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Based on medical record review, document review and interview, in one (1) of 40 medical records reviewed, it was determined the facility failed to conduct a complete and adequate medical screening examination (MSE) during a patient's multiple Emergency Department (ED) visits. Specifically, the facility failed to (a) collect and evaluate collateral information of the patient's past psychiatric care to ensure an adequate MSE and treatment of the patient, and (b) identify the patient's inability to care for their self and their non-compliance with psychiatric medication regimen during multiple ED visits on 4/29/23, 5/1/23 and 5/2/23. These findings were evident in MR #1.

The facility's failure to conduct a complete MSE and stabilizing treatment on each ED visit may have placed the patient and the community at risk for harm.

Findings include:

Review of medical record (MR) for Patient #1 revealed multiple ED visits on 4/29/23, 5/1/23, 5/2/23 and 5/4/23 for mental health assessment and treatment.

On 4/29/23 at 9:04 PM, a triage nurse documented that the Police Department (PD) and the ambulance brought the patient, 39-year-old for a "mental health evaluation". The patient admits to drinking and smoking crack that night. The patient's medication history was unknown. Emergency Medical Services (EMS) and PD reported the patient was found wandering on the road "running around in and out of cars in a parking lot" and had been reported missing for the past week. The patient is homeless. The EMS prehospital report noted the dispatch reason was "psychiatric problem/abnormal behavior/suicide attempt." The patient was alert, the patient spoke "incomplete sentences." The nurse documented upon patient's arrival at 9:04 PM, the patient was combative, their mental status was abnormal, patient was confused and agitated. The patient had a previous history of Schizophrenia since age 15. The nurse was unable to complete the patient's vital signs upon arrival. ED labs showed the patient had Cannabis in their system.

The ED MD documented at 9:10 PM the patient had been missing for a week.

The psychiatric resident saw the patient at 11:55 PM and noted the patient was "singing and talking to self nonsensically random nonsensical words. The patient only identifies he is at Garnet [oriented to place only]." The patient was administered Zyprexa 10 mgs into a muscle (IM) at midnight to manage his acute psychosis. On 4/30/23 at 5:10 AM, the MSE was completed after the patient woke up. The Psychiatrist documented the patient had one (1) prior psychiatric hospitalization and noted the patient was calm and exhibiting chronic auditory hallucination.

On 4/30/23 at 5:16 AM, the patient was cleared for discharge with a diagnosis of Cannabis Use Disorder.

Although the psychiatrist documented on 4/30/23 at 5:15 AM, patient calm and cleared for discharge, review of the form titled "Level of Patient Observation Record" documented by Staff A, Access Technician, revealed the patient was agitated on 4/30/23 at 12:30 AM, he was asleep until 4:30 AM, agitated from 4:45 AM to 5:15 AM. Staff A documented the patient was discharged on 4/30/23 at 5:30 AM. The facility did not contact the patient's family listed as emergency contact prior to discharge.

The patient's MSE did not include an assessment of the patient's level of agitation after he woke up.

During interview with Staff B, conducted on 6/21/23 at 12:05 PM, staff stated "after the patient woke up the patient was talking normally and asking for food." Staff B also stated he checked the previous ED visits and noted the patient did not want housing but Staff B did not check PSYCKES. Staff B stated "a social worker should see the patient after he is cleared for discharge for transportation arrangements because the patient is homeless."

During interview on 6/21/23 at 2:45 PM, Staff G, Director of Social Work stated, for the 4/29/23 visit, "there was no social work note or collateral information documented in the medical record."


There was no documented evidence that collateral information was obtained for the 4/29/23 visit to complete the patient's MSE. The patient's multiple past psychiatric hospitalizations were not documented. There was no specific assessment for the patient's auditory hallucinations. The patient's non-compliance with his psychotropic medications and follow-up with the outpatient mental resources were not assessed. There was no documentation that psychiatry had completed a comprehensive assessment including assessing to ascertain if the patient was gravely disabled.


On 5/1/23 at 4:08 AM, less than 24 hours after patient's discharge on 4/30/23, the patient was brought to the ED by police. The triage nurse noted the PD brought the patient for a "psychiatric evaluation because he was hearing voices. The patient was threatening to kill all the people and yelling." Nurse noted "patient is hallucinating and appears to be hearing voices." The triage nurse documented a score of 6 out of 6 (highest score) on the Broset Violence Screen (The Broset Violence Checklist is a 6-item checklist which assists in the prediction of imminent violent behavior). The violence screen revealed the patient's attacks were directed at objects, patient was irritable, confused, boisterous, threatening physical violence and was making verbal threats.

The RN documented at 4:39 AM that the patient refused vital signs and he was placed on 2:1 sitter observation. Zyprexa 10 mg tablet was given for the patient's acute psychosis. The psychiatrist evaluated the patient at 5:09 PM and cleared the patient for discharge. The patient was discharged to a shelter on 5/1/23 at 7:13 PM with a discharge diagnosis of Substance Induced Psychotic Disorder.

During interview conducted on 6/21/23 at 2:45 PM, Staff G, Director of Social Work stated, for the visit on 5/1/23, there was no social work disposition and no social work collateral
information collected on 5/2/23.

On 5/2/23 at 1:30 PM, approximately 18 hours after the patient's discharge on 5/1/23, the police returned the patient to the ED for a psychiatric evaluation because the patient was very restless and agitated. According to the police, the patient was wandering the streets, very psychotic, agitated, and disorganized. The nurse's assessment identified the patient was irritable, bizarre, behavior, pacing, aggressive, and his speech was loud and pressured.

The psychiatrist documented at 2:32 PM, "the police brought the patient to the ED because of agitation, and his combative behavior. The patient was previously seen in the ED on 4/30/23 and on 5/1/23. Per police the patient was found wandering in the streets of Newburgh. Patient was aggressive and agitated when writer tried to interview the patient. Patient demanding and grabbing food, posturing, banging on glass, pacing, screaming, and shouting incoherent statements. Gave patient Ativan 2 mg IM and Prolixin 5 mg IM for psychotic agitation. Patient at this time is currently disorganized in speech, mood, behavior and thought processes."
No outpatient medication was documented for the 5/2/23 encounter. The resident was also "unable to assess the patient's mental status" and behavior was described as bizarre.

On 5/3/23 at 5:57 AM, the resident documented that the patient was seen multiple times for substance induced psychosis over the past few days. The patient's insight and judgment were poor, and the patient was malodorous and disheveled. The discharge diagnosis was Substance Induced Psychotic Disorder.

On 5/3/23 at 6:17 AM, the nurse documented that the patient was "agitated and verbally abusive towards staff. He is demanding to be discharged." The physician discharged the patient on 5/3/23 at 6:31 AM with a diagnosis of Substance Abuse Disorder.

No re-evaluation was documented, and no vital signs were taken at discharge.

There was no documented evidence that the patient was psychiatrically stable before his discharge. There is no documented evidence the patient's ED visit trends and presentation, compliance with previously prescribed psychiatric medications and referrals for mental health follow-up were assessed prior to discharge.

The ED MD documented labs and imaging were reviewed and the patient was made aware, however no labs or imaging were obtained during this visit. No attempts to gather collateral information or to contact patient's family regarding patient safety at discharge and evaluate if patient gravely disabled. At 5:58 AM the patient was cleared for discharge, however nursing notes at 5:55 AM and 6:17 AM indicated patient was becoming increasingly agitated.


On 5/4/23 at 6:00 PM, approximately 36 hours after his discharge from the ED on 5/3/23, the police brought the patient back to the ED. The nurse documented the police reported the patient was at a bank acting erratic and rambling. Upon arrival to the intake area, the patient was delusional, manic, disorganized, and unable to focus. Patient's affect was bizarre, was pacing, disorganized, speech was loud, and judgement was impaired. The Broset Violence Score was 6 on a scale of 0-6. Patient was administered Zyprexa at 6:20 PM and later was admitted to the Behavioral Health Unit.

The psychiatrist noted at 7:35 PM that the patient was unable to function in the community and was a danger to self. The admitting diagnosis was Schizo-Affective Disorder.

The policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Regulation & On-Call Physician," last reviewed 4/14/22, states for a "medical screening examination ... if the individual presents with symptoms of severe emotional distress, the Medical Screening Examination should include a mental health assessment that evaluates the individuals mood, speech, thought content and process, judgement, insight, psychomotor activity, suicidal ideation, potential for causing bodily harm to self or others, social support structure, availability of personal transport. Ongoing assessment must be documented in the medical record."

The patient presented to the ED for multiple consecutive visits from 4/29/23, 5/1/23, 5/2/23 and 5/4/23 before the staff identified that the patient was non-compliant with their psychiatric medication, and was not following up with their provider in the community. Providers did not identify that the patient was decompensating during these ED visits, and was not medically stable to seek outpatient community resources. The ED provider did not utilize resources such as the Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES) which is a New York State web-based application designed to access behavioral health clients' information, to support clinical decision making and care coordination in order to perform a complete MSE for each of the patient's psychiatric presentations at the ED.

Staff B, ED Psychiatrist, stated in an interview conducted on 6/21/23 at approximately 12:05 PM, that for each presentation to the ED the patient abuses cannabis in the community, arrives in the ED in a psychotic state, is medicated, calms down and is no longer psychotic. There is no justification to admit patient. The patient's diagnosis of Schizophrenia is not the issue because the patient's psychosis clears after the patient was medicated.

These findings were shared with Staff C, Director of Quality on 6/22/23 at 3:45 PM.