HospitalInspections.org

Based on review of facility policy, medical record review, review of a police report and interviews, the facility failed to provide stabilizing treatment for 1 patient (#20) who presented to the Emergency Department (ED) for Suicidal Ideations (SI) and aggressive behaviors, of 20 patients reviewed.

The findings include:

Patient #20 was admitted to Facility A's ED on 5/17/2025 at 12:35 AM, with SI and aggressive behaviors. While in the ED the patient continued with aggressive and threatening behaviors towards the ED staff and police officers. The patient was placed under a Certificate of Need for Emergency Involuntary Admission (CON). The patient refused to have blood work drawn. A telepsychiatry evaluation was performed and the patient's diagnoses included Psychosis and SI. Psychiatry recommended the following: involuntary commitment for inpatient psychiatric services, the use of antipsychotic and sedative medications, and a reconsult for psychiatry services within 24-48 hours as needed. The patient refused the medications and continued with aggressive and threatening behaviors. There was discussion between the ED staff, the ED physician and law enforcement related to the patient's behaviors and the patient's refusal of the medications. There was a discussion with the patient including if he refused the medications, he would be taken to jail. The patient refused the medications. The patient was discharged and sent with law enforcement out of the ED for the jail. The CON was not rescinded upon discharge. The patient continued to have aggressive and threatening behaviors. The patient was taken by law enforcement to Facility B where the patient required the use antipsychotic and sedative medications related to his aggressive behaviors. A medical screening examination and psychiatric evaluation was performed. Patient #20 remained under an involuntary hold, in the ED until 5/20/2025, when the patient was transferred to an inpatient behavioral health facility.

Cross Refer to A-2407.

Based on review of facility policy, medical record review, review of a police report and interviews, the facility failed to provide ongoing treatment and stabilization for 1 patient (#20) who presented to the Emergency Department (ED) for Suicidal Ideations (SI) and aggressive behaviors of 20 patients reviewed.

The findings include:

Review of facility policy "EMTALA-Medical Screening Examination and Stabilization," revised 12/20/2024, showed "...Purpose: to establish guidelines for providing appropriate medical screening examinations [MSE] and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA...[7] Stabilizing Treatment Within Hospital Capability: the determination of whether an individual is stable is not based on clinical outcome of the individual's medical condition. An individual has been provided sufficient stabilizing treatment when the physician treating the individual in the DED [Dedicated Emergency Department] has determined, within reasonable clinical confidence, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during a transfer or the individual from a facility...or in the case of an individual with a psychiatric or behavior condition, that the individual is protected and prevented from injuring himself/herself or others...[a] Stable. The physician or QMP [qualified medical provider] providing the medical screening examination and treating the emergency has determined within reasonable clinical confidence, that the EMC [Emergency Medical Condition] that caused the individual to seek care in the DED has been resolved although the underlying medical condition may persist..."

Patient #20 was admitted to Facility A's ED on 5/17/2025 at 12:35 AM, for a mental health evaluation related to Suicidal Ideation (SI), aggressive and threatening behaviors.

Medical record review revealed Patient #20 was placed under a Certificate of Need for Emergency Involuntary Admission (CON) on 5/17/2025 at 12:44 AM. Review revealed the patient had a history of depression with current SI with a suicide plan and needed inpatient psychiatric treatment. Continued review revealed the CON was not rescinded upon the patient's discharge.

Medical record review of an ED Nursing Triage dated 5/17/2025 at 12:51 AM, revealed the patient was admitted for a mental health evaluation and SI. His suicide risk assessment showed the patient was a high risk. Continued review revealed Patient #20 was placed in a safe room with a 1:1 sitter in attendance.

Medical record review of an ED Provider Record dated 5/17/2025 at 12:51 AM, revealed the patient presented with SI, "very manic" with rapid speech. Patient #20 stated he did not have an actual plan, but he would "shoot his brains down." The physical examination showed the patient was alert, euphoric, with flight of ideas and pressured speech.

Medical record review of an ED Nursing Note dated 5/17/2025 at 2:33 AM, revealed "...pt. [Patient #20] is continually escalating. While this RN [Registered Nurse] and charge RN were attempting to draw blood, pt. looked at this RN and stated 'I will hammer fist the [expletive] out of your face' and then raised his arm and flexed his bicep stating 'you see how big my arm is and I don't get no smaller. You better stop trying to take my [expletive] blood.' Charge RN and this RN left the room at that time to try to allow the patient to deescalate. Pt. began pacing and muttering under his breath. Notified [named Police Department] officer...staff attempted to decrease external stimuli by closing door to room 17 and notified pt. we were just closing the door but it was not locked. Pt. got up and became verbally aggressive towards...officer stating things such as 'I'm not suicidal, I could bust your head easy, see how big I am' and also arguing with officer about who the officer's father was and what year he was born. Notified hospital security and provider. Officer was able to verbally deescalate, and pt. went back and sat on the bed. Security standing by in the ER [Emergency Room] with [named police department] officer at this time..."

Medical record review of a Psychiatric Assessment dated 5/17/2025 at 3:19 AM, revealed Patient #20 presented with SI, psychosis and mania. He had rapid speech stating he will "shoot his brains out." He was belligerent, pressured speech, screaming non-stop, threatening staff and the provider. He exhibited paranoid delusions and hallucinations. The patient continued to escalate during the interview. During the telepsychiatry interview, the patient hit the teledoc (video monitor) machine across the room. It was unknown if the patient was taking his psychiatric medications. He was diagnosed with Psychosis. He was high risk for suicide. Patient #20 was deemed a likely danger to himself and others related to the patient's mental impairment and poor coping strategies, Recommendations included involuntary hospitalization to prevent harm to self and others, to have an inpatient psychiatric admission once medically cleared, the patient should not be allowed to sign-out AMA (Against Medical Advice) and consult psychiatry in 24-48 hours for reevaluation if needed. Recommended medications included Zyprexa (antipsychotic medication) 5 milligrams (mg) BID (twice a day). Comfort medications included Trazodone (antidepressant medication) 50 mg at nighttime, Vistaril (sedative medication) 50 mg TID (three times a day) and Zyprexa 5 mg every 6 hours as needed (PRN) for mild to moderate agitation. For severe aggression, recommendations included Haldol (antipsychotic medication) 5 mg IM (intramuscular), Ativan (medication used for anxiety) 2 mg IM, and Benadryl (antihistamine medications used to treat insomnia) 50 mg IM. Continued review revealed there was a discussion with the ED Provider.

Medical record review of an ED Provider Progress Note dated 5/17/2025 at 3:24 AM, revealed "...throughout his course here in the ED patient became agitated and aggressive. Upon reevaluation patient was offered medications to help manage his agitation. Medications were recommended by psychiatrist. Due to patient's continued aggressive behavior refuse of medications...police deemed necessary for the safety of the patient and others around him. The patient was given the choice between accept a medical intervention or taken into police custody. Patient offer [elected] police custody over received a medication..." Patient #20's diagnosis was Agitation and he was discharged into the custody of the police. He was given discharge instructions related to Psychosis and the police officer signed the discharge instructions.

Medical record review of an ED Nurses Note dated 5/17/2025 at 4:11 AM, revealed "...pt. became agitated during tele-psych assessment and became aggressive towards the monitor. Provider offered IM medications for safety of pt. and staff. When this RN informed pt. that the doctor had ordered him some meds to be given in a shot form pt. replied 'you can't pierce my skin, I have been hit with 29 nuclear bombs and now my skin glows green. You aren't giving me a shot, you can try to but I'll bust your head wide open. You all can't hold me down, you can try but I have killed hundred of people.' Charge RN approached this RN and asked if this RN agreed it would be safer for pt. and staff if patient would be taken into [named Police Department] custody due to pt. level of agitation and aggression and the multiple verbal threats towards staff. This RN agreed that would be the safest route for all parties involved due to multiple staff members attempting to deescalate pt. without success. Pt. had made multiple threats towards nursing staff and [named police officer]. Charge RN spoke with [named police officer] and two other [named local police department officers] who arrived during the agitated outburst about possibly taking the pt. into custody for safety of staff. [Named police department] officers informed pt. that if he would not calm down and refrain from threatening staff then they would have to take him into custody. The pt. responded, 'fine with me to jail, they are my family there.' At that point pt. turned around and was placed into handcuffs without further incident. Pt. continued to threaten the arresting officers and staff on his way out the ambulance bay doors..." The patient left the ED in police custody.

Review of a local Police Department report dated 5/17/2025 at 3:12 AM, revealed Patient #20 was brought to the ED earlier for a mental health evaluation. The patient was agitated, argumentative, and maintained an aggressive stance. The patient made statements related to his "veins were so big that could not be penetrated by a butcher knife, he was 750 pounds, he could not be sedated and his father would shoot anyone who attempts to medicate him." The patient was delusional, stated he was the anti-Christ and he had killed Bin Laden. The ED staff had informed the patient he needed to take the medications or go to jail. Continued review of the police report revealed Patient #20 was taken into police custody and discharged per the facility's request. The police officer spoke with patient who expressed he wanted to be transported to [Facility B] for a mental health evaluation. The patient was transported to Facility B's ED. Further review of the police report revealed on arrival at Facility B the patient made similar remarks he had made at Facility A. He was aggressive with the staff at Facility B including the security and ED staff. The patient was placed on his stomach and administered medications. The patient did not resist and he was cooperative with the staff.

Medical record review revealed Patient #20 arrived at Facility B's ED, transported by local police on 5/17/2025 at 4:05 AM. The patient had been evaluated at Facility A for a voluntary evaluation, however while at Facility A the patient became agitated and refused all treatment. The patient was discharged from Facility A into the custody of local law enforcement to be transported to the jail. The patient was transported by law enforcement to Facility B with complaints of agitation and for a psych (psychiatric) evaluation. Continued review revealed the patient was placed in seclusion with a 1:1 sitter, given Ketamine (medication for sedation) 300 mg IM and Zyprexa 10 mg IM. He was placed under a CON by the ED Provider. Diagnostic testing included blood work for a Complete Blood Count, Basic Metabolic Panel, alcohol levels, Urine Drug Screen and COVID 19 testing, ordered and completed.

Medical record review of an ED Provider Note from Facility B dated 5/17/2025 at 4:13 AM, revealed Patient #20 arrived via local police for Psychosis. The staff at Facility A reported to police that they offered medications, but the patient refused. The documentation from Facility A "...suggested the patient presented with mania with psychotic features. He was evaluated by tele-psychiatry there and recommended involuntary inpatient psychiatric treatment. The patient was recommended antipsychotic regimen of medications and PRN agitation medications. ED documentation suggested the staff there was concerned about their safety due to patient's agitation and threatening behavior. Police report there was no crime committed and patient could not be taken to jail...Upon discharge from [Facility A] the police brought patient to [Facility B] for further evaluation due to symptoms of acute psychosis..." Continued review revealed in the ED at Facility B, the patient was hyperactive, aggressive, threatening staff, paranoid, with pressured speech, he endorsed religious delusions and appeared internally stimulated. The plan of care included placing the patient in seclusion, medication treatment including IM Ketamine and additional antipsychotics. Review revealed Patient #20 was placed under a CON with a plan for inpatient psychiatric treatment.

Medical record review of a Psychiatric Evaluation dated 5/17/2025 at 11:02 AM, revealed the patient was previously at Facility A and involuntary hospitalization was recommended. It was unclear why Patient #20 was discharged but medical record review revealed either staff felt he was too acute/threatening or were hoping he would be discharged to police custody. The police brought the patient to Facility B for ongoing psychosis and agitation. The patient had previous history of Bipolar Disorder and Polysubstance Use Disorder. The plan of care included inpatient psychiatric involuntary admission, Risperdal (antipsychotic medication) 1 mg BID and Haldol (antipsychotic medication) 5 mg PO/IM every 6 hours as needed (PRN).

Medical record review revealed Patient #20 remained in Facility B's ED from 5/17/2025-5/20/2025. The patient was followed by the ED Physician daily and reassessed. Multiple referrals were made for the patient. On 5/20/2025 at 5:50 PM, the patient was accepted and transferred to an inpatient psychiatric facility.

During a telephone interview on 5/28/2025 at 9:55 AM, RN #1 (employed at Facility A) stated the patient (Patient #20) was brought into the ED by local police related to a violent episode at a rehab facility. The patient was psychotic with internal stimulation. The patient was alert to himself, aggressive and uncooperative with the staff and the police. Interview continued and RN #1 stated he and another nurse had gone into the room to draw blood and the patient was threatening to the staff with expletive statements related to he would fight and harm the staff. The patient was given oral Valium for his agitation, but the medication did not appear to decrease the behaviors. The patient remained aggressive and threatening. During the psychiatric assessment, the patient become violent and knocked the teledoc machine across the room. There were IM medications ordered for the patient. When he and another nurse went in to give the medications, the patient stated he would not take the medication, he would fight them, and they could not hold him down. RN #1 stated he, the charge nurse, the physician and the police felt the patient was violent and felt their safety was in jeopardy while administering the medications. They felt the patient would be better served with the local police in the jail. The patient was offered the medications or to be discharged with local police to the jail. The patient stated "take me to jail." The ED physician discharged the patient. RN #1 confirmed the patient was discharged to the local police with the agreement the patient would be taken to jail.

During a telephone interview on 5/28/2025 at 10:05 AM, RN #2, (employed at Facility A) stated the patient (Patient #20) was brought into the ED by local police with Psychosis and SI. The patient presented violent and psychotic. The patient was place under a CON. When she and another nurse attempted to obtain blood from the patient, he stated he would 'hammer our heads' if we attempted to draw blood and was very threatening. Interview continued and RN #2 stated the patient remained very aggressive with the staff and remained manic. There were IM antipsychotic medications ordered for the patient per psychiatry and the ED provider. She and the other nurse went into the room to give the medications. The patient refused the medications. He stated he would fight and no one could hold him down. There were discussions between the nursing staff, the ED Provider, law enforcement and with the patient regarding the patient could take the medications or go to jail. The patient stated he would go to jail. The ED Provider stated the patient was medically cleared and he could go to jail in police custody. The patient left the ED in police custody to go to the jail.

During a telephone interview on 5/28/2025 at 10:40 AM, Officer #1 stated the patient (Patient #20) was transported to the ED by local police with disruptive and aggressive behaviors. The patient was threatening the ED staff and law enforcement. The patient refused to take medications or to have his blood drawn. There were discussions with the patient by the ED staff regarding the patient taking the medications or going to jail. Officer #1 stated "...I asked the patient if he wanted to take the medications or go to jail, and the patient stated take me to jail. The local police officers placed the patient in handcuffs..." The patient left the ED with the local police officers to go to the jail.

During a telephone interview on 5/28/2025 at 12:35 PM, the ED Physician #1 (employed at Facility A) stated the patient (Patient #20) presented to the ED with SI and acute behaviors. She had evaluated the patient and ordered diagnostic testing. The patient refused to have blood work drawn. Psychiatry was consulted and evaluated the patient by tele-psychiatry. The psychiatric assessment showed the patient met involuntary inpatient behavioral health criteria. Interview continued and ED Physician #1 stated she had placed the patient under an involuntary hold (CON). The patient's aggressive behaviors continued. The patient refused the IM injections and threatened the staff. She stated the staffing was limited in the ED, she was the only provider in the ED and the staff did not feel safe. She had discharged the patient and he was taken out of the ED by local police with the intent to take the patient to jail.