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Based on review of medical records and staff interviews, the hospital failed to ensure that Patients #8 and #16 (2 of 27 sampled patients who presented to the emergency department seeking care) received further medical evaluation and treatment as required to stabilize their emergency medical condition, and failed to ensure that Patients #8 and #16 were appropriately transferred.

These failures resulted in the following:

Patient #8, an adolescent patient, who presented with an emergency psychiatric medical condition with behaviors of intentional drug overdose and violent behaviors towards others, to be discharged without treatment against the recommendations of the initial consulting staff psychiatrist and without transfer to a hospital with the capabilities to treat an adolescent patient.

Patient #16 presented to the Emergency Department (ED) with law enforcement after family reported the patient was experiencing a psychotic episode. In the ED, the patient repeatedly exhibited bizarre and potentially dangerous behaviors, including jumping off a bed, where her foot slid and struck the side of the bed. An x-ray of the foot showed that she sustained a fracture of the long bone that leads to the pinky toe, however, no examination or care of the foot injury was documented in the medical record. The patient continued the bizarre and dangerous behaviors throughout her stay, which required frequent seclusion and sedation. The patient was accepted as an admission to the Behavioral Health Unit (BHU) by a BHU Nurse Practitioner (NP), was evaluated by a Telepsychiatrist and determined to need inpatient psychiatric care, yet the patient was never admitted to the hospital for stabilizing treatment because she tested positive for influenza (the flu). The hospital had available beds and Telepsych practitioners who could provide psychiatric care on the medical/surgical/telemetry unit, until the patient recovered from the flu and could be transferred into the BHU for ongoing psychiatric stabilization. After two days in the ED, with the same ongoing behaviors and need for sedation and seclusion, the patient was reevaluated, determined stable, and discharged. There was no indication in the discharge documents that indicated the patient had a fractured foot. The same day of the patient's discharge, she was taken to Hospital B, determined to need inpatient psychiatric care, and was transported to Hospital C for psychiatric stabilization.


See A 2406, 2407 and A 2409 for further detailed information

Based on interview, record review and policy review, the hospital failed to provide an appropriate medical screening examination (MSE) to determine whether or not an emergency medical condition (EMC) existed for one patient (#16) of 27 sampled records reviewed, of patients who presented to the hospital seeking emergency care from 01/29/24 through 07/28/24.

Finding included:

1. Review of the hospital's policy titled, "Medical Screening and Treatment of Emergency Medical Conditions," dated 02/2024, showed that all individuals coming to the dedicated emergency department seeking assessment or treatment for a medical condition, or coming to the hospital property requesting (or obviously requiring) treatment for an emergency medical condition, receive an appropriate MSE as required by the Emergency Medical Treatment and Labor Act (EMTALA). A MSE is the process to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists, and must be done within the facility's capability and available personnel, including on-call physicians. The MSE must be performed by a Physician or other Qualified Medical Personnel, is an ongoing process, and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized of appropriately transferred.

Review of the hospital's policy titled, "Diagnostic Imaging Scope of Service," dated 04/2022, showed that radiology services are available for all ages of patients, that inpatient and outpatient procedures were performed in the imaging department with the same level of care, and a third party telehealth radiology service was provided 24-hours per day.

Review of Patient #16's medical record showed that local law enforcement brought Patient #16 to the Emergency Department (ED) on 04/20/24 at 8:15 AM, after they responded to the family's request for assistance, when the patient became violent with her family and harmful to herself. While in the ED, the patient was agitated and violent, exhibited erratic behaviors, and soon after arrival, the patient threw water on the floor, and jumped off the bed. At 9:30 AM, Emergency Department Physician (EDP) K ordered an x-ray of the right and left ankle, due to the patient's complaint of pain and possible injury. There was no documented examination of the patient's ankles by the EDP or nursing staff. Both x-ray results showed there was no ankle fracture. At 7:00 PM, the patient's care was transferred to EDP II, and at 10:06 PM, he ordered an x-ray of the patient's right foot due to "trauma." There was no documented examination of the foot by the EDP or nursing staff. At 11:12 PM, the x-ray result showed that the patient had a fracture of the long bone of the foot that led to the pinky toe. The patient remained in the ED with continued erratic behaviors until 04/22/24, when she was discharged with psychiatric diagnoses and a "sprain" of the foot. She received instructions to ice, elevate and rest the foot, and take ibuprofen or Tylenol for pain. There were no additional x-rays taken of her foot between the order placed on 04/20/24 at 10:06 PM and the patient's discharge, despite the fact that her foot may have been further injured during the patient's ongoing erratic behaviors.

During an interview on 08/13/24, EDP GG (discharging physician) stated that he did not recall Patient #16 having a foot fracture when she was discharged from the ED on 04/22/24.

Review of an addendum to Patient #16's medical record dated 04/24/24 and signed by EDP II, showed that the patient suffered a fracture of the long bone in the foot that led to the pinky toe. The EDP documented that the patient's family member had concerns that the patient had injured her foot, and the fracture was not addressed with the patient at the time she was discharged.

During an interview on 08/01/24 at 11:21 AM, Patient #16's family members stated that during the patient's discharge, they demanded that an x-ray be completed of the patient's foot. The patient was limping (which was new), her foot was bruised, and no one had bothered to get an x-ray. She contacted the Chief Nursing Officer and filed a complaint, and later received a letter apologizing for the experience.

Review of a grievance dated 04/24/24, submitted by Patient #16's family member, showed that the complainant alleged that the hospital had caused a hairline fracture of the patient's foot, and that care was not provided for the fracture. EDP II (physician who ordered the foot x-ray) reported that the patient had jumped off an ED bed during her stay, and that her foot slid against the bed. EDP II consulted Orthopedic Physician OOO, who stated the patient could use an orthopedic boot or shoe if she had pain, and follow-up with Orthopedic Physician OOO if necessary.

During an interview on 08/08/24 at 10:32 AM, Orthopedic Physician OOO confirmed that if the fracture caused the patient severe pain, a surgical shoe or boot could be provided for additional stabilization.

Based on medical record review, hospital policy review, law enforcement surveillance video reivew, family interview and staff interviews, the Hospital failed to provide, within their capabilities, 2 of 27 sampled patients (Patients #8 and #16) selected for review the necessary stabilizing treatment for the emergency medical condition (EMC) hospital staff identified prior to discharging the patients.

Failure to provide the necessary and appropriate stabilizing treatment, placed patients at risk for deterioration
of their health or bodily functions (including, but not limited to a deterioration in mental health and increased risk for self harm for both Patients #8 and #16).

Findings include:

Review of the hospital's policy titled, "Medical Screening and Treatment of Emergency Medical Conditions," dated 02/2024, showed that all individuals coming to the dedicated emergency department seeking assessment or treatment for a medical condition, or coming to the hospital property requesting (or obviously requiring) treatment for an EMC received an appropriate MSE as required by the Emergency Medical Treatment and Labor Act (EMTALA), and if an (EMC) was determined to exist, such individuals were offered stabilizing treatment within the hospital's capabilities. Stabilized, with respect to an EMC, meant that no material deterioration of the condition was likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility. A patient would be deemed stabilized if the treating physician of the individual with an EMC had determined, within reasonable clinical confidence, that the EMC had been resolved.

1. On 8/1/24 at 11:30 AM an interview with Staff AA, Telehealth Psychiatrist revealed, their opinion for the safest care of Patient #8 was to recommend an involuntary adolescent inpatient psychiatric admission due to the combination of medications ingested, evasiveness of the patient, inability to speak to the guardian since the patient was a minor and the inability to obtain all risk factors.

2. On 8/1/24 at 2:25 PM an interview with Staff R, Emergency Department (ED) Medical Director revealed, adolescent inpatient psychiatric patients were a difficult population to find placement for and there were times they never got placed. Staff R further revealed those patients were held in the ED, given food and water and Telehealth Psychiatrist reevaluated them daily for discharge criteria.

3. Review of Patient #8's medical record revealed the following:

a. On 6/16/24 at 7:12 PM, the 911 dispatch call report revealed Patient #8's friend had called 911 after the patient called and told the friend they had taken additional prescribed pills to try to get high.

b. On 6/16/24 at 7:34 PM, the ambulance report revealed Emergency Medical Service (EMS) crew found Patient #8 in their dwelling sitting on the floor vomiting with vomit in their hair. Staff J, EMT initiated intravenous (IV) access, administered Lactated Ringers (electrolyte replacement) 1 Liter IV, and Narcan (medication used to reverse the effects of opioids) 2 milligrams (mg) IV. The patient aroused, vomited and went unresponsive again. Staff J administered Ondansetron (medication to prevent nausea and vomiting) 4 mg IV. EMS brought Patient #8 to the ED for an overdose. EMS staff found pill bottles in the room with the patient and brought them into the ED.

c. On 6/16/24 at 7:40 PM Staff D, ED RN, documented Patient #8 arrived non-responsive, and was vomiting.

d. On 6/16/24 at 7:40 PM Staff K, ED Physician, medically evaluated Patient #8 and ordered a urinary catheter, head computed tomography (CT) (scan of head that uses x-rays to develop a 3D image of the skull and brain), chest x-ray, and screening lab work that included a urinalysis, urine drug screen. At 7:45 PM Staff K ordered Narcan 0.4 mg IV. The urine drug screen resulted at 7:48 PM was positive for Tetrahydrocannabinol (THC) (the main mind-altering ingredient in the cannabis plant), and blood Potassium level was low at 2.6 millimole (mmol/L) (normal measured 5.0 mmol/L to 3.5 mmol/L per the hospital lab report). ED nursing staff administered the following additional medications ordered by Staff K: Lactated Ringers 1 Liter IV x two, Ondansetron 8 mg IV, Pantoprazole (medication used to decrease stomach acid and heartburn) 40 mg IV, repeat Narcan 1.2 mg IV, Potassium Chloride (used to treat low blood potassium) 10 milliequivalents (MEQ)/100 mL water IV x two.

e. On 6/16/24 at 8:00 PM Staff D, ED RN, completed an initial nursing assessment of the patient. Staff D documented Patient #8's primary reason for treatment was not a behavioral health condition, but due to ingestion and intentional overdose per EMS. Staff D documented the patient did not have an underlying behavioral condition that warranted additional suicide screening. Staff D, ED RN, did not complete any type of suicide screening assessment, as part of the patient ' s assessment.

f. On 6/16/24 at 8:04 PM Staff C, ED RN, documented that they called Poison Control. Per Staff C, Poison Control recommended lab work and observation of Patient #8 for seizure activity and blood pressure fluctuations.

g. On 6/16/24 at 8:03 PM Staff K, ED Physician, documented Patient #8's legal guardian called and explained that they were unable to locate the patient's Oxcarbazepine (medication used to decrease nerve impulses that cause seizures) bottle. The legal guardian reported that it was possible the patient overdosed with that medication. Staff K documented the patient found with the following medication bottles: EMS handed over the following pill bottles to ED staff that EMS found in the patient's room: one bottle of Hydroxyzine (medication used to treat anxiety) 25 mg with about 10-12 pills left in the bottle; and one bottle, about half-empty, of Ibuprofen (medication used to treat pain, fever, and inflammation) 600 mg. Staff K ordered further lab work suggested by Poison Control, including Tylenol and Salicylate levels.

h. On 6/16/24 at 9:00 PM Staff K, ED Physician, ordered a one to one sitter for Patient #8 (no reason identified).

i. On 6/16/24 at 10:00 PM and 10:15 PM Staff G, CNA Sitter, documented Patient #8 was awake and uncooperative.

j. On 6/16/24 at 10:22 PM, a physician order, included documentation of an order by Staff K, ED Physician, for 4-point restraints due to Patient #8 violent behaviors and striking out.

k. On 6/16/24 at 10:31 PM, Staff K ordered Lorazepam (medication used to treat anxiety; when given by injection, onset of effects is within one to thirty minutes) 2 mg IV; administered by Staff D, ED RN while staff had the patient restrained.

l. On 6/16/24 at 10:45 PM to 6/17/24 at 12:45 AM Staff D, ED RN, documented 15-minute restraint checks.

m. On 6/16/24 at 11:00 PM Staff D, ED RN, documented Patient #8 was alert and oriented and agitated.

n. On 6/16/24 at 11:10 PM Staff K, ED Physician, ordered a Telehealth Psychiatric consultation due to "ingestion".

o. On 6/17/24 at 12:45 AM Staff K, ED Physician, discontinued restraints.

p. On 6/17/24 at 4:45 AM Staff D, ED RN, documented Patient #8's urinary catheter was removed, patient was up to the bathroom and changed into scrubs.

q. On 6/17/24 at 5:49 AM Staff D, ED RN, notified the Telehealth Psychiatrist that the patient was alert and oriented enough for the consultation evaluation.

r. On 6/17/24 at 6:25 AM Staff K, ED Physician, documented in a shift summary that Patient #8 received fluid resuscitation and woke up 3 hours after arrival. Head CT and chest x-ray were unremarkable. At approximately 10:22 PM, the patient became extremely agitated, screamed, fought with staff, required 8 staff members to restrain her and required 4-point restraints as well as Lorazepam 2 mg IV. After less than 2 and a half hours, hospital staff removed the 4-point restraints and Patient #8 was calm, conversational and cooperative. Staff K documented Staff AA, Telehealth Psychiatrist, contacted them by telephone after interviewing the patient and felt the patient definitely required inpatient hospitalization, due to the extremely impulsive and dangerous ingestion. Staff K documented the psychiatrist (Staff AA) informed Staff K that Patient #8 stated they took 10 Oxcarbazepine pills in an attempt to get high.

s. On 6/17/24 at 6:53 AM Staff AA, Telehealth Psychiatrist, documented Patient #8, " ...is psychiatrically unstable, and remains an imminent danger to (self). Continues to present with poor insight, unable to engage in safety planning, minimizing circumstances of admission, intentional overdose with unclear amounts of pills, and not being forthright about intentions. Effectively dysregulated, poor impulse control. Poor judgment. No least restrictive option available at this time. Meets criteria for involuntary commitment and would benefit from further psychiatric stabilization."

t. On 6/17/24 at 11:56 AM, Staff X, Case Manager, documented the completion of a Columbia SAFE-T Protocol (a form used to assess the level of suicide risk). Staff X documented the patient denied a wish to be dead in the past month, denied thoughts of killing themselves in the past month, denied ever doing anything or ever starting to do anything to end their life. Staff X documented the patient was "no suicide risk".

u. On 6/17/24 at 12:18 PM Staff X, Case Manager, documented that they held off on attempts to find inpatient placement due to the need to wait 24 hours post ingestion per Poison Control's recommendation. Staff X documented during the initial interview with Patient #8 was sitting in bed crying, labile, and anxious. Staff X documented Patient #8 reported they denied suicidal ideation and reported they took pills to get high.

v. On 6/17/24 at 1:25 PM Staff X, Case Manager, documented Patient #8's legal guardian agreed to sign paperwork for Patient #8 to receive inpatient treatment at a facility once placement could be found.

w. On 6/17/24 at 4:05 PM Staff X, Case Manager, documented after submitting bed requests to 7 inpatient psychiatric facilities, no bed was found. The patient remained in the ED awaiting an inpatient adolescent psychiatric admission. Staff X obtained a copy of the guardianship from the clerk of court.

x. On 6/17/24 at 6:39 PM Staff BB, ED Physician, documented Patient #8 was in bed and appeared well.

y. On 6/17/24 at 7:01 PM Staff C, ED RN, completed a Columbia SAFE-T Screening (a specialized screening tool to determine suicidal ideation severity risk). Staff C documented Patient #8 was agitated, had suicidal ideation within the last month, had thoughts about how they might kill themselves, had thoughts and intentions on how they would carry out the plan. Staff C assessed the patient was a high suicide risk and documented the patient remained in behavioral health safe room with sharp objects, tubing and the call-light cord removed.

z. On 6/17/24 at 9:15 PM Staff C, ED RN, documented Patient #8 was out of their room to the nurses station twice with a request to use the phone to call their significant other. Staff C informed the patient their mother requested the patient not call the significant other. Patient #8 screamed, cried and initially did not listen to redirection from staff to go back to their room. Staff C documented the patient did go back to their room and slammed the door shut. Staff C notified Staff K, ED Physician of the patient's behavior.

aa. On 6/17/24 at 9:28 PM Staff K, ED Physician, ordered 4-point restraints due to Patient #8 violent behaviors and striking out. Staff K ordered Lorazepam 2 mg intramuscularly (IM) and Geodon (medication used to treat schizophrenia and bipolar disorder) 10 mg IM. Staff C, ED RN, administered the medications.

bb. On 6/17/24 at 9:35 PM Staff K, ED Physician, discontinued restraints.

cc. On 6/17/24 at 10:25 PM Staff C, ED RN, documented Patient #8's legal guardian arrived to help assist in calming the patient down. Staff C documented the legal guardian requested for there to be no contact between the patient and the patient's significant other. Staff C documented the legal guardian reported the significant other was the reason why Patient #8 was in the hospital.

dd. On 6/18/24 at 8:00 AM, 12:00 PM and 4:00 PM, Staff Y, ED RN, completed a Columbia Suicide Severity Rating Scale and documented, since last asked, the patient had not had any thoughts of killing themselves, no thoughts or intentions of carrying out any type of plan to kill themselves and the patient was not prepared to do anything to end their life.

ee. On 6/18/24 at 8:15 AM Staff X, Case Manager, documented Patient #8 completed a safety plan.

ff. On 6/18/24 at 2:04 PM Staff Z, Telehealth Nurse Practitioner, documented Patient #8 had an intentional ingestion in an attempt to get high and consistently denied this was a suicide attempt. Staff Z documented the safety plan was for the legal guardian to purchase a safe to lock up all prescription and over the counter medications. Staff Z further documented the legal guardian stated the patient could return home and agreed they would establish treatment with a new therapist.

gg. On 6/18/24 at 3:09 PM Staff Y, ED RN, documented Patient #8's legal guardian agreed with the safety plan and would pick the patient up at 4:30 PM.

hh. On 6/18/24 at 3:09 PM Staff BB, ED Physician, documented Staff Z had cleared Patient #8 for discharge. Staff BB prescribed Oxcarbazepine 300 mg orally twice daily per request of Staff Z, Telehealth Nurse Practitioner.

ii. On 6/18/24 at 4:41 PM Staff Y, ED RN, documented they explained discharge instructions to Patient #8 and the legal guardian. Hospital staff discharged the patient to home.

4. The hospital did have the capacity and capability to care for adult inpatient behavioral health patients on 6/16/24, 6/17/24, and 6/18/24. The hospital's Medical Surgical Unit did have the capacity to admit patients on 6/16/24, 6/17/24, and 6/18/24. The hospital's Pediatric Unit did have the capacity to admit patients on 6/16/24, 6/17/24, and 6/18/24.

5. On 8/1/24 at 10:30 AM, during an interview, Patient #8's legal guardian explained that hospital staff did not do anything to treat Patient #8. The legal guardian stated, "All they did was to put (the patient) in a room; they didn't give (the patient's) regular medication."

The patient's medical record revealed the patient took the following prescribed medications: Sertraline (a medication used to treat depression) 100 mg oral daily; Buspirone (a medication used to treat anxiety) 20 mg oral twice per day; Aripiprazole (a medication used to treat psychosis and depression) 7.5 mg oral daily; Trazadone (a medication used to treat depression and difficulty sleeping) 50 mg oral daily, Hydroxyzine (a medication used to treat anxiety) 25 mg (frequency not identified) and Oxcarbazepine (identified by the legal guardian, but not included in the list of home medications, frequency and dose not identified).

6. On 7/31/24 at 7:57 PM, during interview, Staff K, ED Physician, revealed,"it was not obvious that (Patient #8) sustained a serious overdose." Staff K explained the patient was unresponsive, but when they became alert (on 6/16/24), they were very agitated and upset. Staff K reported it took 5-7 staff to restrain Patient #8. Staff K did not recall that Staff AA, Telehealth Psychiatrist, recommended involuntary adolescent inpatient psychiatric admission, but explained, when indicated, the process would be to contact the Magistrate and request a 48-hour hold.

7. On 7/31/24 at 9:00 AM, during an interview, Staff X, Case Manager, revealed the hospital's behavioral health unit took adult inpatients with a minimum age of 18 years old. Staff X reported they did not recall a time that a patient had been transferred from their ED to another ED due to lack of psychiatric capabilities at their hospital. When there was a delay in placement, the patients received a psychiatric consult every 24 hours. Staff X explained Patient #8 was not forthcoming with what brought them into the hospital. Staff X recalled they explained to Patient #8 that they had a recommendation for inpatient admission. Staff X told the patient they could not be admitted to the hospital because the patient didn' t meet the age requirements. Staff X reported having a discussion with the Behavioral Health Director who determined Patient #8 was not appropriate for admission.

8. On 7/31/24 at 9:05 AM, during an interview, Staff Z, Telehealth Nurse Practitioner, explained they used their medical decision making skills to determine Patient #8 met the discharge criteria after the patient consistently denied the OD was a suicide attempt. The guardian agreed to the appropriate safety plan and the discharge of the patient. When asked if Staff Z was aware of all of the behaviors Patient #8 had displayed while at the hospital, Staff Z responded, Staff Y ED RN had explained the patient required restraints, most recently on 6/17/24 at 9:28 PM. Staff Z explained that after discussion with the patient, legal guardian and complete review of the medical record including the initial psychiatric assessment (completed by Staff AA, Telehealth Psychiatrist), Staff Z determined the patient was just trying to get high and was no longer a risk to themselves or others. Staff Z further explained, "that age group ' s behavior issues fluctuate a lot."

9. On 8/5/24 at 1:15 PM interview with Staff DD, Director of Behavioral Health Unit revealed only one time they were aware of an exception made for an inpatient under 18 years of age because the patient was one or two weeks before their 18th birthday. Staff DD denied knowledge of making any other exceptions for inpatient behavioral health unit admissions under the age of 18 years old.

Review of Patient #8 ' s medical record and staff interviews revealed Patient #8 was a high risk for suicide. The patient was a safety risk to themselves and others due to their illness. The hospital failed to provide Patient #8 appropriate stabilizing treatment or attempt to obtain an involuntary commitment per the recommendations of Staff AA, Telehealth Psychiatrist, while they held the patient in the ED waiting for inpatient psychiatric placement.









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10. Interview for Patient #16 revealed the following:

During an interview on 08/01/24 at 11:21 AM, Patient #16's family member reported that she had been doing great for two years. She was going to school, was a half a semester out from graduating with her associate's degree and working as a pharmacy technician. Around the first part of April 2024, the patient experienced the death of a loved one, which "triggered something." She became manic, stayed up for days, was terrified, and experienced a "spiritual battle" between "angels and demons." In the very early morning of 04/20/24, Patient #16 got in her car and drove around town, while other family members followed and notified police.

11. Review of Law Enforcement Officer (LEO) body cam surveillance dated 04/20/24 at 3:19 AM, showed Law Enforcement (LE) had pulled Patient #16 over. Patient #16 reported she was driving around because she was stressed about life. While the LEO spoke to her, she appeared paranoid, watching her passenger mirror and looking around, asking where people were and what they were saying about her. She denied to the officer that she was homicidal or suicidal, denied that she hadn't slept, and was "OK." Family on scene reported to the LEOs that the patient had been off her psychiatric medications for over a year, had experienced the recent death of a loved one, and had become violent at home and had hit her mother in the head. Officers explained to the family, that because the patient was not suicidal or homicidal, they couldn't take the patient to the hospital, so a family member got in the car with the patient, with plans to drive the patient to a family member's home in a nearby town.

Review of LEO body camera surveillance dated 04/20/24 at 7:48 AM, shows LEOs responded (second call in under four hours) to the family home where Patient #16 was located. Family reported that the patient believed the devil was after her, believed her family members were the devil, and would place her hands on them in attempts to exorcise the devil out of them. LE transported the patient to Ottumwa Regional Health Center Emergency Department (ED).

12. During an interview on 08/01/24 at 10:02 AM, ED RN S stated that when Patient #16 arrived at Ottumwa hospital she was not tracking conversation or answering questions appropriately. The patient would start talking randomly, repeated the same things over, and was unable to follow directions. She would start to run, as if she was going to get out the door, she would throw items into other patients' rooms, and ED RN S was concerned the patient would injure another patient.

13. Review of Patient #16's medical record showed that local law enforcement brought Patient #16 to the hospital's ED on 04/20/24 at 8:15 AM, after they were called by the patient's family to respond to a "psychotic episode." The family reported a history of bipolar disorder for which the patient had not been taking her prescribed medications for two years. Without medication, she had successfully worked and attended college, until the previous two weeks when she experienced the death of a family member. During the patient's triage, she was found to be agitated, delusional, hyperactive, hyperverbal, with mood changes and violent behavior. She would not cooperate with the initial assessment, questions, or physical examination. The patient was placed on suicidal precautions, in a psychiatrically safe ED room, where she began frantically pushing buttons on ED equipment, and grabbing the equipment and would not let go. She became violent, throwing items and water, jumping off the bed, and screaming. She refused to stay in her room and continued these behaviors into the hallway, which resulted in the patient being placed in seclusion. At 8:25 AM, EDP K documented that the patient appeared to be psychotic, an immediate risk to herself and others, and required chemical restraint (medication used to control a patient's behavior). He documented that the patient was currently "Psychotic. Extremely brittle. Intermittently very uncooperative. Seems bizarre and potentially dangerous." The patient exhibited flight of ideas, abnormal insight, abnormal judgement, abnormal thought process, and delusions. A suicide risk assessment showed the patient was at risk for suicide, that hospitalization should be considered, and at 9:40 AM, EDP K obtained a 48-hour court ordered hold (used to legally restrict a person from leaving, who is believed to be seriously mentally impaired and likely to injure themselves or others). Throughout the day, the patient would exhibit violent behaviors that could not be redirected. She would scream, posture and lash out, and leave her room and enter other patients' rooms. She required frequent seclusion and sedation to calm down. Laboratory tests were ordered and resulted, and showed the patient tested positive for influenza (the flu, highly contagious viral infection). EDP II, who assumed care of the patient for the night shift, documented the patient continued to be a danger to herself and others. On 04/21/24 at 1:15 AM, he consulted psychiatry, the decision was made to admit the patient, and the admission was accepted by BHU NP NN, although the patient remained in the ED. The patient's behaviors continued, the patient was not redirectable, and at 9:22 AM, Telepsychiatrist W evaluated the patient. She documented that during the evaluation, the patient was restless, needed constant redirection, and talked in tangents (different lines of thought). The patient would come very close to the camera while drinking water and act as if she was going to spit it at the camera, and then walk around the room. The Telepsychiatrist documented that the patient was at moderate risk for suicide, and determined that because of the patient's history, non-compliance with medication, strong genetic history of bipolar disorder in the family, and severity of symptoms, she recommended inpatient psychiatric admission for stabilization and medication management. While the patient continued to wait in the ED, the patient refused to take ordered oral psychiatric medications, and required injectable sedation and intermittent seclusion for her continued behaviors. At 6:05 PM, after the patient had been accepted for admission to the Ottumwa BHU, ED RN MMM documented that requests to admit the patient were made to three outside hospitals for inpatient psychiatric care. Two of the facilities declined because the patient tested positive for influenza, and the third facility did not have an available bed. A packet of the patient's information was sent to the third hospital for pending admission on 04/22/24, when the hospital had planned patient discharges. Throughout the night, the patient continued to be disruptive and combative, lashing out, refusing to stay in her room, and was documented by the night shift EDP II, as a danger to herself and others. On 04/22/24 at 2:10 AM, RN C documented that she followed up again with the third inpatient psychiatric facility and was informed that the patient was still on the referral list for admission, with "possible admission today." Throughout the morning, while in seclusion, the patient pounded on her room door, stuffed items under the door, and urinated on the floor. At 9:20 AM, while the patient was assisted to the bathroom, she was documented as yelling, and required security to assist her back to her room, where she continued yelling and beating on the room door with her fists. A progress note dated 04/22/24 at 12:04 PM (approximately three hours prior to discharge), of an examination completed by day shift EDP G, showed the patient remained in a locked room and was screaming, kicking and punching the door. The EDP's documented physical examination included that the patient was "agitated at times," and she did not believe she was bipolar or that she needed medications for her psychiatric illness. She was intermittently cooperative with EDP G, then would become defiant and aggressive, had been evaluated by telepsychiatry and was awaiting inpatient placement. At 1:48 PM, Telepsych Nurse Practitioner (NP) Z, reevaluated the patient. She documented in her evaluations that she was aware the patient had been previously evaluated with recommended inpatient hospitalization, she received report from nursing of the patient's ongoing behaviors in the ED, that the patient's legal status was "voluntary," and that she did not meet criteria for involuntary commitment. She documented that the patient was not a danger to herself or others, that the patient was calm during the evaluation, and denied she had been acting out, "smiling as she answers." She documented that the patient stated she was not psychotic, did not need psychiatric medications, did not want to take psychiatric medications and would refuse them. Telepsych NP Z recommended that the patient be discharged home with two weeks' worth of oral psychiatric medications. She was diagnosed as bipolar manic psychotic, oppositional defiant disorder, schizoaffective disorder, documented as "stable," and discharged home at 3:55 PM. Her discharge included instructions to take Seroquel (psychiatrically sedating medication) by mouth (patient refused oral psychiatric medications while in the ED), to follow-up "soon" with her psychiatric providers, and to return to the ED if she became worse.

14. During an interview on 08/01/24 at 7:54 AM, EDP K stated that when Patient #16 presented to the ED on 04/20/24 at 8:47 AM, the patient was jumpy, distractible, and "very labile." She would seem calm and reasonable, and then 20 minutes later, she would bang on the door, yell, scream, and urinate on the floor. Her behaviors were beyond attention seeking and were so severe they had to medically sedate the patient to prevent her from harming herself, injuring staff, and to prevent her from running away. Attempts were made to admit the patient for inpatient psychiatric care but were unsuccessful.

15. During an interview on 08/05/24 at 3:44 PM, BHU NP NN confirmed that on 04/21/24 at 1:16 AM. she accepted Patient #16 on as an admission to the BHU.

16. During an interview on 08/05/24 at 1:52 PM, ED RN C stated that while the patient waited in the ED to be admitted to the BHU, she was placed in the "cue" to be assessed by a Telepsych provider.

17. During an interview on 08/05/24 at 4:00 PM, Telepsychiatrist W stated she evaluated Patient #16 on 04/21/24 at 9:22 AM, and found the patient to be very aggressive and agitated, and recommended inpatient psychiatric admission.

18. During an interview on 08/01/24 at 12:03 PM, ED RN KKK stated that Ottumwa's BHU would not accept Patient #16 because she was influenza positive.

19. Review of the hospital's policy titled, "BHU Scope of Service" dated 09/2023, showed the BHU focused on treating patients who were over the age of 18, admitted voluntary or involuntary, for the evaluation and stabilizing treatment of acute psychiatric conditions, including mania and psychosis. Admission criteria included patients who posed physical or verbal threats to others' safety, acute bizarre behavior or psychomotor agitation that interfered with an individual's ability to function. Patients with acute medical disorders who were not cleared for psychiatric admission could be treated on a medical floor with psychiatric consultation. Once the acute medical condition was stabilized, the patient could be admitted to the BHU.

20. Review of the contract between a Telepsychiatry (Telepsych) company and Ottumwa Regional Health Care showed that effective August 3, 2023, the Telepsych company would provide emergency psychiatry and consult & liaison psychiatry specialty consultative services in the hospital's emergency department, medical-surgical department, and cover the performance of consultative services in the BHU. Effective August 31, 2023, a provider, leased by the Telepsych company, would perform clinical services at the hospital.

21. Review of the hospital's policy titled, "Medical/Surgical/telemetry Unit Scope of Service," dated 02/2023, showed that the Medical/Surgical/Telemetry (MST) unit was a 24-bed unit, which included one negative air-controlled room (prevents contaminants from inside the room to flow out of the room when the door is open, and prevents the spread of viruses, such as influenza).

22. Review of the Medical/Surgical/Telemetry (MST) Unit Census Report showed:
- On 04/20/24, the census was 12 patients.
- On 04/21/24, the census was 12 patients.
- On 04/22/24, the census was 16, with a pending admission.

23. During an interview on 08/05/24 at 4:00 PM, Telepsychiatrist W stated that if a patient had a medical condition along with a psychiatric condition that required stabilization, the patient should be admitted to the floor (Medical/Surgical/Telemetry Unit), and a request for a psychiatric consult should be made. "If they need admission, they need admission ...It's the responsibility of the hospital to provide that."

24. During an interview on 07/31/24 at 9:05 AM, Telepsychiatry Nurse Practitioner (NP) Z stated that she evaluated Patient #16 on 04/22/24, which began with the nurse's report of the patient's ongoing need for seclusion and behaviors. Telepsych NP Z confirmed she had access to, and reviewed the patient's medical record, specific to the previous provider's notes, and was aware of Telepsychiatrist W's recommendation for inpatient admission. During the patient's evaluation, the patient reported that her behaviors in the ED were due to staff not providing her with water (per staff, she received water and threw it on the floor). She denied urinating on the floor, "smiling as she answered," which Telepsych NP Z admitted seemed incongruent with what had been reported by the nurse. However, because the patient was calm, polite, and with good eye contact, she believed the patient was credible in her responses, didn't see a "major" concern with the patient's behaviors, and with a "reasonable degree of psychiatric certainty," believed that the patient was not an imminent danger to herself or others. Staff Z stated the patient showed no evidence of psychosis and recommended the patient be discharged home with oral psychiatric medications, even though she was aware that the patient refused oral psychiatric medications while in the ED. Telepsych NP Z stated that the patient had a right to r

Based on medical record review, hospital policy review and staff interviews, the Hospital staff failed to arrange an appropriate transfer to a hospital with the appropriate capabilities and capacity for 1 of 27 sample patients (Patient #8) selected for review.

Failure to provide an appropriate transfer to a hospital with adolescent psychiatric capabilities and capacity placed Patients #8 at risk for deterioration of the patient's emergency medical condition (EMC), including deterioration of the patient's mental health and at a potential risk for death through self harm.

Findings include:

Review of policy "EMTALA- Medical Screening and Treatment of Emergency Medical Conditions", dated 2/2024, revealed in part "... If the Medical Screening Examination reveals an Emergency Medical Condition, then the Hospital must provide stabilizing treatment within its capacity and capabilities (including on-call physician services and ancillary services) necessary to stabilize the patient or must appropriately transfer the patient to another facility ..."

1. On 8/1/24 at 11:30 AM an interview with Staff AA, Telehealth Psychiatrist revealed, their opinion for the safest care of Patient #8 was to recommend an involuntary adolescent inpatient psychiatric admission due to the combination of medications ingested, evasiveness of the patient, inability to speak to the guardian since the patient was a minor and the inability to obtain all risk factors.

2. On 7/31/24 at 9:00 AM, during an interview, Staff X, Case Manager, revealed the hospital's behavioral health unit took adult inpatients with a minimum age of 18 years old. Staff X reported they did not recall a time that a patient had been transferred from their ED to another ED due to lack of psychiatric capabilities at their hospital. When there was a delay in placement, the patients received a psychiatric consult every 24 hours. Staff X explained Patient #8 was not forthcoming with what brought them into the hospital. Staff X recalled they explained to Patient #8 that they had a recommendation for inpatient admission. Staff X told the patient they could not be admitted to the hospital because the patient didn' t meet the age requirements. Staff X reported having a discussion with the Behavioral Health Director who determined Patient #8 was not appropriate for admission.

3. Review of Patient #8's medical record revealed the following:

a. On 6/16/24 at 7:12 PM, the 911 dispatch call report revealed Patient #8's friend had called 911 after the patient called and told the friend they had taken additional prescribed pills to try to get high.

b. On 6/16/24 at 7:34 PM, the ambulance report revealed Emergency Medical Service (EMS) crew found Patient #8 in their dwelling sitting on the floor vomiting with vomit in their hair. Staff J, EMT initiated intravenous (IV) access, administered Lactated Ringers (electrolyte replacement) 1 Liter IV, and Narcan (medication used to reverse the effects of opioids) 2 milligrams (mg) IV. The patient aroused, vomited and went unresponsive again. Staff J administered Ondansetron (medication to prevent nausea and vomiting) 4 mg IV. EMS brought Patient #8 to the ED for an overdose. EMS staff found pill bottles in the room with the patient and brought them into the ED.

c. On 6/16/24 at 7:40 PM Staff D, ED RN, documented Patient #8 arrived non-responsive, and was vomiting.

d. On 6/16/24 at 7:40 PM Staff K, ED Physician, medically evaluated Patient #8 and ordered a urinary catheter, head computed tomography (CT) (scan of head that uses x-rays to develop a 3D image of the skull and brain), chest x-ray, and screening lab work that included a urinalysis, urine drug screen. At 7:45 PM Staff K ordered Narcan 0.4 mg IV. The urine drug screen resulted at 7:48 PM was positive for Tetrahydrocannabinol (THC) (the main mind-altering ingredient in the cannabis plant), and blood Potassium level was low at 2.6 millimole (mmol/L) (normal measured 5.0 mmol/L to 3.5 mmol/L per the hospital lab report). ED nursing staff administered the following additional medications ordered by Staff K: Lactated Ringers 1 Liter IV x two, Ondansetron 8 mg IV, Pantoprazole (medication used to decrease stomach acid and heartburn) 40 mg IV, repeat Narcan 1.2 mg IV, Potassium Chloride (used to treat low blood potassium) 10 milliequivalents (MEQ)/100 mL water IV x two.

e. On 6/16/24 at 8:00 PM Staff D, ED RN, completed an initial nursing assessment of the patient. Staff D documented Patient #8's primary reason for treatment was not a behavioral health condition, but due to ingestion and intentional overdose per EMS. Staff D documented the patient did not have an underlying behavioral condition that warranted additional suicide screening. Staff D, ED RN, did not complete any type of suicide screening assessment, as part of the patient ' s assessment.

f. On 6/16/24 at 8:04 PM Staff C, ED RN, documented that they called Poison Control. Per Staff C, Poison Control recommended lab work and observation of Patient #8 for seizure activity and blood pressure fluctuations.

g. On 6/16/24 at 8:03 PM Staff K, ED Physician, documented Patient #8's legal guardian called and explained that they were unable to locate the patient's Oxcarbazepine (medication used to decrease nerve impulses that cause seizures) bottle. The legal guardian reported that it was possible the patient overdosed with that medication. Staff K documented the patient found with the following medication bottles: EMS handed over the following pill bottles to ED staff that EMS found in the patient's room: one bottle of Hydroxyzine (medication used to treat anxiety) 25 mg with about 10-12 pills left in the bottle; and one bottle, about half-empty, of Ibuprofen (medication used to treat pain, fever, and inflammation) 600 mg. Staff K ordered further lab work suggested by Poison Control, including Tylenol and Salicylate levels.

h. On 6/16/24 at 9:00 PM Staff K, ED Physician, ordered a one to one sitter for Patient #8 (no reason identified).

i. On 6/16/24 at 10:00 PM and 10:15 PM Staff G, CNA Sitter, documented Patient #8 was awake and uncooperative.

j. On 6/16/24 at 10:22 PM, a physician order, included documentation of an order by Staff K, ED Physician, for 4-point restraints due to Patient #8 violent behaviors and striking out.

k. On 6/16/24 at 10:31 PM, Staff K ordered Lorazepam (medication used to treat anxiety; when given by injection, onset of effects is within one to thirty minutes) 2 mg IV; administered by Staff D, ED RN while staff had the patient restrained.

l. On 6/16/24 at 10:45 PM to 6/17/24 at 12:45 AM Staff D, ED RN, documented 15-minute restraint checks.

m. On 6/16/24 at 11:00 PM Staff D, ED RN, documented Patient #8 was alert and oriented and agitated.

n. On 6/16/24 at 11:10 PM Staff K, ED Physician, ordered a Telehealth Psychiatric consultation due to "ingestion".

o. On 6/17/24 at 12:45 AM Staff K, ED Physician, discontinued restraints.

p. On 6/17/24 at 4:45 AM Staff D, ED RN, documented Patient #8's urinary catheter was removed, patient was up to the bathroom and changed into scrubs.

q. On 6/17/24 at 5:49 AM Staff D, ED RN, notified the Telehealth Psychiatrist that the patient was alert and oriented enough for the consultation evaluation.

r. On 6/17/24 at 6:25 AM Staff K, ED Physician, documented in a shift summary that Patient #8 received fluid resuscitation and woke up 3 hours after arrival. Head CT and chest x-ray were unremarkable. At approximately 10:22 PM, the patient became extremely agitated, screamed, fought with staff, required 8 staff members to restrain her and required 4-point restraints as well as Lorazepam 2 mg IV. After less than 2 and a half hours, hospital staff removed the 4-point restraints and Patient #8 was calm, conversational and cooperative. Staff K documented Staff AA, Telehealth Psychiatrist, contacted them by telephone after interviewing the patient and felt the patient definitely required inpatient hospitalization, due to the extremely impulsive and dangerous ingestion. Staff K documented the psychiatrist (Staff AA) informed Staff K that Patient #8 stated they took 10 Oxcarbazepine pills in an attempt to get high.

s. On 6/17/24 at 6:53 AM Staff AA, Telehealth Psychiatrist, documented Patient #8, " ...is psychiatrically unstable, and remains an imminent danger to (self). Continues to present with poor insight, unable to engage in safety planning, minimizing circumstances of admission, intentional overdose with unclear amounts of pills, and not being forthright about intentions. Effectively dysregulated, poor impulse control. Poor judgment. No least restrictive option available at this time. Meets criteria for involuntary commitment and would benefit from further psychiatric stabilization."

t. On 6/17/24 at 11:56 AM, Staff X, Case Manager, documented the completion of a Columbia SAFE-T Protocol (a form used to assess the level of suicide risk). Staff X documented the patient denied a wish to be dead in the past month, denied thoughts of killing themselves in the past month, denied ever doing anything or ever starting to do anything to end their life. Staff X documented the patient was "no suicide risk".

u. On 6/17/24 at 12:18 PM Staff X, Case Manager, documented that they held off on attempts to find inpatient placement due to the need to wait 24 hours post ingestion per Poison Control's recommendation. Staff X documented during the initial interview with Patient #8 was sitting in bed crying, labile, and anxious. Staff X documented Patient #8 reported they denied suicidal ideation and reported they took pills to get high.

v. On 6/17/24 at 1:25 PM Staff X, Case Manager, documented Patient #8's legal guardian agreed to sign paperwork for Patient #8 to receive inpatient treatment at a facility once placement could be found.

w. On 6/17/24 at 4:05 PM Staff X, Case Manager, documented after submitting bed requests to 7 inpatient psychiatric facilities, no bed was found. The patient remained in the ED awaiting an inpatient adolescent psychiatric admission. Staff X obtained a copy of the guardianship from the clerk of court.

x. On 6/17/24 at 6:39 PM Staff BB, ED Physician, documented Patient #8 was in bed and appeared well.

y. On 6/17/24 at 7:01 PM Staff C, ED RN, completed a Columbia SAFE-T Screening (a specialized screening tool to determine suicidal ideation severity risk). Staff C documented Patient #8 was agitated, had suicidal ideation within the last month, had thoughts about how they might kill themselves, had thoughts and intentions on how they would carry out the plan. Staff C assessed the patient was a high suicide risk and documented the patient remained in behavioral health safe room with sharp objects, tubing and the call-light cord removed.

z. On 6/17/24 at 9:15 PM Staff C, ED RN, documented Patient #8 was out of their room to the nurses station twice with a request to use the phone to call their significant other. Staff C informed the patient their mother requested the patient not call the significant other. Patient #8 screamed, cried and initially did not listen to redirection from staff to go back to their room. Staff C documented the patient did go back to their room and slammed the door shut. Staff C notified Staff K, ED Physician of the patient's behavior.

aa. On 6/17/24 at 9:28 PM Staff K, ED Physician, ordered 4-point restraints due to Patient #8 violent behaviors and striking out. Staff K ordered Lorazepam 2 mg intramuscularly (IM) and Geodon (medication used to treat schizophrenia and bipolar disorder) 10 mg IM. Staff C, ED RN, administered the medications.

bb. On 6/17/24 at 9:35 PM Staff K, ED Physician, discontinued restraints.

cc. On 6/17/24 at 10:25 PM Staff C, ED RN, documented Patient #8's legal guardian arrived to help assist in calming the patient down. Staff C documented the legal guardian requested for there to be no contact between the patient and the patient's significant other. Staff C documented the legal guardian reported the significant other was the reason why Patient #8 was in the hospital.

dd. On 6/18/24 at 8:00 AM, 12:00 PM and 4:00 PM, Staff Y, ED RN, completed a Columbia Suicide Severity Rating Scale and documented, since last asked, the patient had not had any thoughts of killing themselves, no thoughts or intentions of carrying out any type of plan to kill themselves and the patient was not prepared to do anything to end their life.

ee. On 6/18/24 at 8:15 AM Staff X, Case Manager, documented Patient #8 completed a safety plan.

ff. On 6/18/24 at 2:04 PM Staff Z, Telehealth Nurse Practitioner, documented Patient #8 had an intentional ingestion in an attempt to get high and consistently denied this was a suicide attempt. Staff Z documented the safety plan was for the legal guardian to purchase a safe to lock up all prescription and over the counter medications. Staff Z further documented the legal guardian stated the patient could return home and agreed they would establish treatment with a new therapist.

gg. On 6/18/24 at 3:09 PM Staff Y, ED RN, documented Patient #8's legal guardian agreed with the safety plan and would pick the patient up at 4:30 PM.

hh. On 6/18/24 at 3:09 PM Staff BB, ED Physician, documented Staff Z had cleared Patient #8 for discharge. Staff BB prescribed Oxcarbazepine 300 mg orally twice daily per request of Staff Z, Telehealth Nurse Practitioner.

ii. On 6/18/24 at 4:41 PM Staff Y, ED RN, documented they explained discharge instructions to Patient #8 and the legal guardian. Hospital staff discharged the patient to home.

4. The hospital did have the capacity and capability to care for adult inpatient behavioral health patients on 6/16/24, 6/17/24, and 6/18/24. The hospital's Medical Surgical Unit did have the capacity to admit patients on 6/16/24, 6/17/24, and 6/18/24. The hospital's Pediatric Unit did have the capacity to admit patients on 6/16/24, 6/17/24, and 6/18/24.

4. On 7/31/24 at 7:57 PM, during interview, Staff K, ED Physician, revealed,"it was not obvious that (Patient #8) sustained a serious overdose." Staff K explained the patient was unresponsive, but when they became alert (on 6/16/24), they were very agitated and upset. Staff K reported it took 5-7 staff to restrain Patient #8. Staff K did not recall that Staff AA, Telehealth Psychiatrist, recommended involuntary adolescent inpatient psychiatric admission, but explained, when indicated, the process would be to contact the Magistrate and request a 48-hour hold.

5. On 7/31/24 at 9:05 AM, during an interview, Staff Z, Telehealth Nurse Practitioner, explained they used their medical decision making skills to determine Patient #8 met the discharge criteria after the patient consistently denied the OD was a suicide attempt. The guardian agreed to the appropriate safety plan and the discharge of the patient. When asked if Staff Z was aware of all of the behaviors Patient #8 had displayed while at the hospital, Staff Z responded, Staff Y ED RN had explained the patient required restraints, most recently on 6/17/24 at 9:28 PM. Staff Z explained that after discussion with the patient, legal guardian and complete review of the medical record including the initial psychiatric assessment (completed by Staff AA, Telehealth Psychiatrist), Staff Z determined the patient was just trying to get high and was no longer a risk to themselves or others. Staff Z further explained, "that age group ' s behavior issues fluctuate a lot."

6. On 8/5/24 at 3:00 PM interview with Staff BB, ED Physician revealed they did not specifically recall Patient #8, but explained Telehealth Psychiatric providers were professional, spent ample time evaluating the patients, and if they made the decision that the patient was ready for discharge, they (the ED healthcare practitioners) would follow their instructions.

7. On 8/5/24 at 1:15 PM interview with Staff DD, Director of Behavioral Health Unit revealed only one time they were aware of an exception made for an inpatient under 18 years of age because the patient was one or two weeks before their 18th birthday. Staff DD denied knowledge of making any other exceptions for inpatient behavioral health unit admissions under the age of 18 years old.

The hospital failed to transfer Patient #8 to a hospital with adolescent inpatient psychiatric capabilities.