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.

CHRISTIAN HOSPITAL NORTHEAST-NORTHWEST 11133 DUNN ROAD SAINT LOUIS, MO 63136 July 13, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interview and record review of Emergency Department (ED) logs, medical records, staffing and physician on-call schedules, the facility failed to provide an appropriate medical screening examination (MSE) to determine the presence of a medical or psychiatric emergency condition (EMC) within its' capacity and capability for three patients (#33, #37 and #9) of 38 patients' Emergency Department (ED) records reviewed January 2017 through June 2017. The facility's failure to provide an appropriate MSE could negatively impact all patents seeking treatment at the facility.
The inpatient census was 210.

Refer to A2406 for details.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, policy review and video surveillance review, the facility failed to provide an appropriate medical screening examination (MSE) to determine the presence of a medical or psychiatric emergency condition (EMC) within its' capacity and capability for three patients (#33, #37 and #9) of 38 patients' Emergency Department (ED) records reviewed January 2017 through June 2017.

The facility's failure to provide an appropriate MSE could negatively impact all patents seeking treatment at the facility. The facility's ED average daily census over the past six months at the Northeast Campus was 4,539 and at the Northwest Campus was 4,831. The facility census was 210 for the Northeast Campus.

Findings included:

1. Review of the facility's policy titled, "Medical Staff Rules and Regulations," dated 2017 showed that a medical screening examination will be provided for all patients requesting Emergency Department services by 1) a physician, (2) a physician assistant (PA) with a supervision agreement with an Emergency Department physician or a nurse practitioner (Advanced Practice Nurse) with a collaborative practice agreement with an Emergency Department physician; (3) an Emergency Department registered nurse certified in advanced cardiac life support, who has access to an onsite Emergency Department physician, or (4) in hospital-owned ambulances off hospital premises by a Mobile Emergency Medical Technician (paramedic) (in voice consultation with one of the following practitioners who concurs in the assessment: (a) an Emergency Department physician; or (b) a physician assistant with a supervision agreement with an Emergency Department Physician or a nurse practitioner with a collaborative practice agreement with an Emergency Department physician; or (c) an Emergency Department registered nurse certified in advanced cardiac life support, provided that only Emergency Department physicians can authorize the transfer of a patient to a facility other than the facility.

Review of the undated policy titled, "EMTALA Anti-dumping Compliance of Emergency Department and Hospital Patient (Individual) Transfers to Another Facility," showed that:

- The hospital must provide an appropriate medical screening examination beyond medical triage by qualified personnel as determined by the Board of Directors when an individual presents to the emergency department and requests examination or treatment for a medical condition;

- When an individual is determined to have an emergency medical condition, the facility will provide necessary examination and treatment to stabilize the patient within the capabilities of the staff and facilities available at the hospital;

Review of the facility policy for the facility owned ambulance titled, "Emergency Medical Services Medical Protocols," (EMS) dated 04/10/15 showed that:

- This protocol is designed for primary 911 (a call system for emergency medical access and response) responses for the facility's EMS;

- For patients that were not categorized as trauma or burn patients transport would be to the closest appropriate emergency department for emergent medical screening examination; and

- Psychiatry: Transport to facility with emergent psychiatric stabilization services.

2. Observation and concurrent interview on 07/11/17 at 11:30 AM on the parking lot of Professional Office Building (POB) #1, at the Northeast Campus, showed a metal railing around the perimeter of the parking lot with a concrete ledge at the base of the railing. On the West side of the parking lot the railed side overlooked a street with an approximate drop off of 15-20 feet. Staff H, Security Officer stated that there were security cameras that panned the parking lots and were monitored by security staff. He stated that a few weeks earlier there was an incident that involved a female patient (#33) who was upset after seeing her physician at the pain clinic in POB #1 and after her appointment she ran to the end of the parking lot and threatened to jump off of the ledge to the street below. Staff H stated that a drug representative had talked the patient into coming back on the inside of the railing and that the drug representative and the patients' husband had called 911 (emergency response). Staff H stated that when he arrived to the scene the county police were there and that he and Staff M, Security Supervisor were just there on standby that the county police informed the patient that they needed to take her to Hospital B and the patient refused. Staff H stated that this parking lot was considered to be the property of the facility. He stated that he was unsure why the patient was taken to another facility instead of being seen at this ED. The West side of the parking lot where Patient
#33 threatened to jump was approximately 300-400 feet from the Northeast ED Campus' entrance.

Review of video surveillance provided by the facility dated 06/29/17 showed the following:

- At 11:31:41 AM the county police blocked the street with multiple police cars below the area where Patient #33 had threatened to jump.

- At 11:37:06 AM the facility owned ambulance pulled onto the parking lot and parked approximately 20 feet from Patient #33.

- At 11:46:18 AM Staff H, Security Officer, Staff M, Security Supervisor and Patient #33's husband stood in front of the ambulance. Patient #33 was sitting on the inside concrete ledge with her back up against the railing.

- At 11:53:36 AM county police put handcuffs onto Patient #33.
- At 11:55:15 AM county police put Patient #33 into the ambulance.
- At 12:02:44 PM EMS drove out of the parking lot.

During an interview on 07/12/17 at 8:50 AM, Staff M, Security Supervisor, stated that when he arrived at the scene the county police were already there because of the 911 call and that he and Staff H, Security Officer just stayed back and "let them handle the situation." He stated that when the police were on the scene he and the security officers assisted only if asked. He stated that he had overheard the county police say that they were taking the patient to Hospital B.

During an interview on 07/12/17 at 9:50 AM, Staff N, Paramedic, stated that the ambulance was facility owned and had been dispatched to the facility after a 911 call. Upon arrival the county police informed him and Staff O, Paramedic, of the situation and how they had a patient standing on the outer side of the railing. Staff N stated that the police told him that they wanted the patient to go to a psychiatric facility and so they wanted to transport the patient to Hospital B. He stated that since Patient #33 was on Hospital A grounds they needed to call "med control" (Northeast's ED Campus physician). Staff N stated that Patient #33 was alert, coherent, was not violent and was safe. He stated that he did an MSE to the "best of his ability" as the patient didn't want to be touched so she was "visually" assessed. He stated that when they called Northeast ED Campus they spoke to Staff L, ED physician, and informed him that the patient was stable, not at risk to jump and was in police custody and that police wanted to transport patient to Hospital B and Staff L agreed to this since the patient was stable.

During an interview on 07/12/17 at 11:55 AM, Staff O, Paramedic stated the ambulance was dispatched on a 911 call that a female was possibly standing on top of a parking garage at Northeast. Upon arrival Patient #33 was alert, knowledgeable, and understanding of the situation. She stated that the police were in control of the situation. Staff O stated that she assessed the patient as being understanding of the situation, able to breathe properly, walked on her own, and was stable. She stated that vital signs (blood pressure, heart rate) were unable to be assessed because the patient had refused. Staff O stated that Patient #33 was "belligerent" especially to her husband and the police and that she cursed and called them names. She stated that her partner Staff N called the Northeast ED Campus and that the police had informed her and the patient that they were taking the patient to Hospital B and that the ED physician at Northeast had agreed to this. Staff O stated that she rode in the back of the ambulance in route to Hospital B and that Patient #33 was not cooperative and she threatened to kick the ambulance doors open and kicked at her and the police officers. Staff O stated that she was trained to perform a MSE which included both mental and physical assessment. Staff O stated that she did not know if Patient #33 had an EMC and stated "I don't know what that is ma'am."

Review of facility document titled, "EMS Patient Care Report," dated 06/29/17 showed the following documentation:

- Dispatched to Northeast Campus parking lot for a psychiatric call at 11:37 AM.
- Patient making threats of suicide.
- Upon arrival patient was seated on the railing and talking with county police.
- Patient was visibly upset and uncooperative.
- EMS contacted "Medical Control" at the Northeast ED Campus and spoke with Staff L, ED Physician.
- EMS asked Staff L if patient should be transported to NE or should patient be taken directly to Hospital B.
- Medical Control was contacted due to EMTALA (Emergency Medical Treatment and Labor Act, federal law that requires ED's to stabilize and treat patients regardless of their insurance status or ability to pay).
- Staff L asked if patient was stable and EMS informed him that she was stable.
- Staff L replied "then yes," patient can go to Hospital B.
- Patient refused to walk to the ambulance and said "I'm not going in the ambulance because I have anxiety, I will ride with my husband and you can follow us to the hospital."
- Police informed patient that was not an option and that since she had threatened suicide she was in police custody and would be transported in the ambulance because that was the law.
- Patient continued to refuse to walk to the ambulance.
- Police handcuffed patient behind her back and escorted her to the ambulance and placed on EMS stretcher.
- Police escorted the ambulance to Hospital B so that they could write out an affidavit.
- Patient remained uncooperative, sliding legs out of safety belts, sliding down on the stretcher, attempted to kick the back doors open and then attempted to stand up during transport.
- Patient verbally abused EMS and police and continued to tell EMS and the police that she would kill herself as soon as she got out of the hospital.

During an interview on 07/12/17 at 1:50 PM Staff P, Operations Supervisor for EMS, stated that the paramedics were trained to perform MSE's and any MSE had to be in correlation with a physician to determine the situation and what would need to occur next. He stated that they could not determine if an EMC existed as that would require a physician.

During an interview on 07/12/17 at 10:43 AM, ED Physician L, stated that he was on duty on 06/29/17 in the Northeast ED Campus and received a phone call from the facility owned ambulance paramedic stating that a patient had threatened to jump off of the parking lot wall and the paramedic had asked permission to transport to Hospital B. He stated that he was made aware that the police were there on the scene and that they had asked to take the patient to Hospital B.

ED physician L stated that when the ambulance called the ED from "the field" then the paramedics were able to perform the MSE and when the ambulance was in route to the ED with a psychiatric patient then the patient would have the MSE inside the ED. He stated that he was aware that the paramedics had only been able to perform a visual assessment of Patient #33 and that it was a "limited" phone call but he was able to determine the patient was cooperative and patient was under control and the police were there.

He stated that based on the statements given to him by the EMS he felt that Patient #33 was stable and that there was a low chance of deterioration. ED physician L stated "it all happened very quickly" and stated that he thought it was reasonable for the patient to be transported to the other facility. He stated that without seeing the patient himself he could not with "100% certainty" determine that Patient #33 was stable for transport but had a "reasonable conclusion" based on the circumstance and transport time to Hospital B and the fact that it would be considered an "inbound" ambulance and the patient would be immediately assessed and evaluated.

During an interview on 07/12/17 at 9:10 AM Physician E, Chief of Emergency Medicine stated that the police had a strong presence and had control of the scene during the incident on 06/29/17. He stated that the police had handcuffed the patient and wanted to take her to Hospital B. He stated that after the incident he talked with ED physician L who informed him that EMS had called and asked what to do that the police wanted to transport patient to Hospital B and that she was stable.

Physician E stated that by facility by-laws the EMS can do an MSE so ED physician L took their word that Patient #33 was stable and agreed to the transport to Hospital B as the police wanted to do. He stated that Patient #33 had put her leg over the side of the railing and had gestured to commit suicide and that she needed to be evaluated by a psychiatric physician at Hospital B. So that treatment would not be delayed she needed to be transported to Hospital B. He stated that if a psychiatric patient came to the ED with suicide ideations they have mental health evaluators and they would determine if the patient needed inpatient care with consultation from a psychiatric physician at another facility.

3. Review of two undated facility provided documents titled, "Reconcile Timecard," showed 11 staff members names identified by the facility as the mental health evaluators for the ED with two names indicated by the facility to have been on duty on 06/29/17 the day of the incident.

Review of police report dated 06/29/17 showed:
- The call was received at 11:25 AM for an attempted suicide.
- The call indicated that the reporting party's [AGE] year old wife (Patient #33) received bad news from the facility and was on top of the parking garage threatening to kill herself.
- Once outside of the facility Patient #33 ran towards the edge of the parking lot and stood on the edge of the parking garage in an attempt to commit suicide.
- Patient #33's husband made the 911 call.
- Patient #33 wanted to go to Hospital B only if she could ride there with her husband.
- Police officer attempted to convince the patient to go willingly in the ambulance but attempts were unsuccessful.
- Patient #33 was placed in handcuffs behind her back.
- Patient was extremely uncooperative.
- Patient was placed in the ambulance and taken to Hospital B.
- During the transport the patient continued to verbalize that if the doctors at Hospital B didn't help her she was going to kill herself.
- Upon arrival to Hospital B Patient #33 continued to be extremely uncooperative, and required multiple pairs of handcuffs to properly restrain her for treatment.

Review of the medical record from Hospital B showed that Patient #33 was given medications for her agitation, and admitted for treatment of her psychiatric emergency.

Northeast ED Campus had the capability and capacity to provide a MSE to Patient #33 as she was on hospital property.

4. Review of Patient #9's ED record, dated 03/04/17 showed:

- The patient arrived at the Northwest ED Campus per cab on 03/04/17 at 3:29 AM.
- ED Registered Nurse (RN) CC, documented that the chief complaint was request for evaluation for psychiatric sickness, schizophrenia (a mental disorder characterized by abnormal social behavior and failure to understand what is real), hallucinations (a perception in the absence of external stimulus that has qualities of real perception), possible suicidal ideations (SI, thoughts about suicide) and possible homicidal ideations (HI, thoughts of killing someone).
- ED RN CC placed the patient on elopement precautions, on line of site/sitter precautions, and had security stationed at the door of patient's room.

- ED RN X documented at 4:10 AM that the patient was here for a psych evaluation, patients speech was incoherent, patient paced back and forth in the room, patient constantly rambling to staff and talked to herself when staff was not in the room.

- Social Worker (SW) EE, documented at 5:20 AM that a call was made to the psychiatric intake staff regarding patient's need for a mental health assessment. Intake was to complete assessment with patient after medical clearance.

- ED RN X, documented at 5:25 AM that Intake called and informed of patient in emergency department (ED).

- SW EE documented at 5:55 AM that Intake spoke with ED RN regarding patient at this time. Due to the possibility of patient being unable to voluntarily sign in for inpatient psychiatric hospitalization if necessary, Intake requested an affidavit be filled out on the patient's current behavior prior to the change of shift for continuity of care.

- ED RN X completed the affidavit.

- ED Physician DD, documented at 6:42 AM that the patient was depressed, appeared anxious, angry, agitated, paranoid, and had racing thoughts. Psychiatric review of symptoms showed that the patient stated depression and emotional problems.

- The drug screen was positive for marijuana (an illegal recreational drug).

- ED RN Y documented at 7:17 AM that the patient reported a history of marijuana use; patient talking nonstop with flight of ideas; patient will not answer questions appropriately; and patient stated "I'm not suicidal I lied and did the wrong thing by taking a cab here, I don't have any emergency contacts don't know where my mom is. I have my own place."

- Intake Coordinator (IC) AA, documented at 8:02 AM that Intake had spoken with the emergency room nurse. Patient denied SI and HI. Patient stated that she was like this all the time. From past medical charts, patient presented with similar symptoms and behaviors and was discharged . Patient was non-compliant and believed to be malingering. emergency room physician would like to discharge patient. Intake faxed community mental health resources to provide to the patient.

- ED physician BB documented at 8:17 AM that physician spoke with patient who denied SI and HI. She voiced no complaints; Intake provided resources for the patient; and she will be discharged at this time.

- ED RN Y documented at 8:34 a.m. that the patient refused to sign discharge papers and verbal discharge instructions were given. Patient discharged to home at 8:48 a.m.

During an interview on 07/13/17 at 9:30 a.m. ED RN X stated that the normal care process for a patient with SI, HI, hallucinations or altered mental status was:

- ED staff contacted Intake who completed a psychiatric assessment;
- Intake staff completed a psychiatric assessment in person, via Polycom (video), or by phone depending on which emergency department the patient was in and if video equipment was working;
- Intake staff contacted ED physician with recommendations regarding appropriate disposition.
The RN stated that she handed patient off to day shift RN with the understanding that they were still waiting on the psychiatric assessment.

During an interview on 07/13/17 at 9:55 a.m. ED RN Y stated that she doesn't really remember this patient and does not know why the patient did not have a psychiatric assessment.

During an interview on 07/13/17 at 10:30 a.m., the Medical Director of Emergency Medicine, stated that this patient discharge was not a safe discharge; old medical records should have been reviewed but not have swayed the decision made in the present; and the psychiatric assessment should have been completed.

During an interview on 07/13/17 at 11:20 a.m. Intake Coordinator AA stated that she did not have any interaction with the patient and does not remember talking to the nurse. She noted that if a psychiatric assessment had been completed it would be done on the Mental Health Services Intake Assessment form.

During an interview on 07/13/17 at 11:50 a.m. ED Physician BB stated that he did not remember this patient. He stated that patients often said they had SI or HI when they were really seeking food, warmth, or drugs. Sometimes they came in at night, sleep it off and then went home. He stated that Patient #9's status had changed and she wanted to go home. He stated that it was not usual for him to not obtain a psychiatric evaluation if the previous shift ED physician wanted one done.

The facility failed to perform a medical screening examination sufficient to determine whether an emergency medical condition existed prior to discharing patient # 9 from the ED. The hospital had the capability of performing a mental health examination and the capacity to admit for stabilization of her alcohol withdrawal symptoms. The inpatient census was 210, with a total of 485 beds.

5. Review of the facility's undated policy titled, "Tele-psych with Facility Hospital Intake Office", showed:
- Facility to notify Intake office (staff trained to complete psychiatric assessment) for any requested tele-psych (psychiatric assessment completed by video) consults.
- Intake is to start the assessment within 30 minutes of the requesting facilities first call.
- Intake coordinator to scan or fax assessments into HMED (electronic medical record).
- Intake coordinator to contact the treating physician to discuss disposition plan.
- If patient is to be discharged , the Intake Coordinator will explain discharge to the patient over Polycom (video) to make sure the patient can teach back the plan for discharge.

6. Review of the medical record showed that patient # 37 (MDS) dated [DATE] at 9:46 p.m. after cutting her right forearm. At 9:58 p.m. the ED physician documented the patient has had multiple episodes in which she has cut herself due to stress. Patient also stated she drank 2 shots of alcohol about 5 hours ago. "She reports that she was admitted to [Hospital B] for 1 night for alcohol withdrawal about 10 days ago." The ED physician cleaned the patient's wound and closed the laceration with staples. At 11:27 p.m. documentation in the medical record indicated "Intake ready for assessment." "Video assessment not possible due to technical problems." "Phone assessment started at this time." At 11:50 p.m. documentation showed patient # 37 denied suicidal or homicidal thoughts while talking to staff over the phone. Further documentation showed patient # 37 stated "I'm a cutter." "I cut too deep." "I got scared and panicked because I was bleeding and I came to the ER." Further documentation showed the patient reported increased stress and admitted to drinking 1 - 2 shots 3 times a week and "Denies any desire or need for rehab." "Denies drug use." "Patient does not meet criteria for inpatient psychiatric admission." "Patient was seen in ER a week ago and received 3 sutures for cutting as well." "States she has been cutting for 2 years." At 12:04 a.m. on 3/7/17 documentation showed the patient was discharged .

The medical record did not contain evidence the patient received an examination sufficient to determine whether an emergency medical condition existed.

7. Review of a second ED record showed patient # 37 returned to the ED at the Northwest Campus on 03/10/17 at 2:23 PM concerned about alcohol withdrawal.

Documentation by staff showed the following:

-On 03/10/17 at 2:32 PM Staff GG, ED RN, documented the patient stated that she had 12 shots (of alcohol) in the last hour and believed she would experience seizures and that she takes medication at night to keep from going into withdrawal while she sleeps.

-On 03/10/17 at 2:55 PM ED Physician HH, documented the patient presented to the ED requesting treatment for alcohol abuse. Further documentation showed the patient had been drinking for the last two hours and had seven shots of rum in that time. The patient stated she was afraid of having withdrawals if she stopped drinking. She had been drinking excessively for six months, adding that her normal day includes 15 - 20 shots of rum. She takes medication for these withdrawals but cannot afford a refill and cannot afford treatment. Further documentation showed, "this is the third time this year she has presented to the ED with ETOH (alcohol) abuse."

-On 03/10/17 at 3:08 PM ED RN GG documented the patient stated that she abuses alcohol and drinks 15 to 20 shots of rum a day. The patient stated that she had about seven so far today and wanted to go into treatment but was unable to find a place to accept her. The patient stated that she was sure she was going to go into DT's (Delirium Tremens - a rapid onset of confusion usually caused by withdrawal from alcohol) today because she drank so much so fast. The patient's right forearm had multiple staples placed recently for self-cutting injuries. The patient stated that she cuts to relieve the stress but denied cutting at this time.

-On 03/10/17 at 4:15 PM ED RN GG, documented since the patient's arrival she had been very anxious and worried about multiple things, being dehydrated, afraid she was going into DTs and if the cutting wounds on her right arm were healing properly.

-On 03/10/17 at 4:29 PM ED RN GG, documented the patient stated that she needed to smoke and if she couldn't she would leave. ED RN GG told patient # 37 about their no smoking policy but the patient continued to request to smoke. ED RN GG discussed this with the ED physician and was instructed to have the patient sign out of the ED against medical advice (AMA).

-On 03/10/17 at 4:55 PM ED RN GG, documented she had a lengthy discussion with the patient regarding leaving AMA and the need for further evaluation. Patient # 37 decided to leave.

-On 03/10/17 at 5:10 PM ED Physician HH, documented that staff talked with the patient and were unable to find a place to get into this weekend (for treatment of alcohol abuse). Further documentation showed the patient did not want to stay any longer, that someone was with her and that she signed out AMA.

Review of the patient's laboratory tests showed the following information:
-On 03/10/17 at 3:45 PM the patient's Ethanol (alcohol) level flagged H (high) at 244 (normal range is 0 - 10).
-On 03/10/17 at 3:47 PM the patient's urine Drug of Abuse test was positive for Amphetamine (potent stimulator of the central nervous system) and Benzodiazepines (medication used to treat anxiety).

Review of the patient's ED Medication Administration Record (MAR) showed the patient received the following medications:
-Thiamine (Vitamin B1) 100mgs (milligrams) IV (Intravenous - a needle inserted into a vein to administer medications and fluids).
-Zofran (medication used to treat nausea) 4mgs IV.
-Normal Saline 0.9% 1000ml (milliliters) IV.
-Valium (medication used to treat anxiety) 2mg IV.

Review of the patient's Emergency Department Release of Responsibility form signed and dated by the patient at 5:00 p.m. showed the following information:

-Under section #4 of the form titled: LEAVING AGAINST MEDICAL ADVICE: I am leaving this facility even though more testing and/or treatment, and/or admission to hospital is recommended. Patient/Responsible person initials - this section was not initialed by the patient.

-Under section #4 the last bullet stated: I am of sound mind and not under the influence of alcohol or any agents that may impair my ability to make sound decision.

The hospital failed to provide patient # 37 with an examination sufficient to determine whether an emergency medical condition existed and allowed patient # 37 to leave the ED while under the influence of drugs and alcohol. The evidence in the medical record indicated the patient told staff of her concerns regarding alcohol withdrawal. The hospital's capabilities include inpatient admission for medical detox.

During an interview on 07/17/17 at 3:15 PM ED RN GG, Stated that:
-She offered to go outside with the patient so she could smoke a cigarette but when she asked ED Physician HH he stated absolutely not, she cannot go smoke.

-The patient did not finish receiving an IV bag of fluids (that contained vitamins and minerals) because she removed the IV by herself.

-She questioned why the patient was being discharged on a Friday and not admitted until Monday for alcohol withdrawal since that was an option for the patient.

-She did not feel like ED Physician FF, gave the patient a proper exam to rule out an emergency medical condition and did not do a proper exam during the return ED visit on 03/10/17 at 6:52 PM because Staff FF did not or any lab testing to check her alcohol level.

8. Review of a third medical record showed that patient # 37 returned to the Northwest ED Campus on 03/10/17 at 6:52 PM (almost two hours after leaving against medical advice) complaining of alcohol withdrawal.

Review of the patient's ED record showed the following documentation by staff:

-On 03/10/17 at 7:10 PM ED RN GG, documented the patient was here earlier today and signed out AMA.

-On 03/10/17 at 7:22 PM the scribe for ED Physician FF, documented: History of Present Illness: The patient has a history of ADHD (a disorder that makes it difficult for a person to pay attention and control impulsive behaviors), anxiety, depression with history of suicide attempt, alcohol abuse, and alcohol withdrawal related seizures, who presented to the ED for treatment of alcohol withdrawal. The patient had another drink of alcohol since she left earlier today.

-On 03/10/17 at 7:48 PM ED RN GG documented after a conversation with the patient, she has agreed to go home and wait for Social Services to contact her for placement to help with rehab. The patient understood there is not placement available and was willing to wait until Monday. The patient verbalized understanding that she could not keep coming back into the ER (emergency room ) all weekend after being discharged today again for the second time. The patient kept stating that she needed help. Explained to the patient thoroughly that placement was not able to be found today after multiple tries.

-On 03/10/17 at 7:51 PM the scribe for ED Physician FF documented: Progress Notes/Medical Decision Making: The patient has admission to a rehab facility available to her on Monday, 03/13/17. Further documentation showed the patient was advised that "she cannot keep visiting the ED." The patient will be accompanied by a responsible adult upon her discharge (ED physician FF documented on 03/10/17 at 7:55 PM that he had personally performed the services described in the documentation, reviewed the documentation, as recorded by the scribe in my presence, and it accurately and completely records my words and actions).

-On 03/10/17 at 8:06 PM ED Physician FF documented orders for discharge.

The medical record did not contain evidence that the hospital provided patient # 37 with an examination sufficient to determine the presence of an emergency medical condition, no lab tests were performed to determine if the patient remained under the influence of drugs or alcohol. In addition, the hospital advised patient # 37 that she could not continue to come to the ED seeking care.

During an interview on 07/13/17 at 10:30 AM, the Medical Director of ED stated that based on the documentation in Patient #37's ED record it was difficult to determine if Patient #37 was competent to make an informed decision to leave AMA on the first presentation to the ED on 03/10/17 at 2:23 PM. The medical director stated that he would expect for the patient's return visit on 03/10/17 at 6:52 PM the following:

-A second alcohol level drawn.
-Administration of fluids depending on the results of the second blood alcohol level or offer food.
-Chart why he (ED Physician FF) let the patient leave or why he did not order another alcohol level.
-An option could have been to allow staff to accompany the patient outside to smoke before admission.

During a telephone interview on 07/17/17 at 10:17 AM ED Physician FF, stated that:
-The scribe's documentation reflected his assessment and interactions with the patient.
-He confirmed he told Patient #37 that she had been advised that she could not keep visiting the ED all weekend.
-The patient's Ethanol level (blood alcohol level) did increase but he did not remember if the level was re-drawn.
-He did not order any lab testing when patient #