022 at 3:22 p.m. EDT indicated he was taking a patient to CT scan down the hallway adjacent to the emergency department, when a young male patient came running out of the ED doors and ran past him towards the exit doors to outside of the building. EDT indicated he chased after the male patient, exited the building and followed him out towards the parking garage. EDT stated he watched the patient notice an individual get out of a car parked in front of an office building and move around to the passenger side to assist an elderly woman out into a wheelchair. EDT indicated the male patient then "made a bee line" for the car and jumped into the driver side seat.

In the same interview, EDT indicated he witnessed the car move backwards, crashing into the parked car behind it. EDT stated at that point he had arrived at the car, jumped in through the driver side window, and reached over Patient 1 to turn the car off and remove the keys. EDT stated Patient 1 was then escorted back to the ED with security and arrested by police.

During an interview with Security Guard (SG) 1 on 11/04/2022 at 10:00 a.m., SG 1 confirmed he was assigned to watch Patient 1 in the ED and the patient was placed on a gurney in front of the nurse's station, adjacent to double exit doors. SG 1 stated he was positioned at the nurse's station within six feet of Patient 1. SG 1 indicated Patient 1 had two elopement attempts, where the first time the patient jumped off the gurney, ran out of the double doors, and was caught in the hallway. SG 1 indicated in the second elopement attempt, the patient jumped off the gurney, ran out of the double doors, and made it outside of the ED to the front of the Medical Office Building (MOB) where he attempted to steal a vehicle.

In the same interview, SG 1 recalled Patient 1 was always looking around at the doors to see where everything was and confirmed no changes were made to the patient's gurney location after the first elopement attempt.

A concurrent interview and observation of the ED was conducted on 1/24/2023 at 11:42 a.m. with the ED Nursing Director (EDD) and the Quality Utilization Coordinator (QUC). QUC indicated where Patient 1 was brought in by ambulance and placed in bed 47 adjacent to the double doors leading to the hallway to radiology. The double doors were observed to open and close automatically when staff walked by them, and QUC confirmed the double doors opened automatically anytime a person approached them.

Video footage of the second elopement incident was reviewed on 1/25/2023 at 1:00 p.m. with the Director - Accreditation, Regulation & Licensing and Risk Management, Patient Safety (DARLS), and the Security Manager (SM). The video revealed the patient [Patient 1] lying on a gurney directly to the right side of double doors. The SM confirmed the head of the patient was directed towards the double doors, and the patient's feet pointed towards the ED nurse's station. The video revealed a security guard positioned adjacent to the nurse's station, approximately 6-8 feet away from the foot of the gurney, facing the gurney and the exit doors. The video showed the patient jump off the gurney, run out of the double doors, with the security guard chasing after him.

Further observational review of the elopement video footage, and confirmed by SM, revealed Patient 1 exit the ED, run East past a large parking structure, and get into a car that was parked in front of a MOB. The car was observed to move backward into another parked car.

An interview was conducted with ED Nurse Manager (EDNM) and ED RN 1 on 1/25/2023 at 2:20 p.m. ED RN 1 indicated for patients in the ED placed on an involuntary psychiatric hold, nurses would ensure security was watching them and they needed to be watched for safety. ED RN 1 further indicated patients on a hold were not allowed to leave the hospital on their own. ED RN 1 indicated Patient 1 was brought back to the same gurney location (near the double doors) after the first elopement attempt because the behavioral health area of the ED was full of other patients. ED RN 1 indicated the behavioral health area in the ED was a "safer location."

An interview was conducted with Marriage and Family Therapist (MFT) on 1/25/2023 at 3:10 p.m. MFT confirmed she had seen and evaluated Patient 1. MFT indicated Patient 1 was suspicious and paranoid with no insight and was not safe for discharge. MFT stated patients are placed on a psychiatric hold so they cannot leave. MFT further indicated, placement of patients on a hold near the door is not ideal, and "space is an issue for our patients."

A review of facility policy entitled "Code Green," effective date 12/3/2020, indicated the intent of the policy is to "Provide guidelines for responding to an 'at risk' patient who poses a risk of eloping. Prevent an elopement." The policy defined an "at risk patient" as "Any person who lack decisional capacity as a result of a mental disorder, presents as a danger to him/herself or others, or a physician determines is gravely disabled and therefore cannot be safely released from the Emergency Department and/or hospital."

The "Code Green" policy further defined "ELOPEMENT" as an at risk patient "leaves the Emergency Department and/or Hospital without consent of the medical staff." The policy directed to, "Use the least restrictive intervention that will effectively protect the patient from harm."

A review of facility policy entitled "Management of Behavioral Health Patients in the Emergency Department," approval date 4/2/2020, indicated the purpose was "2.1 To provide a safe and secure environment for all members, patients, staff and visitors in the ED." The policy further directed, "5.4 Behavioral Health patients presenting to the ED for treatment (No 5150 in place) Step 2 Action a behavioral health patient who is experiencing a psychiatric emergency will be assigned, at a minimum, a triage acuity level of two (emergenct-ESI2)."

A review of facility policy entitled "Constant Observation by Sitter or Security Standby," effective date 6/10/2020, indicated, responsibilities of the sitter/security officer include "Maintain a safe environment at all times."

A review of facility policy entitled "Suicide Screening and Management NCAL [sic]Regional Policy," approval date 9/9/2021, indicated "Policy Statement 1.1 To describe the process for the appropriate screening, assessment, ongoing evaluation, and treatment of patients who are a danger to self or others, or who are gravely disabled and to ensure a safe environment."

The "Suicide Screening and Management NCAL [sic] Regional Policy" further indicated, "5.4 Patient Safety Precautions include the following: 5.4.2 All attempts will be made to assign the patient to a room near the nurse's station, allowing for the high visibility of the patient. 5.4.2.1 Minimize elopement: Exits and elevators should not be easily accessible from where the patient is located."

A review of facility policy entitled "Emergency Medical Screening Examination, Treatment and Transfer - EMTALA (NCAL)," effective date 4/06/2021, indicated "To Stabilize means: 4.17.3 In the case of an individual with a psychiatric or behavioral condition, the individual is protected and prevented from injuring himself or herself or others." The policy further indicated "Stabilizing Treatment: 5.4.1 When it is determined that the individual has an EMC [Emergency Medical Condition], the hospital will: 5.4.1.1 Provide further medical examination and treatment required to stabilize the EMC within its capability and capacity."

Citation Text for Tag 2409

Based on observation, interview, and record review [Hospital] emergency department (ED), did not provide the appropriate transfer of care for 1 of 27 patients with an acute unstable psychiatric medical condition when Patient 1 was discharged to an inappropriate environment and delayed care.

This failure resulted in Patient 1, an acutely ill and psychotic patient on a 5150 (72-hour involuntary detainment/Hold of a patient who is danger to self (DTS), danger to others (DTO) and/or gravely disabled (GD) that are initiated by behavioral health (BH) professionals) to go to jail without being transferred to an appropriate psychiatric inpatient facility which caused a delay in treatment and additional potential mental and psychological harm.

Findings:

On 1/25/2023 Patient 1's hospital security report, titled "Incident Report", and chart for admission to the ED on 9/25/2022 at 11:47 p.m. to his departure 9/25/2022 at 12:43 p.m., were received from Director Risk Manager, Patient Safety (DARLS). DARLS stated it was the "complete" chart and reports. The review of the records indicated the following events:

On 9/25/2022 at 11:32 p.m., Patient 1, an adult black male was brought in by ambulance (BIBA) for an "Emergent (immediate response), ALS (Advance Life Support ambulance) for "Behavioral/Psychiatric Crisis." Patient 1 had "hallucinations, visual [and] auditory [hearing], 'unsafe' feeling with history of schizophrenia (a lifelong mental disorder characterized by thoughts or experiences out of touch with reality, disorganized speech and/ or behavior, hallucinations, and difficulty with concentration and memory)."

On 9/26/2022 at 12:16 a.m., "ED Care Timeline" indicated, ED physician 1 (MD - Medical Doctor 1), ordered a 1799 Hold (24- hour involuntary detainment/Hold of a patient who is a DTS), DTO and/or GD initiated by medical professionals).

On 9/26/2022 at 12:16 a.m., "ED Care Timeline" indicated, Resident Physician in training, (MD 6) ordered Olanzapine (antipsychotic medication that is used to treat schizophrenia) and given at 12:39 a.m. by the ED Registered Nurse (ED RN 7).

On 9/26/2022 at 12:55 a.m., the "ED Care Timeline" indicated that ED RN 7 documented Patient 1 has "altered mental status: Hallucinations."

On 9/26/2022 at 2 :16 a.m., ED Care Timeline" indicated, Patient 1 received a second dose of Olanzapine.

On 9/26/2022 at 3:08 a.m., the chart indicated that MD 6 evaluated Patient 1. MD 6 documented "emotional disturbance....Auditory hallucinations, behavioral problems ..responding to internal stimuli ...slow response to questions, asks inappropriate questions...medical concerns cough, chest pain abdominal pain, diagnosis 'schizophrenia' ...patient will include psychiatric consultation...disposition pending psychiatry." The documentation indicated Patient 1 had no history of alcohol abuse, tobacco use or drug abuse. The chart indicated Patient 1 had a history of schizophrenia and "unknown if he takes his medications." The names of Patient 1's home medications were not located in the chart.

On 9/26/2022 at 7:30 a.m., the "ED Care Timeline" indicated that ED RN 7 documented Patient 1's "altered mental status: Hallucinations."

On 9/26/2022 at 9:34 a.m., the chart indicated ED physician (MD 5) wrote an assessment note. MD 5's documented that Patient 1 "presents with auditory hallucinations, Hx [medical history] schizophrenia ...Review of systems: unable to accurately obtain due to acute psychiatric presentation ...chemical/physical restraints required, No....imp [impression] Psychosis, medication non-compliance ...5150 and medically cleared ....acute exacerbation of hallucinations...Care plan: Psychiatric Hospitalization."

On 9/26/2022 at 10:25 a.m., ED RN 7 documented that Patient 1 "leapt over bed railing and attempted to run down CT [Computed tomography scan (CT), like Xrays, records images inside the body] hallway [outside ED] ... security and EDT [emergency department technician] were able to detain pt [patient] ...cooperated in going back to his bed [hallway gurney OH 47,which had access to exit door to parking area] next to [ED] exit at CT main hallway ...remained that he is on a mental health hold and that he cannot leave."

On 9/26/2022 at 10:41 a.m., the chart indicated ED Marriage Family Therapist (MFT) from the [Hospital] Behavioral Health Team, MFT completed the 5150 Hold form titled, "Application for Assessment, Evaluation and Crisis Intervention or Placement for Evaluation and Treatment ". MFT documented Patient 1 "has a history of disruptive mood dysregulation, psychosis, and one known psychiatric hospitalization. No known substance abuse ...He [Patient 1] reported to MD that he has been hearing voices for weeks...exhibited blocking and paranoia". MFT documented that Patient 1 was a "danger to others, gravely disabled adult." MFT indicated Patient 1 had a "psychotic disorder...DOES meet criteria for a 5150 application for GD-Adult-Grave-Disability, with recommendations that the Patient 1 is referred to an accepting LPS [Lanterman-Petris-Short Act is another name for 5150] Designated Inpatient Psychiatric Facility". The form indicated Patient 1 was to be transferred to a "5150 Designated Facility."

On 9/26/2022 at 11:00 a.m., ED RN 7 documented "pt leapt from bed and ran down CT hallway eastbound outside ER [ED]. Code elopement was page ...abrasions to LLE [left lower extremity] from event." The chart indicated this was 2 of 2 elopements from gurney hallway bed next to the ED exit doors, OH 47.

On 9/26/2022 at 11:18 a.m., MFT wrote an addendum to the "Emergency Department Psychiatric Initial Consult". MFT documented, "after I informed MD, I was placing pt on hold, jumped into someone's vehicle and took off in our parking lot, crashing the car. Apparently, the car was running, and someone was helping an elderly lady get out of the vehicle. Will add DANGER TO OTHERS to the hold based on this." "Remains high risk if discharged." The documentation indicated MFT "informed" MD 5 , security, and nursing staff of Patient 1's psychiatric status and plan: "Patient not psychiatrically cleared for discharge ... Patient meets criteria for Involuntary Commitment due to danger to others and grave disability." The plan was transfer Patient 1 to a "5150 Designated Facility."

On 9/26/2022 at 12:14 p.m., ED RN 1 documented "Wound injury care" for Patient 1.

On 9/26/2022 at 12:30 p.m., "[County] Intent to Incarcerate Form" for an "Adult Prisoner", a two sided form, was signed by a Law Enforcement Officer. The front page documentation had the following completed sections: Patient Identification, Law Enforcement Officer Identification, and Custody Information with "Destination Main Jail." The blank sections were Provider Identification, Treatment Requested from Person Authorized to Request Treatment. A copy of the back of the form "Medical Care, necessity for continuity of patient care at county facility provided" was not present in the chart. The form did not indicate Patient 1 was psychotic, on a 5150 hold for DTS, DTO or GD, required medications, or was to be transferred to an inpatient psychiatric facility. There was no documentation that the police were provided a copy of the 5150 Hold form or transfer documentation of ED hospital care and events.

On 9/26/2022 at 12:36 p.m. to 12:41 p.m., ED RN 1 documented "Pt currently in process of being discharged to jail with PD [police]...ED RN 6, completing paperwork with MD 5...Pt currently handcuffed for safety of self and others ....pt in green scrubs...do not need to notify family about pt...Going to jail." At 12:41 p.m., ED RN 1 documented "patient discharged to: "jail...ambulatory...accompanied by patient: Law enforcement."

On 9/26/2022 at 12:43 p.m., the chart indicated Patient 1 left ED with police. There was no documented evidence in the chart that MD 5, ED RN 1 or ED RN 6 provided Patient 1 with prescriptions, discharge or follow-up information and instructions. There was no evidence in the chart that MD 5, ED RN 1, or ED RN 6 provided the police or jail Patient's 5150, transfer documents or patient records. There was no evidence in the chart MD 5, ED RN 1 or ED RN 6 contacted the medical personal at the jail to transfer care.

On 9/26/2022 at 12:49 p.m., MD 5 documented a "Discharge /Disposition Note". MD 5 provided Patient 1's final disposition as Patient 1 " incarcerated" and "Final Diagnosis: Schizophrenia ...Condition on Disposition: stable ..see patient Discharge Instructions/AVS for being discharged to community." There was no documentation in the chart that MD 5 evaluated Patient 1's medical and mental status after 9:34 a.m., or after the first or second elopement MD 5 completed Patient 1's "After Visit Summary (AVS)". The AVS indicated follow-up care was "if you are in an emotional crisis, please reach out for help"...online or call "National Hopeline" or "National Suicide Prevention Lifeline." The AVS did not include medical or psychiatric follow-up care appointments in any type of setting, 5150 Hold, Behavioral Health Team treatment plan, medications provided, e.g., Olanzapine (anti-psychotic medication), prescriptions, or transfer of care to a psychiatrist and inpatient psychiatric facility.

During an interview and record review, on 1/24/2023 at 4:05 p.m. with MD 1, MD 1 indicated he placed Patient 1 on 1799 Hold because Patient 1 was "psychotic", "danger to self" and "gravely disabled." MD 1 reviewed the 9/26/2022 10:41 a.m., 5150 Hold written by MFT. MD 1 stated it was "appropriate" because Patient 1 was "DTS, DTO". MD 1 indicated "5150's aren't discharged into the community, not stabilized to leave the ED...[they are] transferred to acute psychiatric care facility." MD 1 stated 5150's are "removed" by the BH team.

During an interview and record review, on 1/24/2023 at 3:11 p.m. with MFT acknowledged she was a member of the [Hospital] Behavioral Health Team, and provides consultations for the ED. MFT indicated she recalled Patient 1 and acknowledged on 9/26/2022 that she completed and stated Patient 1 was "paranoid ...unable to answer questions ... suspicious ...appeared psychotic." MFT placed a 5150 Hold for DTO and GD. MFT acknowledged Patient 1 was not safe to discharge to the community. MFT indicated Patient 1 was not "stable" and did not remove Patient 1's 5150. MFT stated the plan for Patient 1 was to be "admitted to an in-patient psychiatric unit." MFT stated she reviewed her notes and confirmed she informed MD 5 of Patient 1's 5150 and psychiatric plan.

During an interview and record review, on 1/25/2023 at 1:18 p.m., with ED Nurse Manager (EDNM) and ED RN 1, ED RN 1 stated Patient 1 was wearing "green scrubs" indicating he was a "psychiatric hold, 5150 and 1799" per hospital policy. ED RN 1 indicated that she "witnessed the first elopement" at 10:25 a.m. and indicated Patient 1 was "confused ...escorted back to bed [OH-47 hallway gurney next to automatic doors]." ED RN 1 stated that she "called a [second] elopement" at 11:00 a.m. ED RN 1 indicated police were at Patient 1's bedside when he returned to the ED.

ED RN 1 reviewed the 5150-hold written by MFT. ED RN 1 stated she "agreed with the hold ...[Patient 1] very large safety issues", and was a danger to self and others, especially after elopement and car theft. ED RN 1 stated she had "no recall of the [5150] hold being lifted [removed after a psychiatric exam]" and could not locate documentation in the chart of the 5150 being "lifted." ED RN 1 indicated the [Hospital] procedure is that "5150 holds are removed by the psychiatry care team." ED RN 1 stated Patient 1 was "going to jail ...discharged to the community, not a psychiatric facility," and he was "accompanied by law enforcement." ED RN 1 acknowledged ED RN 6 and MD 5, were "making decisions ...and took over discharge and completed discharge paperwork."

During an interview and record review on 1/26/2023 at 11:21 a.m., with ED RN 6 and EDD, ED RN 6 acknowledged she was involved with Patient 1's care. ED RN 6 indicated during the second elopement Patient 1 "crashed car" and returned to ED with security. ED RN 6 stated Patient 1 was "cooperative ...had no external signs of agitation ...flattened affect ...eyes moving back and forth ...not normal." ED RN 6 indicated that there was "paperwork for incarceration" and the ED physician "signs medically cleared, fit for incarceration." ED RN 6 and EDD were not able to locate documentation completed by ED nurses or MD 5 that the police or jail were provided documentation related to Patient 1's ED care, including the 5150 Hold, psychiatric and medical needs, medications, follow-up instructions, or transfer to an inpatient psychiatric facility. There was no evidence in the chart that ED RN 1 or ED RN 6 contacted the medical personnel at the jail to transfer care. ED RN 6 and EDD stated that there was a "problem if the 5150 was not lifted and discharged to jail". ED RN 6 and EDD indicated Patient 1's mental status "wasn't stable."

During an interview and record review, on 1/26/2023 at 3:36 p.m., with Physician Chief of Psychiatry, (MD 4), MD 4 acknowledged he was the director of the Behavioral Health (BH) Team and has been involved with ED 5150 patients transfer to the jail. MD 4 indicated discharges and transfers mean the same when patients go to jail from the hospital. MD 4 indicated the 5150 patients are "transferred" and "can't be discharged" to the community. MD 4 stated the ED did not contact him on 9/26/2022 to provide consultation on Patient 1. MD 4 explained the [Hospital] BH referral process for the ED. MD 4 indicated the ED physician will contact the BH team for a psychiatric consultation. If a patient "meets the criteria for a 5150," a member of the BH team will write a 5150 Hold. MD 4 stated only the psychiatrist and/or MFT "can lift [remove] a 5150...ED doctors do not lift 5150's, not designated to do so." MD 4 stated if a 5150 patient is "going to jail or if under arrest ...[patient] presents to inpatient psychiatric services in the jail." MD 4 stated the ED staff and physician "need" to provide the jail with the completed 5150 form, medical information, treatment, medications, and transfer documentation.

During an interview and record review, on 1/24/2023 at 3:46 p.m., with Behavioral Health Manager (BHM), BHM stated Patient 1 "clearly needed psychiatric care" and the 5150 was "not lifted". BHM indicated 5150s are transferred to an accepting psychiatric facility with a transfer package, which includes the 5150 form. BHM indicated the jail has psychiatry services but stated she "did not know how it worked." BHM stated the BH team is "not involved with discharges or transfers of 5150's", and the process is completed by the ED staff and physicians.

During a phone interview on 1/26/2023 at 11:15 a.m., with DARLS and Psychiatrist Physician, on call (MD 2), MD 2, stated that she was on-call and available for ED psychiatric emergencies on 9/26/2022. MD 2 stated she did not receive any calls or requests for consultation for Patient 1. DARLS confirmed there were no records for MD 2 from the ED requesting consultation for Patient 1.

During an interview and record review on 1/26/2023 at 1:23 p.m., with ED Physician Director (MD 3), MD 3 indicated he was not directly involved the with the care of Patient 1 but was familiar with the events and EMTALA (Emergency Medical Treatment and Labor Act requires hospitals with EDs to provide a medical screening examination to any individual who comes to the ED). MD 3 indicated the [Hospital] BH team evaluates behavioral health and psychiatric patients, and complete the 5150 Hold forms. MD 3 stated ED Physicians "don't independently remove 5150s...don't discharge patients with active 5150 to the community." MD 3 indicated ED physicians complete County "Intent to Incarcerate Form" for any patient going to jail. Patient 1's form indicated he was going to the "Main Jail" with "law enforcement." MD 3 acknowledged the form was blank for sections "Provider Identification or Treatment Requested" or "Medical Care, necessity for continuity of patient care at county facility". MD 3 indicated this information is provided by [hospital] to the police. MD 3 was not able to locate documentation that the police or jail were provided Patient 1's 5150 form, medical treatment, medications given, accepting physician, accepting psychiatric facility or transfer documentation to an inpatient psychiatric facility. MD 3 acknowledged Patient 1 was provided with an AVS. MD 3 acknowledged the AVS did not include medical or psychiatric follow-up care appointments in any type of setting, 5150 Hold, Behavioral health Team treatment plan, medications provided, Olanzapine (anti-psychotic), prescriptions, or transfer to an inpatient psychiatric facility. MD 3 indicated that Patient 1 "went to jail, and [he] was still a 5150", and was discharged in the custody of "law enforcement" at 12:41 p.m. from the ED.

During an interview and record review, on 1/25/2023 at 11:40 A.M. and 1:05 p.m., with DARLS, DARLS indicated he did not know the status of Patient 1 after he was taken into custody at [Hospital]. DARLS stated he would need a "subpoena" to obtain any information that the [Hospital] provided to the jail and police regarding the care, discharge, disposition and transfer of Patient 1. DARLS provided a Booking/arrest report [County] and "[County] Intent to Incarcerate Form" as references for Patient 1's status. The documents indicated Patient 1 was a "Pickup (Fresh Arrest) [from hospital for] Felony ...Carjacking and taken to the "Main Jail" by police. The report, [case number], indicated Patient 1 was booked into the "[County] Main Jail" on 9/26/2022 at 3:18 p.m. Since a "subpoena" was required by the hospital for any information related to Patient 1's transfer or discharge, County Court case information for case number was obtained from [Hospital]. It indicated the following: Patient 1 was in the Main Jail. On 9/28/2022 Patient 1 was arraigned. On 11/2/2022 court appointed a psychiatrist or licensed psychologist to examine the defendant. On 12/27/2022 doctors report determined "defendant found incompetent." On 1/12/2023 "defendant committed to state hospital." https://services.saccourt.ca.gov/PublicCaseAccess/Criminal/CaseDetails (accessed 1/27/2023).

An interview and record review with MD 5 was requested on 1/24/2022, 1/25/2022 and 1/26/2022, but DARLS informed the survey team, MD 5 was not available.

Policy and Procedure Record Review

Review of [Hospital] Policy and Procedures, "Emergency Medical Screening Examinations, treatment and Transfer- EMTALA", last revision 6/9/2021 Section titled "Medical Screening Examination (MSE)" indicated a Transfer means the movement, including discharge, of an individual outside a hospital's facilities". Section titled "Transfers" indicated that "the transferring physician will indicate the reasons for transfer and describe the benefits and risks outlined to the patient in the medical record. The form titled "Physician Assessment and Certification ...will be completed ...The transferring physician will contact a physician at the receiving facility, obtain his/her agreement to accept the transfer...The physician will document the reason for the transfer..A copy of the certification will be forwarded to the receiving facility...At the time of transfer, the hospital will send copies of all available medical records related to the patient's emergency medical condition ...The individual being transferred will be provided with appropriate care."

Review of [Hospital] Policy and Procedures, "Basic Unit Care Standards for Emergency Services," last revision 7/8/2021, indicated "all Patients presenting to the ED will receive a medical screening exam (MSE) by a physician, physician assistant or nurse Practitioner ...Multidisciplinary resources (social services, discharge planner, behavioral health professionals) ... are contacted and utilized to meet Patient's needs ... Upon transfer to an outside facility the sending nurse provides a telephone report to the receiving hospital/facility nurse or designee to facilitate continuity of care. This includes but not limited to ...psychiatric hospitals ...and jail" ... document any extenuating circumstances to patient's discharge ...documentation of Patient's condition upon discharge."

Review of [Hospital], "Rules and Regulation of the Professional Staff", last revision 2021, section I-D indicated "appropriate service, whether available in the hospital or requiring outside referral, shall be offered to Patients based on their clinical needs, including patients who are mentally ill." Section I-F indicated "a patient shall be transferred to another facility only when such transfer is authorized by attending physician and has been agreed upon by an accepting physician and facility." Section II-A indicated "the attending Practitioner(s) shall be responsible to assure the medical record is complete. It indicated "a medical record is complete when its contents reflect the patient's condition on arrival, diagnosis, test results, therapy, condition and inpatient progress and condition on discharge ...all final diagnosis and complications are recorded ...minimum information shall include ...Reports covering all consultations ...Referrals to other providers and agencies ...Medications, assessments and treatments ordered ...Legal status of patients receiving Mental Health Services ...Discharge instructions ...Condition on discharge ...Discharge summary ...Post Discharge plan. Section II-F indicated a "concise discharge summary shall include the reason for hospitalization, significant findings, procedures performed, and treatment rendered, the patient's condition at discharge ...a minor problem or intervention is a problem or intervention which does not pose a significant hazard to the patient."

Review of [Hospital] Policy and Procedures, "Constant Observation by Sitter or Security Standby", last revision 3/5/2021, indicated "implementation of constant observation for safety is ...based on an individual patient assessment ...a physician order for constant observation is not required ...Involuntary Holds ...Probate Code 5150 a means by which someone who has a primary mental health disorder which makes him or her a danger to self, a danger to others, and/or gravely disabled (unable to provide for food clothing or shelter), can be transported to a designated psychiatric inpatient facility for evaluation and treatment for up to 72 hours against their will. [Hospital] is not a 5150 designated facility ...Criteria for use of Constant Observation ...highly impulsive with risk of injuries to self or others ...Elopement risk in patient without decision-making capacity ... confused/psychotic behaviors ...always Maintain a safe environment ...Collaborate with psychiatrist [physician] to identify when constant observation is no longer needed."

Review of [Hospital] Policy and Procedures, "Management of Behavioral Health Patients in the Emergency Department", last revision 4/2022, indicated the purpose of the policy was "to ensure all laws and regulations are followed ...At Risk patient: Any person who because of a mental disorder, presents a danger to him/herself or others ....and cannot be safely released from the Emergency Department (ED) and/or hospital. Patients who are risk have the potential to elope ...Elopement occurs when a patient leaves the Emergency Department (ED) and /or hospital without informing medical staff". Section 5.1.3 indicated "Patients being transferred or admitted to an inpatient status, wither at a County-Designated evaluation facility or inpatient medical floor, must be accompanied by the original 5150 form". Section 5.9, Physical Exam and Statement of Medical Stabilization for Behavioral Health Evaluation indicated "a patient will be considered medically stable for behavioral health evaluation, when the examining physician can verify that the patient: Has no acute medical condition (emergency medical condition) requiring further emergency or in-patient hospital care ...and the patient can now be treated on an outpatient basis." Section 5.10 Transferring a patient in a 5150 Involuntary Hold indicated "transfer of the patient on a 5150 hold will be accomplished in a manner that maintains the safety of the patient and others consistent with applicable laws and hospital policies ...The ED physician must write a discharge order and conditions which the patient is to be transported and is responsible for the transfer of the patient ...The patient's primary care nurse is responsible for reviewing the transfer orders with the transport personnel ...the discussion should include Presenting condition and behavior, Diagnosis, Progress in ED, Precautionary measures ...Copies of the entire ED medical record will be sent with the patient to the receiving County-designated Evaluation Facility, including the original '72 hour Hold' form ...Complete transfer documentation."

Review of [Hospital] Policy and Procedures, "Suicide Screening and Management NCAL [sic] Regional Policy", last revision 11/2020, indicated "the process for the appropriate screening, assessment and ongoing evaluation and treatment of patients who are a danger to self, others or who are gravely disabled to ensure a safe environment ... At risk: any person who cannot be safely discharged from the hospital because of a mental disorder, presents a danger to themselves or others or the physician determines is gravely disabled. At risk patients have the potential to elope and include ... Patients without the capacity to make medical decisions ... ...Minimize elopement: Exits and elevators should not be easily accessible from where the patient is located ...reduce risks to other patients". The policy indicated plans for patients being discharged home. "Discharge Home: A qualified Behavioral Health Professional from the Department of Psychiatry will document the Safety Plan ...Accountable Attending Provider (e.g. Hospital Based Specialist) will review and approve the safety plan ...Physician confirms that a follow-up appointment has been made with a clinically appropriate provider (e.g. Behavioral Health Provider) ...Transfer to an inpatient psychiatric facility: A Qualified Behavioral Health Professional evaluates the patient... determines that the patient is still at risk ...will initiate a '5150' ...The patient is transferred to the Psychiatric Facility" ....the [physician and nurse must ...perform handoff. Including self-harm, flight risk and any necessary precautions ...receiving department will be notified that if the patient is on involuntary hold before transport takes place."

Review of [Hospital] Policy and Procedures, " Discharge - Multidisciplinary NCAL Regional Policy", last revision 10/18/2021, indicated "discharge planning is a multidisciplinary process involving all members of the health care team ....Special Discharge Planning Situations: Inpatient individuals with psychiatric symptoms and/or suicidal ideation or suicide attempt during the course of their admission should be referred to the Department of Psychiatry ...Re-assessment: Discharge plans are re-assessed on changes in the patient's condition ... A copy of the Discharge Instructions and/or Discharge Summary are provided to the patient/family/legal representative ...if there was a change in the patient's physical/mental status, confirm that the Patient's discharge destination is still appropriate."

Review of [Hospital] Policy and Procedures, "Transfer Protocol: Interfacility", last revision 12/16/2021, indicated "Patients being transported for involuntary hospitalization are to be transported via ambulance ... Patients on legal holds are to be transported by a psychiatric transport van". The policy described the following for transported transfer of Patients: "Physician Responsibilities ... making contact with the accepting physician at the receiving facility ...discussing the transfer with the patient/designee ....communication the plan with the members of the care team ....documentation must include ...orders ...mode of transport ...discussion with the patient ...discussion with name of accepting physician ...medication reconciliation ...discharge summary ...Nursing responsibilities [for transport transfer] ensure patient and family informed ...preparing patient ...providing the individuals transporting the patient with Handoff ... provide receiving facility RN with verbal Handoff via phone ...assessing patient immediately prior to transport ...documentation." Since a subpoena was required by the hospital for Patient 1's disposition, County Court case information for [case number] was obtained. It indicated the following: On 9/28/2022 Patient 1 was arraigned. On 11/2/2022 court appointed a psychiatrist or licensed psychologist to examine the defendant. On 12/27/2022 doctors report determined "defendant found incompetent". On 1/12/2023 "defendant committed to state hospital." https://services.saccourt.ca.gov/PublicCaseAccess/Criminal/CaseDetails. (Accessed 1/27/2023)