The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

UC SAN DIEGO HEALTH HILLCREST - HILLCREST MED CTR 200 WEST ARBOR DRIVE SAN DIEGO, CA 92103 April 24, 2012
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on observation, interview and record review, the hospital failed to comply with the requirements to provide an appropriate medical screening examination and necessary stabilizing treatment, to 1 of 31 (1) sampled patients, who presented to the hospital with an emergency medical condition.

Findings:

There was no documented evidence that Emergency Department (ED) physicians evaluated Patient 1's co-existing medical/psychiatric diagnoses, in an effort to determine if additional monitoring or referrals were necessary, to ensure the patient's safety and stability for discharge. There was no documented evidence that relevant patient information, pertaining to Patient 1's medical history and associated diagnoses and medications, which was unable to be obtained during triage due to the patient's condition, was obtained or attempted to be obtained, as the patient's mental condition improved. That resulted in a failure of the Emergency Department (ED) physicians to be able to take into account the effects of those diagnoses and medications when developing a treatment plan, monitoring for drug interactions and side effects, and plans to provide the patient with coherent discharge instructions regarding all medications.



In addition, the hospital failed to implement its EMTALA (Emergency Medical Treatment and Active Labor Act) policy and procedure by not ensuring that a complete medical screening examination was performed. On 4/24/12, the hospital's policy entitled, "Transfer and Compliance with EMTALA," dated 9/16/10, was reviewed. Per the policy, "the medical screening examination is an ongoing process"....and... "the scope of a medical screening examination must be tailored to the presenting complaint and the medical history of the patient."

(See A tag 2406)
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview and record review, the hospital failed to implement its EMTALA (Emergency Medical Treatment and Active Labor Act) policy and procedure, by not ensuring that a complete medical screening examination was performed, for 1 of 31 sampled patients (1). There was no documented evidence that relevant patient information pertaining to medical history, diagnoses and medications, which was unable to be obtained during triage due to the patient's condition, was obtained, or attempted to be obtained, as the patient's mental condition improved. That resulted in a failure of the Emergency Department (ED) physicians to be able to take into account the effects of those diagnoses and medications when developing a treatment plan, monitoring for drug interactions and side effects, and plans to provide the patient with coherent discharge instructions.

Findings:

An investigation and electronic record review was initiated on 4/5/12, at 8:20 A.M. as a result of a complaint which alleged that, on 2/21/12, during the course of being treated for alcohol intoxication in the ED, Patient 1 "disappeared" from the ED, ingested something he found in the ED waiting room, and was later found pulseless in the waiting room bathroom. Patient 1 became brain dead and died sometime thereafter.

On 4/5/12 at 8:35 A.M., a review of the ED's registry log revealed that Patient 1's name was entered into the log twice, once at 12:55 P.M. for "ETOH" (ethyl alcohol), and then at 6:15 P.M. for "CPR" (cardiopulmonary resuscitation).

Patient 1 presented to the Emergency Department (ED) via paramedics on 2/21/12 at 12:55 P.M., with a chief complaint of "ETOH" use. Patient 1 was triaged as a category "2." Per the Department of Emergency Medicine Triage Guidelines, a category 2 patient was "acute" and 1. had an illness or injury that posed no immediate threat to life or limb, and 2. held a risk for deterioration into critical state without medical attention within hours.

Per the Triage Nurse notes, Patient 1 presented with "heavy ETOH," intermittent level of consciousness, "fell out of his wheelchair and urinated on the waiting room floor." The triage nurse documented that the patient had "chronic ETOH," and was seen at the hospital within the last few days "for same." His past medical history included diagnoses of chronic depressive person, schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and alcoholism. Per the Triage Record, Patient 1's medications included Abilify (an antipsychotic and antidepressant medication) and Seroquel (antipsychotic medication used in treatment of schizophrenia). The entries in the electronic record pertaining to the dosages and frequencies of those medications contained "N/A" (not assessed).

Per the hospital's "Medication Reconciliation" policy, dated 11/18/10, "all patients with an emergency department encounter with an Emergency Department Licensed Independent Provider will have their home medication....information collected and documented."

Per the ED record, Patient 1 was placed in a room on 2/21/12 at 12:55 P.M. and assessed by Registered Nurse (RN) 1 at 1:00 P.M. RN 1's documented neurological assessment of the patient was "alert but confused" and verbal responses were "incomprehensible." RN 1 documented that the patient expressed no suicidal ideation/intent. RN 1 documented that the patient had not attempted suicide in the past. Patient 1 was placed on a heart monitor. Per RN 1 the patient has sinus tachycardia (fast heart rate) with a rate of 101.

Per an entry made in the record at 1:12 P.M., the patient's breathalyzer ( a device for estimating blood alcohol content (BAC-milligrams (mg) of alcohol per 100 mg. of blood, from a breath sample) result was 0.278. Per RN 1's notes, the patient followed simple commands and mumbled with slurred speech.

According to the electronic record, a physician's initial assessment of Patient 1 occurred at 12:56 P.M. At 5:25 P.M., Medical Doctor (MD) 2, fourth year Resident (physician in training), documented the following: "acute etoh intoxication, no e/o (evidence of) trauma, + (positive) elevated breathalyzer, will monitor closely as pt. (patient) metabolizes."
At 6:20 P.M., MD 2 entered her physical assessment of Patient 1 into the electronic record. The assessment included a review of vital signs, general appearance, head, ear, nose and throat, chest, cardiac, abdomen, extremities, skin and neurological systems. The neurological exam documented that the patient had slurred speech, was alert and oriented times 1, followed simple commands, and moved all four extremities. There was no documented evidence that MD 2 included in her initial history and physical examination, an attempt to review Patient 1's other diagnoses of depression and schizophrenia, or his current use of or adherence to, antipsychotic/antidepressant medications.

On 2/21/12, the attending physician, MD 1, entered her history and physical (H&P) examination of Patient 1 into the electronic record at 4:02 P.M. MD 1 documented that the patient had multiple visits to the ED due to alcohol intoxication or "alcohol related." Per the H&P, the patient had slurred speech, answered a few yes and no questions only, and opened eyes to voice command. MD 1's plan was to allow Patient 1 to sober and reassess for any additional complaints and proceed with a work up as indicated.
At 3:10 P.M., RN 1 documented that Patient 1 was sleeping, but aroused easily, denied pain and had slurred speech. He remained on a heart monitor.

At 4:40 P.M., RN 1 documented "pt. (patient) awake and alert pulled off monitor leads and attempted to walk out of hospital. pt. returned to rm. (room) and put shirt on. ambulates steady gait. denies pain admits to ETOH. slow to respond unable to state year. knows name, president and that he as at (name of hospital). pt. calm and cooperative, will wait for discharge re-evaluated by (names of MD 2 and MD 1- the attending physician)."

At 4:56 P.M., RN 2 documented that Patient 1 decided to walk out of the ED, and that "MD 2 aware."

Another note by MD 2, also entered into the electronic record at 5:25 P.M., indicated that the patient was re-evaluated (at what specific time that re-evaluation occurred was unclear based on the electronic record which only recorded the time the entry was made by the physician, not the actual bedside evaluation time). Per the second 5:25 P.M. note, Patient 1 ambulated with a steady gait and was in the process of getting ready to discharge when the patient left without waiting for a discharge order and paperwork. There was no documented evidence that, during MD 2's re-evaluation of Patient 1 as he was metabolizing the alcohol, that an assessment of the patient's mental status, inclusive of his diagnoses of depression and schizophrenia, his recurrent use or abuse of alcohol, or his use of antipsychotic/antidepressant medications, occurred. In addition, there was no documented evidence that an assessment or reassessment occurred relative to the patient's risk to harm himself or others.

On 2/21/12 at 6:34 P.M., MD 1 made 2 entries into the electronic record. MD 1 documented a "delayed note," which indicated that Patient 1 was reassessed and was "metabolizing appropriately." He was, "awake, talkative, still with slightly slurred speech, knows name, place, month, unclear of year but knows (last name of current United States president) is president." Per the note, the patient wanted to leave and requested a bus token. MD 1 documented that the patient was able to ambulate with a steady gait out of his room and back to his gurney. The patient was instructed to stay in his room and a meal and bus token would be provided. The second note by MD 1 at 6:34 P.M., documented that Patient 1 left the ED without waiting for discharge paperwork and "without official discharge." MD 1 documented that she looked around the ED for the patient but could not find him. There was no documented evidence that, during MD 1's reassessment of Patient 1, as he was "metabolizing appropriately," an evaluation of the patient's mental status, inclusive of his diagnoses of depression and schizophrenia, his recurrent use or abuse of alcohol, or his use of antipsychotic/antidepressant medications, occurred. In addition, there was no documented evidence that an assessment or reassessment occurred relative to the patient's risk to harm himself or others.

On 4/5/12 at 10:00 A.M., a joint interview was conducted with the Nursing Director of the ED (NDED) and the Licensing and Certification Principal Consultant (LCPC). Per the NDED, on 2/21/12, Patient 1 apparently eloped and was "found down" in a locked ED waiting room bathroom. Per the NDED, Patient 1 had numerous visits to the ED within the past year related to alcohol use. The LCPC stated that, per a quality variance report, it was presumed that Patient 1 drank a bottle of hand sanitizer gel, as an empty bottle of sanitizer was found next to the patient's body and some of the gel was on the patient's face. Patient 1 was in full cardiac arrest when he was found, and emergency resuscitative measures were implemented. On 2/21/12 at 6:15 P.M., Patient 1 was re-triaged into the ED and admitted into the Intensive Care Unit (ICU).

Per an H&P, dated 2/21/12 at 8:18 P.M., Patient 1 was in the ICU, intubated and nonresponsive. Per the H&P, the patient had possible ethanol poisoning with a BAL of 0.526, "confounded by his presumed ingestion of hand sanitizer."

Per a physician's ICU progress note, dated 2/28/12, Patient 1 was made a DNR (do not resuscitate)/comfort care status, after his clinical status and his poor prognosis was reviewed with the patient's father. Compassionate extubation protocol was implemented and Patient 1 expired on [DATE], at 12:28 P.M.

On 4/13/12 at 9:30 A.M., an interview was conducted with RN 1. RN 1 stated that she was unaware of Patient 1's history of depression and schizophrenia. RN 1 confirmed that her assessment pertaining to the patient's risk for suicide was completed when the patient was intoxicated from alcohol. RN 1 acknowledged that she should have reassessed the patient for being a danger to himself as he was becoming more coherent and less intoxicated. RN 1 stated that she didn't think about a reassessment of the patient from a psychosocial standpoint or requesting a referral for a social worker consult.

On 4/13/12, the ED Standards of Patient Care were reviewed. Per the Standards, potential indications for Social Work Services or Case Management referrals included patients who made frequent visits to the ED. In addition, patients who had problems with alcohol or psychiatric issues should be considered for counseling referrals.

On 4/13/12 at 1:20 P.M., an interview was conducted with MD 2. MD 2 stated she was aware of the patient's history of depression and schizophrenia. MD 2 stated that she didn't know if the patient was taking any medications or not and didn't recall if she asked him about medications. MD 2 stated that she didn't think it was necessary to ask every patient who came to the ED if they were suicidal. When MD 2 was asked if she thought it was necessary to ask a patient with diagnoses of alcoholism, depression, and schizophrenia about suicide intent or ideation, MD 2 replied that she didn't ask Patient 1 about suicide ideation or intent because she could tell by "the way he was talking he was okay."

On 4/24/12 at 1:45 P.M., an interview was conducted with MD 1. MD 1 stated that she reassessed Patient 1 as he metabolized. She said her usual process for a patient who entered the ED with alcohol intoxication was to talk with the patient about detoxification and plans for entering a detox center. MD 1 acknowledged that she didn't ask Patient 1 about his medications, dosages, or compliance. MD 1 stated that she only asked the patient if he needed his medications refilled and the patient replied that "he didn't need them."

On 4/24/12 at 2:00 P.M., an interview was conducted with the Medical Director of Emergency Services, MD 3. Per MD 3, the hospital had psychiatrists on call and available to consult. Per MD 3, there was no indication to call psychiatry for Patient 1, based on MD 1 and 2's assessment of the patient.

On 4/24/12, the hospital's policy entitled "Transfer and Compliance with EMTALA," dated 9/16/10, was reviewed. Per the policy, "the medical screening examination is an ongoing process"....and... "the scope of a medical screening examination must be tailored to the presenting complaint and the medical history of the patient."

MDs 1 and 2 failed to provide an appropriate medical screening examination, in accordance with the hospital's own EMTALA policy. There was no documented evidence that MDs 1 and 2 incorporated Patient 1's medical history, which included diagnoses of depression and schizophrenia, or his use of, or compliance with antipsychotic and antidepressant medications, into their evaluation or reassessment of the patient, who presented to the ED with acute alcohol intoxication.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on interview and record review, the hospital failed to ensure that 1 of 31 sampled patients (1), with an emergency medical condition was stabilized, to include providing further medical examination and possible treatment. There was no documented evidence that Emergency Department (ED) physicians evaluated Patient 1's co-existing medical and/or psychiatric diagnoses in an effort to determine if additional monitoring or referrals were necessary to ensure the patient's safety and stability for discharge. Patient 1's medical record did not contain evidence that other medical diagnoses and medications, that were prescribed prior to their ED visit, were evaluated by the ED staff. In addition, the hospital failed to ensure that its patient elopement policy was implemented by staff in an effort to diligently search for Patient 1, who left prior to being formally discharged , and was subsequently found pulseless in the ED waiting room bathroom.


Findings:


An investigation and electronic record review was initiated on 4/5/12 at 8:20 A.M., as a result of a complaint which alleged that, on 2/21/12, during the course of being treated for alcohol intoxication in the ED, Patient 1 "disappeared" from the ED, ingested something he found in the ED waiting room, and was later found pulseless in the waiting room bathroom. Patient 1 became brain dead and died sometime thereafter.

On 4/5/12 at 8:35 A.M., a review of the ED's registry log revealed that Patient 1's name was entered into the log twice, once at 12:55 P.M. for "ETOH" (ethyl alcohol), and then at 6:15 P.M. for "CPR" (cardiopulmonary resuscitation).

Patient 1 presented to the Emergency Department (ED) via paramedics on 2/21/12 at 12:55 P.M., with a chief complaint of "ETOH" use. Patient 1 was triaged as a category "2." Per the Department of Emergency Medicine Triage Guidelines, a category 2 patient was "acute" and 1) had an illness or injury that posed no immediate threat to life or limb, and 2) held a risk for deterioration into critical state without medical attention within hours.

Per the Triage Nurse notes, Patient 1 presented with "heavy ETOH," intermittent level of consciousness, "fell out of his wheelchair and urinated on the waiting room floor." The triage nurse documented that the patient had "chronic ETOH," and was seen at the hospital within the last few days "for same." His past medical history included diagnoses of chronic depressive person, schizophrenia , and alcoholism. Per the Triage Record, Patient 1's medications included Abilify (an antipsychotic and antidepressant medication) and Seroquel (antipsychotic medication used in treatment of schizophrenia). The entries in the electronic record pertaining to the dosages and frequencies of those medications contained "N/A" (not assessed).

Per the ED record, Patient 1 was placed in a room on 2/21/12 at 12:55 P.M., and assessed by Registered Nurse (RN) 1 at 1:00 P.M. RN 1's documented neurological assessment of the patient was "alert but confused" and verbal responses were "incomprehensible." RN 1 documented that the patient expressed no suicidal ideation/intent. RN 1 documented that the patient had not attempted suicide in the past. Patient 1 was placed on a heart monitor. Per RN 1 the patient has sinus tachycardia (fast heart rate) with a rate of 101.


Per an entry made in the record at 1:12 P.M., the patient's breathalyzer (a device for estimating blood alcohol content (BAC-milligrams (mg) of alcohol per 100 mg. of blood, from a breath sample) result was 0.278. Per RN 1's notes, the patient followed simple commands and mumbled with slurred speech.

According to the electronic record, a physician's initial assessment of Patient 1 occurred at 12:56 P.M. At 5:25 P.M., Medical Doctor (MD) 2, fourth year Resident (physician in training), documented the following: "acute etoh intoxication, no e/o (evidence of) trauma, + (positive) elevated breathalyzer, will monitor closely as pt. (patient) metabolizes." At 6:20 P.M., MD 2 entered her physical assessment of Patient 1 into the electronic record. The assessment included a review of vital signs, general appearance, head, ear, nose and throat, chest, cardiac, abdomen, extremities, skin and neurological systems. The neurological exam documented that the patient had slurred speech, was alert and oriented times 1, followed simple commands, and moved all four extremities. There was no documented evidence that MD 2 included in her initial history and physical examination, an attempt to review Patient 1's other diagnoses of depression and schizophrenia, or his current use of, or adherence to antipsychotic/antidepressant medications.

On 2/21/12, the attending physician, MD 1, entered her history and physical (H&P) examination of Patient 1 into the electronic record at 4:02 P.M. MD 1 documented that the patient had multiple visits to the ED due to alcohol intoxication or "alcohol related." Per the H&P, the patient had slurred speech, answered a few yes and no questions only, and opened eyes to voice command. MD 1's plan was to allow Patient 1 to sober and reassess for any additional complaints and proceed with a work up as indicated.

A review of the ED physician treatment orders for Patient 1 was conducted. There were a total of 3 orders. Two orders were entered at 12:57 P.M. The orders prescribed an ETOH breathalyzer and a blood sugar test. The last order entered by a physician was at 7:19 P.M. which stated "gone."

At 3:10 P.M., RN 1 documented that Patient 1 was sleeping, but aroused easily, denied pain and had slurred speech. He remained on a heart monitor.

At 4:40 P.M., RN 1 documented "pt. (patient) awake and alert pulled off monitor leads and attempted to walk out of hospital. pt. returned to rm. (room) and put shirt on. ambulates steady gait. denies pain admits to ETOH. slow to respond unable to state year. knows name, president and that he as at (name of hospital). pt. calm and cooperative, will wait for discharge re-evaluated by (names of MD 2 and MD 1- the attending physician)."


At 4:56 P.M., RN 2 documented that Patient 1 decided to walk out of the ED, and that "MD 2 aware."

Another note by MD 2, also entered into the electronic record at 5:25 P.M., indicated that the patient was re-evaluated (at what specific time that re-evaluation occurred was unclear based on the electronic record which only recorded the time the entry was made by the physician, not the actual bedside evaluation time). Per the second 5:25 P.M. note, Patient 1 ambulated with a steady gait and was in the process of getting ready to discharge when the patient left without waiting for a discharge order and paperwork. There was no documented evidence that, during MD 2's re-evaluation of Patient 1 as he was metabolizing the alcohol, that an assessment of the patient's mental status, inclusive of his diagnoses of depression and schizophrenia, his recurrent use or abuse of alcohol, or his use of antipsychotic/antidepressant medications, occurred. In addition, there was no documented evidence that an assessment or reassessment occurred relative to the patient's risk to harm himself or others.

On 2/21/12 at 6:34 P.M., MD 1 made 2 entries into the electronic record. MD 1 documented a "delayed note," which indicated that Patient 1 was reassessed and was "metabolizing appropriately." He was "awake, talkative, still with slightly slurred speech, knows name, place, month, unclear of year but knows (name of current United States President) is President." Per the note, the patient wanted to leave and requested a bus token. MD 1 documented that the patient was able to ambulate with a steady gait out of his room and back to his gurney. The patient was instructed to stay in his room and a meal and bus token would be provided. The second note by MD 1 at 6:34 P.M., documented that Patient 1 left the ED without waiting for discharge paperwork and "without official discharge." MD 1 documented that she looked around the ED for the patient but could not find him. There was no documented evidence that, during MD 1's reassessment of Patient 1, as he was "metabolizing appropriately," an evaluation of the patient's mental status, inclusive of his diagnoses of depression and schizophrenia, his recurrent use or abuse of alcohol, or his use of antipsychotic/antidepressant medications, occurred. In addition, there was no documented evidence that an assessment or reassessment occurred relative to the patient's risk to harm himself or others.

On 4/5/12 at 10:00 A.M., a joint interview was conducted with the Nursing Director of the ED (NDED) and the Licensing and Certification Principal Consultant (LCPC). Per the NDED, on 2/21/12, Patient 1 apparently eloped and was "found down" in a locked ED waiting room bathroom. Per the NDED, Patient 1 had numerous visits to the ED within the past year related to alcohol use. The LCPC stated that, per a quality variance report, it was presumed that Patient 1 drank a bottle of hand sanitizer gel, as an empty bottle of sanitizer was found next to the patient's body and some of the gel was on the patient's face. Patient 1 was in full cardiac arrest when he was found, and emergency resuscitative measures were implemented. On 2/21/12 at 6:15 P.M., Patient 1 was re-triaged into the ED and admitted into the Intensive Care Unit (ICU) for further management.

Per an H&P (history & physical), dated 2/21/12 at 8:18 P.M., Patient 1 was in the ICU, intubated and nonresponsive. Per the H&P, the patient had possible ethanol poisoning with a BAL of 0.526, "confounded by his presumed ingestion of hand sanitizer."

Per a physician ICU progress note, dated 2/28/12, Patient 1 was made a DNR (do not resuscitate)/comfort care status, after his clinical status and poor prognosis was reviewed with the patient's father. Compassionate extubation protocol was implemented, and Patient 1 expired on [DATE] at 12:28 P.M.

On 4/13/12 at 9:30 A.M., an interview was conducted with RN 1. RN 1 stated that she was unaware of Patient 1's history of depression and schizophrenia. RN 1 confirmed that her assessment pertaining to the patient's risk for suicide was completed when the patient was intoxicated from alcohol. RN 1 acknowledged that she should have reassessed the patient for being a danger to himself as he was becoming more coherent and less intoxicated. RN 1 stated that she didn't think about a reassessment of the patient from a psychosocial standpoint or requesting a referral for a social worker consult. RN 1 stated that she did not look for Patient 1 or inform the Charge Nurse that he had left without notification.

On 4/13/12, the ED Standards of Patient Care were reviewed. Per the Standards, potential indications for Social Work Services or Case Management referrals included patients who made frequent visits to the ED. In addition, patients who had problems with alcohol or psychiatric issues should be considered for counseling referrals.

On 4/13/12, a review was conducted of the hospital's policy entitled "Patient Leaving Against Medical Advice (AMA) and Patient Elopement, dated 7/19/07. The policy defined "elopement" as "when a patient leaves the hospital without notification to the treating physician or hospital staff." The policy defined "decisional capacity" as when a patient, "can understand the condition and the risk and benefits of the recommended treatment and available alternatives and make a choice." Per the policy, in the event of an elopement of a patient that lacks decision making capacity, but not assessed as a flight risk, "the nurse caring for the patient shall notify the physician, the nursing supervisor and or the unit manager/designee immediately upon finding the patient's absence." Per the policy, the nursing supervisor was required to notify hospital security.

Further review of the record revealed no documented evidence that RN 1 or RN 2 attempted to locate Patient 1 after he left. There was no documented evidence that the Charge Nurse or hospital security was informed of the patient's unexpected departure, so that a diligent search could be performed for the patient, in an effort to ensure that he was safe and expressed an understanding of his condition, need for follow up care, and discharge instructions.

On 4/13/12 at 12:15 P.M., an interview was conducted with the Associate Medical Director of the ED, MD 4. Per MD 4, a patient's decisional capacity and safety should be determined during reassessment of the patient before they are discharged . MD 4 stated that decisional capacity is determined by talking to the patient and assessment of orientation. MD 4 acknowledged that during the discharge process determination of decisional capacity is often made when the patient can verbalize understanding about their medical condition, treatment options, and discharge instructions. MD 4 acknowledged that Patient 1 left prior to being formally discharged and receiving discharge instructions. MD 4 acknowledged that there was no documented evidence in the record concerning Patient 1's decision making capacity other than he was awake and oriented to person, place, month, and knew who the President was.

On 4/13/12 at 1:20 P.M., an interview was conducted with MD 2. MD 2 stated she was aware of the patient's history of depression and schizophrenia. MD 2 stated that she didn't know if the patient was taking any medications or not and didn't recall if she asked him about medications. MD 2 stated that she didn't think it was necessary to ask every patient who came to the ED if they were suicidal. When MD 2 was asked if she thought it was necessary to ask a patient with diagnoses of alcoholism, depression, and schizophrenia about suicide intent or ideation, MD 2 replied that she didn't ask Patient 1 about suicide ideation or intent because she could tell by "the way he was talking he was okay." MD 2 stated that they were planning for Patient 1's discharge when he left. MD 2 stated that a patient was safe to discharge when he had the capacity to make decisions, was no longer intoxicated, could walk, act appropriately, and answer questions. There was no documented evidence in MD 2's reevaluation of Patient 1 relative to his decisional capacity and safety other than he ambulated with a steady gait.

On 4/24/12 at 1:45 P.M., an interview was conducted with MD 1. MD 1 stated that she reassessed Patient 1 as he metabolized. She said her usual process for a patient who entered the ED with alcohol intoxication was to talk with the patient about detoxication and plans for entering a detox center. MD 1 acknowledged that she didn't ask Patient 1 about his medications or compliance. MD 1 stated that she only asked the patient if he needed his medications refilled and the patient replied that "he didn't need them."

On 4/24/12 at 2:00 P.M., an interview was conducted with the Medical Director of Emergency Services, MD 3. Per MD 3, the hospital had psychiatrists on call and available to consult. Per MD 3, there was no indication to call psychiatry for Patient 1, based on MD 1 and 2's assessment of the patient.

On 4/24/12, the hospital's policy entitled "Transfer and Compliance with EMTALA," dated 9/16/10, was reviewed. Per the policy, "a medical patient is considered "stable" for discharge if the treating physician has determined within reasonable clinical confidence that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, may be performed on an outpatient basis or a later inpatient basis so long as the patient is given a plan for appropriate follow-up care with the discharge instructions."

There was no documented evidence in the clinical record that the physicians and nurses attempted to obtain more information from Patient 1 about his diagnoses of depression or schizophrenia, and antipsychotic and antidepressant medications as he was "sobering" and became more cooperative. If that information was obtained and not documented, there was no indication that the information was used in decisions concerning the care and treatment of the patient, particularly as it pertained to his safety for discharge. The patient was deemed stable from the standpoint of ETOH intoxication, but had not been evaluated adequately for his other mental illness diagnoses and medication regimens to manage those diagnoses, and therefore, not fully shown to be stable for discharge. In addition, when Patient 1 eloped from the ED prior to a formal discharge, nursing staff did not follow policy and procedure to ensure that a diligent search was conducted in an effort to ensure that Patient 1 was safe and expressed an understanding of his condition, need for follow up care, and discharge instructions.