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.

Based on review of hospital policies, documents, medical records, and staff interview, the hospital failed to enforce EMTALA policies requiring staff to provide an appropriate medical screening examination for 4 of 30 sampled patients requesting care in the Emergency Department (ED) of the hospital between January 2016 through April 25, 2016 (Patient #1, #3, #4, and #5 ). The patients presented to the ED for care for an emergency psychiatric condition.

Failure by the ED staff to follow the hospital's EMTALA policies to provide a complete and ongoing appropriate medical screening exam for each patient requesting emergency psychiatric care in the ED may result in delay in identification and/or treatment of psychiatric conditions potentially resulting in harm for patients.

The hospital's EMTALA policy revised 8/22/14 included in part..."The Facility with an emergency department must provide to any individual...who comes to the emergency department an appropriate Medical Screening Examination (MSE) within the capability of the Facility's emergency determine whether or not and emergency medical condition (EMC) exists...The EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED)...if an EMC (emergent medical condition) is determined to exist, the hospital must provide either (i) further medical examination and any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or (ii) an appropriate transfer to another facility...EMC means: ...with respect to an individual with psychiatric symptoms: that acute psychiatric...symptoms are manifested; or that individuals are expressing...gestures and are determined to be a danger to self..."

Refer to A 2406 for additional information concerning the medical screening examination of Patients # 1, #3, # 4 and # 5.

Based on review of Medical Staff Rules and Regulations, hospital policies, documents, medical records, and interviews with staff, the administrative staff failed to ensure the ED (Emergency Department) staff provided patients who presented to the ED with emergent psychiatric conditions; with an appropriate and on going medical screening examination for 4 of 30 patients (Patient #1, #3, #4, and #5 selected for review from January 30, 2016 to April 25, 2016.

Failure to ensure the ED staff provided an appropriate medical screening examination to patients who presented to the ED requiring care could potentially delay evaluation of the individual's mental condition in coordination with his or her physical condition to treat and minimize the symptoms and illness and/or result in harm to the individual.

Findings include:

The following information relates to Patient #4.

1. Review of Patient #4's closed medical record showed on 3/7/16 at 10:25 AM the patient presented to the emergency department (ED) for a psychiatric evaluation.

a. emergency room Rapid Initial Assessment completed on 3/7/16 at 10:30 AM by Staff O, RN revealed:
- Subjective assessment: Patient presents to ER complaining of worsening anxiety and feeling paranoid since December. She states she feels like she has been on an acid trip, reports she took 2 hits of marijuana to calm herself down. Patient states she doesn't know what is real or not real. Feels her children are in danger, feels people are following her and trying to kill her. Denies suicidal or homicidal ideation.

- Objective assessment: Alert and oriented. Patient on phone calling school to make sure her daughter is there because she believes she may be dead. Staff O, ED RN placed Patient #4 in a secure room close to the nursing station, implemented 1 to 1 staff monitoring, suicide and elopement precautions, and every 15 minute checks at 10:30 AM.

b. Review of document titled "Timed Observation Record" dated 3/7/16 revealed from 10:30 AM to 1:00 PM nursing staff documented the patient was in the secure room, awake, with one staff at bedside. Documentation showed from 11:15 PM to 2:30 PM the patient was in a secure room, asleep, with one staff at bedside. At 2:45 PM nursing staff documented "Patient Left."

c. The behavioral health assessment on 3/7/16 at 10:57 AM completed by Staff P, ED RN documented the following:
- Presenting signs and symptoms (s/s) behavioral
health: Delusional, depressed mood, hyperactive,
lack of eye contact, mood changes, panic attacks, and sleep disturbances, paranoid. Onset of symptoms 1-2 weeks ago.
- Did you ever seriously consider killing yourself in the past year: Yes
- Patient at risk for suicide: Yes

d. ED Physician note, on 3/7/16 at 10:58 AM completed by ED Physician D documented the following:
- Narrative assessment of Present Illness: Patient is a [AGE] year old female who is here for evaluation. Reports she is paranoid, very anxious, worried about a lot of issues, talking very fast and jumping topics frequently, reports she has been mad, can't sleep, reports poor appetite. Denies alcohol use or substance abuse outside of smoking pot today to try to calm down. Aware that some of these things are not reality based, and she wants help, needs to get in to psychiatrist and therapy but does not want committal. Denies suicidal or homicidal ideation, reports needs to start meds and then get in to psych for close follow up, she feels that some people are putting critical messages on license plates about her.

- Complaint: Manic, depressed, other (anxiety)
- Time - started/began: Months (December 2015)
- Quality: confusion, anxious, paranoid.
- Associated with: Reports: agitation, delusions.
- Context - history: decreased sleep.
- Exacerbated by: drug use (smoke marijuana), family stress, recent stress, relationship stress.
- Relieved by: nothing.
- Suicide risk factors: family history of suicide.
- Psych: stress, anxiety, depression, agitation.
- Past social history: alcohol, drugs, other (numerous family members visited in ED). Denies: IV drug use, homeless.
- Psychiatric: anxious, depressed, flight of ideas, delusions (paranoid, thinks other out to get her.)
- Laboratory tests: Marijuana (THC) screen: Positive
H (high).

- Medication Orders: Ordered by Physician D on 3/7/16 at 11:26 AM: Lorazepam 0.5 milligrams (medication to treat anxiety) by mouth.

e. Tele-Psychiatric evaluation: completed by
Psychiatric Physician G on 3/7/16 at 1:37 PM
documented the following:

- Overall Assessment: Paranoid Schizophrenia ...anxiety attacks ...fabricating things in my head daughter is being hurt son is being hurt husband is going to kill me ...anger outbursts ...I usually dance or yell underwear...Singing in my car.

- ED physician reported the patient was displaying manic symptoms and tangential thought processes. Patient refused inpatient stabilization and psych consultation requested due to current symptoms.

- Patient was seen, she presents with disorganized thought process, at times evasive, just stating she is fabricating things in her head like paranoid schizophrenic, beliefs that her husband will kill her, that her children will be hurt etc. Patient reports sleeping about 3-4 hours every night due to "worries and anxiety" for the past 2 months. Patient also reports her appetite has been poor.

- Patient with poor insights and judgement, patient may inadvertently place herself or others in danger, or place herself in a neglectful situation. Patient needs further stabilization in inpatient psychiatry.

- Past Psychiatric History: Patient reports being diagnosed with manic depression, personality disorder and anxiety.

- Mental Status Examination: Alert and oriented x 2. Speech is rapid, at time incoherent. Mood is anxious. Affect is mildly labile. Disorganized, tangential thought processes. Loosening association at time. Reporting anger outbursts, paranoid delusions, having cancer cells and not being able to tell the follow up treatment, etc.

- DSM V Diagnosis: Bipolar 1 Disorder. Current or most recent episode manic with psychotic features.

- Treatment Recommendations: Admit to Psych Unit.
- Treatment & Medication Recommendations: Patient is NOT psychiatrically stable and needs inpatient treatment due to potential of placing herself in a neglectful situation or herself and others in danger due to reported anger outbursts. Change legal status to involuntary.
- Additional notes: Disposition: Disposition discussed with Physician D.

f. Review of Court Committal Documents dated 3/7/16, no time, included the following in part, "...RN J at ORHC - ER allege Respondent Patient #4 is suffering from serious mental impairment. In support thereof I state as follows: Based on the above facts, I believe Respondent is a danger to himself/herself or others or may be causing serious emotional injury to persons who are unable to remove themselves from Respondent's presence. Do you request the respondent be taken into Immediate Custody? YES. Attached hereto is a written statement of a licensed physician in support of this allegation ... I Physician D of Ottumwa Regional Health Center (ORHC) ER ...statues that I am acquainted with the Respondent Patient #4 in ER at ORHC ...I believe that the above named person is seriously mentally impaired ..."

g. ED Physician progress note, on 3/7/16 at 2:45 PM, completed by Physician D documented the following:

- Patient eloped while we were getting court order, law enforcement notified.
- Disposition-Psych Illness: Clinical impression: Anxiety, depression, manic
- Forms: Suicide Risk Prevention.

h. General nurse's note, on 3/7/16 at 2:46 PM,
completed by Staff Q, RN included in part, "...Went in patient's room to give her Abilify (an anti-psychotic medication used to treat manic depression), patient stated she wanted to check in on her father. This RN explained that her dad was here earlier and would check to see if he had left or not. Patient proceeded to walk out to lobby and spoke with her father. Began to walk outside and this RN told her to return to her room. Patient stated, "I'm here on a voluntary basis so I don't have to go back to my room. I'm going to talk to my dad and have a cigarette." This RN told patient her father could go back to her room with her but that she couldn't have a cigarette as this is a non-smoking facility and that she could have a nicotine patch instead. Patient's father held his hand up, signaling this RN to stop talking, and walked away following the patient out to the parking lot..."

Emergency discharge date /time: 3/7/16 2:46 PM.
Discharge Disposition: Psych/Elopement.

The medical record failed to reveal staff intervention or attempts to institute an involuntary court committal to prevent the patient from leaving for her own safety.

2. The information in this section relates to the care Patient #3 received in the ED.

a. Review of Patient #3's closed medical record showed on 4/6/16 at 8:27 PM the patient presented to the ED for a psychiatric evaluation.

b. The emergency room Rapid Initial Assessment completed on 4/6/16 at 8:29 PM by Staff N, RN revealed:
- Subjective assessment: Patient to ER reporting that she is having thoughts of killing herself. Patient denies any specific plan.
- Presenting signs and symptoms behavioral health: Depressed mood, suicidal ideation.
- In the past week have you been having thoughts/making plans about hurting yourself? Yes.
- Patient at a high risk for suicide? Yes

The medical record failed to contain documentation indicating patient # 3 received a medical screening examination sufficient to determine the presence of an emergency medical condition. The patient was discharged at 11:31 PM.

c. The HPI completed on 4/6/16 at 8:39 PM by ED Physician C revealed:

Narrative History of Present Illness: Depressed, had a thought she might be better off dead; overwhelmed; now says she doesn't really feel like she is going to hurt herself; living at the halfway house (for drug related offense).
Complaint: Suicidal ideation.
Timing - started/began: gradual.
Quality: anxious.
Context - history: Decreased sleep.
Exacerbated by: recent stress.
Psych: Reports stress, anxiety, depression, suicidal ideation (did have some thoughts this evening, but currently stating she is no longer having these (after talking to her mom on the phone) insomnia.
Laboratory tests: Marijuana (THC) screen: Positive.

At 11:12 PM, Physician C documented:

Status: Improved (smiling, states she feels better; no suicidal ideation); scores 3 on SAD PERSONS scale (a suicide risk assessment using a scoring system, 3 indicates the patient may be sent home but checked frequently), so feels she is safe to go home.

Clinical Impression: Depression, other (adjustment disorder)
Additional instructions: Return to ER if having any suicidal thoughts.
Forms: Suicide Risks and Warning Signs
Discharge Education Materials. The patient signed the form, Staff N cosigned the form.

The hospital failed to provide a medical screening examination within its capabilities to determine whether patient # 3 had an emergency prior to discharge.

3. Review of Patient #5's closed medical record showed on 1/30/16 12:00 AM the patient presented accompanied by police to the ED for a psychiatric evaluation
a. The emergency room Rapid Initial Assessment completed on 1/30/16 at 12:09 AM by Staff R, RN revealed:

- Subjective assessment: Patient brought by police for thoughts of suicide and drug and alcohol (ETOH) abuse. Patient states that he is having suicidal ideation with thought of hanging himself and states that he is hearing voices and seeing things that are not there.

- Presenting signs/symptoms: Alcohol use/abuse, auditory hallucinations, depressed mood, drug use/abuse, suicidal ideation, and visual hallucinations.

b. Staff R, RN placed Patient #5 in a secure room, close to the nursing station, removed all sharp objects and tubing/cords from the room, implemented 1 to 1 staff monitoring, suicide and elopement precautions, and every 15 minute checks at 12:00 AM.

c. Review of document titled "Timed Observation Record" dated 1/30/16 revealed from 12:00 AM to 10:45 PM nursing staff documented the patient was in the secure room, awake, with one staff at bedside. From 10:45 PM to 8:15 AM on 1/31/16 nursing staff documented the patient was in the secure room, asleep, with one staff at bedside.

d. Review of the clinical data table - current diagnosis dated 1/30/16 at 12:09 AM revealed the following diagnosis including but not limited to; major depressive disorder, recurrent, with severe
psychotic symptoms, suicidal ideation, alcohol - cannabis-cocaine abuse.

e. The HPI completed on 1/30/16 at 12:30 AM by ED Physician N revealed:
Narrative History of Present Illness: Patient is a [AGE] year old male whose past medical history includes depression, ETOH and substance abuse, who presents to the ED under police escort with reports of suicidal ideation. Patient reports he has been abusing alcohol (1 bottle of liquor daily) and meth, most recently this morning. Of note, the patient does mention that he has had some visual and auditory hallucinations, though he knows they are not real. He denies formal diagnosis of schizophrenia or schizo-affective disorder.
Complaint: Suicidal ideation.
Counseled patient: regarding diagnosis, need for admission.
Laboratory tests: Ethyl Alcohol: 241 (normal level 0-10)
Disposition: Clinical impression; depression, substance abuse, suicidal ideation. Transfer to Psych Hospital.
Patient #5's care was transitioned to ED Physician C on 1/30/16 at 7:00 AM.

f. Review of Physician C's assessment note dated 1/30/16 at 10:46 AM revealed: Re-eval status: unchanged. (Stable, cooperative, awaiting acceptance a mental health unit.)
Condition: clear for psych facility.
Differential Diagnosis: Depression, suicidal.
Patient #5's care was transitioned to ED Physician N on 1/31/16 at 7:00 PM.

g. The medical record lacked a clinical assessment of the patient's physical or psychological status by ED Physician N.

Patient #5's care was transitioned to ED Physician B on 1/31/16 at 7:00 PM until the patient was discharged from the hospital on [DATE] at 11:45 AM.

h. The medical record lacked a clinical assessment of the patient's physical or psychological status by ED Physician B or the patient's condition at discharge and disposition status. Staff F, RN/ED nurse manager acknowledged the medical record lacked a clinical assessment of the patient's physical or psychological status by ED Physician B during an interview on 5/11/16 at 3:30 PM and stated "This is inexcusable."

i. On 1/30/16, at 3:21 PM, ORHC contacted the call center for psych bed placement.
Review of documents titled "Transfer Center" call sheets revealed:

Diagnosis: Psych
HPI: Suicidal ideation, plan to hang himself, denies in ED though. Brought by police escort, history of depression, ETOH abuse, and meth. Visual and auditory hallucinations (seeing little people). Dual diagnosis, voluntary. From 1/30/16 at 3:34 PM to 2/1/16 at 5:13 AM the call center contacted 14 hospitals for bed placement and were denied. On 2/1/16 at 11:50 AM the transfer call center contacted ORHC and Staff S, RN said the patient was discharged .

j. Further review of nursing behavioral health reassessment notes revealed nursing staff continued to monitor the patient every shift for suicidal ideation. Patient #5 remained in a secure room, monitored by one staff from the time he presented to the ED until the time of discharge.

k. Further review of "Timed Observation Record" sheets revealed nursing staff documented the patient was in the secure room, asleep, with one staff at bedside from 8:30 AM to 2:15 PM. From 2:30 PM until 2/1/16 the patient slept intermittently. On 2/1/16 the patient was awake from 6:00 AM to 11:00 AM with continued monitoring/observation by staff for suicide.

l. Review of Behavioral Health Assessment nursing notes dated 2/1/16 at 10:40 AM, by Staff S, RN revealed: Patient fully alert. Discharge instructions (Suicide Risk Prevention) provided 11:45 AM, verbalizes understanding. Left: in private vehicle. Destination: home.

The hospital failed to provide the patient with an appropriate medical screening examination sufficient to determine the presence of an emergency medical condition.

4. a. Review of Patient #1's closed medical record showed on 4/17/16 at 4:24 PM the patient presented to the ED accompanied by his mother, for a psychiatric evaluation. The Current Diagnoses Table completed on 4/17/16 at 4:25 PM revealed the following diagnosis: Attention-Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Other symptoms and signs involving appearance and behavior, Other Long Term (current) drug therapy.

b. The emergency room Rapid Initial Assessment completed on 4/17/16 at 4:25 PM by Staff D, RN revealed: Chief Complaint: Behavioral health - emergent

- Subjective assessment: Per mother patient setting things on fire at home
- Objective assessment: Patient states is suicidal with a plan. History of sexual abuse at [AGE] months. Diagnosis: Bipolar, Schizophrenia
- Presenting signs/symptoms of behavioral health: Agitated, auditory hallucinations, difficulty concentrating, suicidal ideation, violent behavior.
Onset - Greater than 1 months ago, Duration of discomfort - Constant
- Safety precautions implemented: Family with patient, placed in safe room, security near, see patient from nursing station, seizure precautions, sharp objects removed, sharp box secured, sitter with patient, suicidal precautions, tubing/cords removed.

- Suicide risk assessment: Is there a concern that patient is suicidal - YES
- In the past few days have you been having thoughts of plans about hurting yourself - YES
- I want to ask you if your child ever tried to hurt or kill themselves intentionally in the past year - YES, per mother patient hits head against wall and punches self in face
- Other new behaviors of child: Setting fires in house
- Do you feel safe at home, work, and school/day care - NO

c. Review of 1:1 Observation Record Emergency Department/Acute Care In-Patient Unit sheets dated 4/17/16 revealed nursing staff implemented 1 to 1 monitoring on 4/17/16 at 4:15 PM for suicide precautions. Patient #1 remained on 1 to 1 monitoring for suicide precautions from the time he was admitted to the ED until 4/19/16 at 9:00 PM when the patient left accompanied by his mother.

d. The HPI completed on 4/17/16 at 4:28 PM by ED Physician D revealed:
Narrative History of Present Illness: Patient is a 6 year old who is here with mom for behavioral issues. Patient has two episodes of starting fires in the home. Mom says he climbed on top of the refrigerator and got matches or lighter, started carpet and a box on fire. In the past started a fire, but mother still keeps matches above fridge. Patient says he guessed where matches were
and found them. Mom states has alarm on his door and it has not been waking her up lately, so child doing things in house. She states he has talked about killing himself. Mom reports she called psychiatrist office and was told to come here and call police and that we might try and place child in inpatient psych. Patient is very energetic and bounces around room. He listens and follows instructions when engaged, when not engaged making noise, rolling around, hoping around room. Mom reports sometimes pees and poops in pants and child says he can do it if he wants; he laughs, and says will do it now and gets a rise out of mom then goes to restroom.

Complaint: aggressive behavior
Associated with: sexual abuse - alleged, other (Attention Deficit Hyperactivity Disorder - ADHD, Oppositional Defiant Disorder - ODD)
Exacerbated by: family stress
Suicide risk factors: Not Applicable (NA) patient says going to jump off bridge or bed, has no means to get to bridge nor does he seem serious as laughing and saying it to manipulate mom.
Physical Exam - Ped Psychiatric: Psychiatric: normal mood (cheerful and laughing. Listens and follows commands when engaged. When ignored hops around room and falls onto bed and rolls off and repeat. Was jumping into door at times, but appeared to get a rise out of mom. Normal affect. Psychiatric: Patient not currently suicidal, has mentioned it in past and agrees to the past, mentions and laughs, really appears that he is manipulating mom for attention. Patient did say he was stupid, repeated it a few times. Has voiced that he will jump off bridge if does not get his way, says several times. Mom wants placement. States has tried everything, and cannot leave him alone while she goes to bathroom, as he leaves the house.

e. Review of General Nurse's note entered by Staff T, RN on 4/17/16 at 7:12 PM revealed: Patient states he wants to kill himself because he is stupid and he has a plan of jumping off of bed onto something sharp. Does not feel safe at home, but refused to identify why to this RN. Mother yelling at Patient #1 frequently during his time in the ED. Staff T, RN documented Patient #1's mother sat outside of his patient room on her cell phone most of the time the patient was in the ED. Mother requested to go home due to need to care for another child.

f. Tele-Psychiatric evaluation entered by Psychiatric Physician F on 4/18/16 at 2:20 PM revealed:
- Reason for consult: Threatening to harm self/others, setting fires at home.

- Overall Assessment/HPI: 6 year old brought in by mother on 4/17/16 after starting a small fire in home while parents were asleep in the early morning. Mother reports found candles and matches and states this is the second time in the past 2 weeks that the patient has been playing with matches. Patient is unable to provide explanation as to why he started the fire. Does not demonstrate insight into the consequences of starting a fire. Mother also reports patient has been talking about wanting to jump off a bridge to his death. Patient reports if he jumped off a bridge and died he would have to see a doctor, so he lacks insight into the possible consequences of actually doing this. However, mother reports family lives close to a bridge. Mother reports she feels unable to manage patient's behavior at home and worries about the safety of other family members.

Mom afraid he will start house on fire again. Will attempt tele-psych as well.

- Past Psychiatric history: Patient has an outpatient psychiatrist that he sees monthly. Taking Strattera 18 (a medication used to treat ADHD) mg po two times daily (BID)
- Family history: Significant for biological father with multiple psychiatric diagnoses and hospitalization s. Mother has history of panic disorder with agoraphobia, Post-traumatic stress disorder (PTSD), and major depressive disorder. Mother is also in recovery from substance abuse for the past 16 months.
- Social history: There is a Department of Human Services (DHS) case open because patient was living in an area where people were doing drugs, mother reports the case was opened when mother approached police to get help.
- Mental status exam: Patient makes minimal eye contact.
- Overall Impression: Increased impulsive behavior, including fire starting and making statements about jumping off a bridge to die. Mother feels unable to safely manage behavior at home.
- Treatment recommendations: Admit to inpatient psychiatry service.
- Recommend inpatient psychiatric hospitalization for psychiatric stabilization when medically stable.
- Recommendations discussed with ED attending (ED Physician O)

g. On 4/17/16 at 9:21 PM, ORHC contacted the call center for psych bed placement.
Review of document titled "Transfer Center: call sheets revealed:
Diagnosis: Psych
HPI: Starting fires in home, climbed on top of fridge to get lighters, here for ADHD, hyperactive, since patient voluntary can go out of state with patient.
From 4/17/16 at 10:07 PM to 4/19/16 at 10:28 PM
the call centers contacted 15 hospitals for bed placement and received denial from all 15 hospitals contacted. On 4/19/16 at 10:28 PM the transfer call centers contacted ORHC and received information the patient was discharged per mother's request.

h. The Pediatric Psychiatric note completed on 4/18/16 at 2:18 PM by ED Physician P revealed: Psychiatrist recommends admission to inpatient facility for child's own good. Remarks about poor management of child's behavior and tough situation.
Disposition-Pediatric Psychiatric: Suicide risk prevention.

i. Review of General Nurse's notes dated 4/18/16 at 7:59 PM, completed by Staff J, RN revealed; Patient #1 awaiting placement.

j. The Pediatric Psychiatric note completed on 4/19/16 at 5:29 PM by ED Physician C revealed: The mother of the patient is very agitated tonight. She was told that a family member would have to be with the patient 24 hours a day until placement could be found. The tele psychiatrist had recommended placement for the child. The mother of the patient failed to complain previous days and rarely visited her child. According to Physician B, DHS reported all the children are scheduled for removal from the home but has not occurred at this time. Mom became hostile towards staff and threatened to take the patient home due to a lack of placement by the hospital.
She refused to allow Patient #1 to remain in the ED until appropriate placement was found and decline to go home unless she could take Patient #1. The mother was informed the hospital will call the police if she failed to cooperate. She proceeded to leave with the patient. The hospital attempted to contact DHS to no avail. Police arrived after the patient was unwillingly removed by the mother.

k. Review of General Nurse's notes completed on 4/19/16 at 6:34 PM by Staff H, RN revealed:
6:25 PM - Mom back, relates that if we cannot place child soon that she wants to take him home. Mercy Des Moines is reviewing patients chart. Physician B in to speak to mom.
The medical record lacked a clinical assessment of the patient's physical or psychological status by ED Physician B.

l. Review of General Nurse's notes completed on 4/19/16 at 8:52 PM by Staff U, RN revealed:
8:09 PM - Had a recliner brought to floor for patient's mom. She became upset and stated she was not going to be here all night, was taking patient out of here, continued to get louder. Staff U, RN contacted DHS and informed Patient #1's mother to stay with patient, DHS was involved and planned to take patient out of the home. Mom stated she's leaving with the patient and the hospital can't stop her.

8:30 PM - Spoke with mom, supervisor present and talking with mom, attempted to contact DHS again and tell them someone needed to come out, they stated to contact police, called dispatch to have officers come out STAT.

8:35 PM - DHS called back, wanted to speak with mom who stated they could call her cell on her way home. Mom exited with patient who was crying and stated he didn't want to go, Patient 1 asked his mother to calm down.

8:36 PM - Officers here from Ottumwa City Police, informed them of situation, stated they would contact the sheriff department. Leaving against medical advice form provided to Patient #1's mother which she refused to sign.

The medical record lacked evidence that staff contacted the telepsychiatrist for assistance in arranging an appropriate transfer to a hospital with pediatric psychiatric capabilities or to provide further examination and treatment while patient # 1 remained in the ED from 4/17/16 at 4:24 PM till 4/19/16 at 8:36 PM.

During an interview on 4/28/16 at 7:00 AM, ED Nursing Director A said the hospital has a contractual agreement with the Access Call Center to assist in bed placement for patients who required in-patient psychiatric services.

During an interview at the time of entrance and tour of the emergency department on 4/28/16 at 11:35 AM, ED Physician C said it was a challenge finding placement for psychiatric patients and that sometimes they "sit" in the ED for days. He said it was definitely a system that was not working.

During an interview on 4/28/16 at 8:10 AM, Staff E, RN/Director of the Senior Behavioral Health Unit said she was available for consultation for any patients presenting to the ED for an acute psychiatric emergency and would assist the staff in finding appropriate placement.

During an interview on 5/2/16 at 8:45 AM, the Chief Nursing Officer (CNO) said the hospital had a contractual agreement with the SOC (Specialist On-Call) Tele-psychiatric group and they are on call 24/7. She said they are available for any patient who presents to the ED with an emergent psychiatric condition but they do not write orders and they are not managing the case. The CNO said the ED physician would initiate the psychiatric consult and would be responsible for determining the frequency of reassessment of the patient by the tele-psychiatrist depending on the patient's condition.

During an interview on 5/4/16 at 3:35 PM, Geri Psychiatric Physician E confirmed she was the Medical Director of the Behavioral Health Unit at the hospital. She said on "occasion" she provides consultation to hospital in patients on the medical surgical nursing unit. Physician E said there were 2 psychiatric physicians and 1 psychiatric nurse practitioner on staff at the hospital to provide services to acute psychiatric patients over the age of 55 and if there were a patient over the age of 55 in the ED they would assist if the ED physician requested. When asked what types of services are available on the behavioral health unit she said typically patients are admitted to their unit for "acute" problems and that this was required for admission. She stated, "For example acute exacerbation of a chronic illness and medication management of a biological psychiatric illness." She emphasized they do not provide behavioral modification or therapy and do not treat routine chronic conditions on their unit or in their hospital. She stated, "Basically we wouldn't consider a patient under 55 because our scope of practice is for [AGE] and over."

During an interview on 5/4/16 at 4:45 PM, Tele-Psychiatric Physician F confirmed she does not have access to patient's electronic medical record information and her assessments are based
on what physicians and nursing staff tell her and what she observes and hears during her on camera assessments with patients.