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Based on interview, record review of Emergency Department (ED) Logs, 72 Hour Return Logs, Medical Records, Staff and Physician On-Call Schedules, the facility failed to provide within its capabilities and capacity, an appropriate medical screening examination (MSE) sufficient to determine whether one Patient (#22) of 29 patient's records reviewed, had an emergency psychiatric condition prior to discharge on two separate occasions within 24 hours. The Emergency Department average daily census was 204. The facility census was 282.

The facility had the capability and capacity to provide an appropriate MSE and to reconcile patient # 22's (a minor child) denial of suicidal thoughts which contradicted the mother's account of the patient's recent changes in mood, behavior and alleged suicidal statements. .

Please refer to A2406 for details.

Based on interview, record review, and policy review, the facility (Facility A) failed to provide an appropriate medical screening exam (MSE) sufficient to determine whether patient # 22 (a minor child) of 29 patient records reviewed had an emergency medical condition prior to discharge after two visits to the emergency department on the same day. Patient #22 presented to the Emergency Department (ED) after reportedly making suicidal comments. After an assessment in the ED as well as the Behavioral Health Department, staff discharged the patient who left the hospital ED with her parent. Approximately 30 minutes later, the patient returned to the ED after intentionally punching through a glass window lacerating her arm. Staff again discharged the patient after treatment to repair her laceration. The patient's parent took her to the ED at Hospital B and was subsequently transferred to a psychiatric hospital (C) for inpatient admission and treatment. St. Anthony's failure to provide an appropriate and sufficient medical screening examination to any individual who presents to the ED requesting care could potentially delay treatment to stabilize an emergency and increase a patient's risk for a negative outcome, including death. The Emergency Department average daily census was 204. The facility census was 282.

Findings included:

1. Review of St. Anthony's policy titled, "EMTALA (Emergency Medical Treatment and Active Labor Act) - Emergency Department," dated 11/23/16 showed:
-An Emergency Psychiatric Condition was defined as a psychiatric condition that manifested itself by acute symptoms so severe that the absence of immediate psychiatric attention could reasonably be expected to jeopardize the mental or physical health of the individual, or the individual poses a risk of serious harm to themselves or others as a result of their mental illness;
-Qualified Medical Personnel (QMP) are licensed physicians, as well as licensed clinical social workers (LCSW) and registered nurses (RN's) who completed education and training and successfully demonstrated competency in performing screening examinations for psychiatric patients that presented to the Emergency Department or Behavioral Health Department;
-The triage nurse assigned all individuals who came to the ED a QMP who performed a screening examination to determine if the individual had an emergency medical condition; and
-If as a result of the screening examination, the QMP determined that the individual had an emergency medical condition, the QMP was to stabilize the individual. If the facility did not have the capability and capacity to stabilize the individual, they would be transferred to another facility.

2. Review of the pre-hospital ambulance trip report dated 03/13/17 at 6:55 PM showed:
-Upon arrival at the patient's home, the patient paced around her room and was visibly distraught/emotionally upset with her mother and screamed profanities;
-The patient stated that her mother destroyed her room and told her that she was going to call the cops and make false accusations that she was suicidal to get her removed from the house;
-Patient's mother disputed the claims and stated that while her and her daughter were arguing, her daughter stated that she would "slit her own wrists or blow her own head off."; and
-Patient willingly agreed to be transported, but continued to be verbally aggressive towards her mother.

3. Review of Patient #22's ED record dated 03/13/17 showed:
-The patient arrived at the ED per ambulance on 03/13/17 at 7:02 PM.
-Physician Assistant (PA) "M'"s notes showed that the chief complaint was psychiatric evaluation.
-PA "M" assessed the patient at 7:44 PM and noted the patient was a [AGE] year old who stated that she and her mom had been fighting frequently, and that her mom called police tonight because she would not give up her tablet (electronic device) as requested, and that the mom had lied about her making suicidal threats.
-PA "M" documented the patient's mother stated that the patient had threatened to cut herself, and a knife was found in her bed as well as marijuana, and the stepfather had reportedly found what looked like a crack pipe.
-It was also reported that the patient had in the past, cut her arm with a plastic knife, but had not had any known suicide attempts.
-Patient confirmed marijuana use, but denied any other drug use or alcohol use. Patient # 22 denied suicidal ideation (SI) or homicidal ideation (HI), denied any visual or auditory hallucinations (sound or visions that are not present in reality) and any medical complaints.
-PA "M's" psychiatric assessment was that the patient was tearful, anxious, and argued with the mother when she was present in the room.
-PA "M" documented the patient had no pertinent medical history.
-Suicide Risk Assessment completed at 9:05 PM by ED nurse H, noted that the patient stated she did not want to harm herself.
-PA "M" documented review of lab tests and noted the patient had a Urinary Tract Infection (an infection in part of the urinary system) and was prescribed antibiotics (medication used to stop the growth or destroy infection causing organisms). The toxicology (drug) screen was positive for marijuana, and the patient was medically stable for transfer to the Behavioral Health Unit for further evaluation.

-At 11:58 pm, staff took patient # 22 to the hospital's Behavioral Health Assessment and Referral (A&R) Department for further evaluation.

-Progress Notes and Behavioral Health Assessment by Licensed Clinical Social Worker (LCSW) "K", on 03/14/17 at 1:29 AM showed:
-Mother reported patient # 22 called grandfather today and stated she wanted to cut her wrists, and reported to mother directly she wanted to cut her wrists and blow her head off;
-Mother reported patient had anger outburst and hit and threw things, and had told mother she would get someone to shoot the mother and "beat her ass";
-Patient # 22 denied she was suicidal, denied she threw items, denied she made threats, but admitted she yelled at her mother;
-Patient # 22 denied history of suicide attempts;
-Mother reported patient # 22 made suicidal threats a month ago when she was pulled over for running a red light, having marijuana and alcohol in the vehicle, and curfew violations;
-Mother also noted a superficial cut with a plastic knife at that time to arm, but denied any other known history of self-harm;
-Patient # 22 denied depression or anxiety;
- Mother previously had tried to get patient to go to counseling but she refused;
-Mother wanted patient # 22 admitted due to concerns for her safety;
- Patient tested positive for marijuana, reports she smokes it occasionally and will not give further details on her use;
-Patient wanted to be discharged ;
- At 1:27 am, LCSW K documented "Mother states pt (patient) will have bouts of rage and then cries and moods have been worse the past 4-5 months";
- Patient has had a drop in grades the past 2 months and was suspended for fighting several months ago;
- At 1:59 am, LCSW K documented the patient's step father used the patient's I pad and saw pictures of patient # 22 smoking marijuana and cocaine and a picture of the patient with a gun to her head by her boyfriend;
- Patient # 22 denied all of this;
-Psychiatrist N, was consulted after assessment and recommended Intensive Outpatient Therapy (IOP; a kind of treatment service and support program used primarily to treat eating disorders, depression, self-harm and chemical dependency);
-Mother did not feel patient would agree to IOP;
-Staff provided the patient and mother with referrals for IOP, the patient contracted for safety;
-On 03/14/17 at 2:29 AM patient # 22 was discharged with a diagnosis of Oppositional Defiance Disorder, urinary tract infection and suicidal ideations.
- Documentation in the medical record showed inconsistent statements by patient and mother;
- Documentation regarding ongoing conflict between patient and mother;
- LCSW K documented a "suicide safety plan" indicating the patient identified her mother as a person with whom she can share personal concerns and agreed to contact if she had increased thoughts of suicide. Further documentation showed, "Mother states the guns in the home are locked and no access." "Mother will work on keeping knives locked up."
- Discharge instructions included contact information for the psychiatrist, information on quitting smoking and the phone number for the suicide prevention lifeline.

During an interview on 03/22/17 at 9:05 AM, PA "M", stated that:
-The role of the ED provider was to medically clear the patient, and then if necessary, they were to go to the Behavioral Health Assessment & Referral Department for the behavioral health portion of the MSE;
-They would not take the patient to the A&R Department unless they were stable;
-Assessment staff would come to the ED for a behavioral health assessment if needed;
-Patients were discharged from the A&R Department, but the ED provider was not consulted prior to this discharge and made aware of the plan of care;
-Patient #22 was tearful and anxious when she was assessed;
-Patient #22 stated that her mom was crazy and making things up; and
-PA "M" felt the patient warranted an evaluation by the staff in the Behavioral Health A&R Department.

The medical record did not contain evidence the hospital provided a medical screening examination sufficient to determine whether or not an emergency medical condition exitsted, and no evidence that staff attempted to reconcile the varying accounts provided by the patient and her mother. At 7:03 PM the ED triage nurse documented patient # 22 arrived to the ED tearful, that the patient was "calm and cooperative", and "making physical threats toward mother." Documentation by the Licensed Clinical Social Worker K (LCSW) at 2:32 AM showed the patient contracted for safety and identified her "mother" as "a person with whom patient can share personal concerns and agreed to contact this person if having thoughts of suicide."

4. Review of Patient #22's second ED record dated 03/14/17 showed:
- At 3:15 am on 3/14/17, the ambulance crew documented that patient # 22 was "agitated and inconsolable" when they arrived at the patient's home;
- That the patient had punched through a kitchen window attempting to leave her parent's home;
- Bleeding from the patient's hand was controlled and the ambulance crew transported patient # 22 back to the hospital ED.

-The patient returned by ambulance to the ED one hour after discharge on 03/14/17 at 3:30 AM;
-Nursing Notes from ED nurse J, on 03/14/17 at 3:30 AM showed that after discharge from the hospital's Behavioral Health A&R Department, the patient returned home and got into another altercation with her mother and punched through a window. The patient reported she hit the window because she was trying to get out of her parent's house and get away from her family. Patient # 22 sustained a laceration to her right hand.

In an Affidavit to support a 96 hour involuntary detention, evaluation and treatment completed by the law enforcement officer who responded to patient # 22's home on 3/14/17 documented the following:
- Patient # 22 stated she was trying to get away from her parents who she allegedly "hates";
- "She punched through the kitchen window she was trying to escape the house";
- She cut her hand and bled all over the floor;
- Patient # 22's parents stated immediately upon returning home from the hospital at "approximately 2:45 am on 3/14/17, [patient # 22] started going crazy, throwing things and breaking things in the house."

-At 3:35 am, the ED physician examined patient # 22 and documented that the patient stated, "I punched through a window to get out of my house because my parents are nut jobs." She noted that her stepdad "shoved her into a wall tonight." She denied any thoughts of suicide or homicide.
-The ED physician's physical assessment showed a 2 centimeter (unit of measurement, equal to 0.79 inches) laceration to the the right hand with no foreign body noted and no active bleeding, the assessment also documented a flat affect (a reduction in emotional expressiveness) and depressed mood.

-At 3:37 am, ED nurse J documented that when asked about a safe environment, the patient became tearful and reported, "My Dad pushed me in to a wall tonight, that's why I tried to get out." "Earlier today I wouldn't give him my tablet (laptop device) and he flipped my bed over with me in it."

-At 4:19 am the ED Physician documented that due to agitation and depression patient # 22 required evaluation by staff in the Behavioral Health A&R Department.
-At 6:16 am, left the ED and went to the Behavioral Health A&R Department of the hospital for further evaluation.

-Progress Notes and Behavioral Health Assessment by LCSW K, on 03/14/17 at 6:37 AM showed:
-Patient denied being suicidal or homicidal and reported she never made suicidal statements;
-Mother reported that when they returned home from the hospital the patient stated she was going to slit her wrists;
-Patient reported she punched the window to get out and go to her Grandpa's house or a friend's; and
-The same psychiatrist was updated on the patient's second visit, and determined that an inpatient stay would not be beneficial and recommended discharge.
-At 6:57 AM, LCSW K documented patient # 22's mother was not comfortable taking her home;
- That the children's division (County Social Services) would contacted if the mother declined to take patient # 22 home; and that
- Mother requested the LCSW to contact the children's division.

At 8:00 AM, the Psychiatric nurse documented a police officer arrived and staff shared the mother's concerns. At 9:00 AM, a LCSW documented the mother contacted a friend and made arrangements to take patient # 22 to a local psychiatric hospital.

During an interview on 03/22/17 at 2:30 PM, ED nurse J stated that:
-She cared for Patient #22 on her second visit to the ED on 03/14/17;
-The patient was calm and cooperative and only became tearful when talking about her stepfather;
-She slept the majority of the time in the ED.

During a telephone interview on 03/23/17 at 8:45 AM, Staff K, LCSW, stated that:
-She was responsible for the behavioral health assessments in the Behavioral Health A&R Department on 03/13/17 and 03/14/17 for Patient #22;
-The situation with Patient #22 was "he said, she said" with different stories presented from the mother and the patient;
-The on-call psychiatrist felt that the situation was a parental issue and the patient needed Intensive Outpatient Therapy with parental involvement;
-The on-call psychiatrist was the same as had previously been consulted on this patient in the first visit, he was made aware that the patient's mother wanted her admitted ;
-The psychiatrist continued to recommend IOP for the patient.

During a telephone interview on 03/23/17 at 10:00 AM, Psychiatrist N, stated that:
-He had been consulted by the on Patient #22 for both visits to the hospital ED;
-Based on the LCSW's assessment of the first visit, he recommended intensive outpatient therapy (IOP) and did not believe she met inpatient criteria;
-On the second visit, the patient napped through the majority of the visit in the A&R Department.

During an interview on 03/23/17 at 11:50 AM, the Associate Director of the ED, stated the process was for the ED provider to assess the patient and stabilize, and staff in the Behavioral Health A&R Department performed the behavioral health MSE. In regards to a patient coming for a second visit so soon after the first, he reported that it would "raise an antenna ..."

The medical record did not contain evidence the hospital provided a medical screening examination sufficient to determine whether or not an emergency medical condition exitsted. There was no evidence that staff attempted to reconcile the varying accounts provided by the patient and her mother, determine the patient's risk of further escalation after she intentionally punched through a window and lacerated her hand or whether she was safe for discharge.

5. Review of Patient #22's ED record for Hospital B, dated 03/14/17 showed:
-The patient arrived at Hospital B on 03/14/17 at 4:56 PM.
-The chief complaint was psychiatric/medical clearance.
-The ED triage nurse noted the patient was calm, cooperative, but tearful, and denied SI or HI.
-The ED provider psychiatric/behavioral assessment noted the patient was negative for agitation and suicidal ideation, but noted her affect was labile (unstable emotional response) and she was tearful at times.
-The ED provider ordered a psychiatry consult completed at 6:40 PM;
-The ED provider noted that the behavioral health assessment personnel indicated stories differed from the mother, patient, and others involved in her care. Due to patient # 22's admission of risky behavior, inpatient admission was recommended.
-At 11:22 PM on 3/14/17, patient # 22 was transferred to Psychiatric Hospital C.

6. Review of Patient #22's medical record from Psychiatric Hospital C dated 3/15/17 showed:
-A psychiatrist evaluated Patient #22 and determined she was a danger to self and required inpatient admission for treatment of a psychiatric emergency.