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METHODIST HOSPITAL 7700 FLOYD CURL DR SAN ANTONIO, TX 78229 Nov. 29, 2017
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the facility did not follow their policies and procedures for one of one patients (Patient #1) who did not receive an appropriate medical exam (psychiatric evaluation) when presenting to the hospital in police custody with an order of emergency detention because of mental health issues.

This could affect all patients who present to the emergency department in police custody with an order of emergency detention because of mental health issues.

Findings included:

Record review of state agency complaint form revealed that on or about 11/07/2017, "a telephone call was received from a law enforcement officer regarding the attempt of admitting [AGE] year old female into the facility on a Peace Officers Warrantless Emergency Detention Order, after the female verbalized suicidal ideation. On a call with the facility when the officer was en route with the patient (Patient #1), the facility initially stated they would accept the patient. On arrival, they initially accepted the patient, then asked the patient to produce a urine specimen. The patient refused. According to the caller, the nurse then asked the patient if she was refusing treatment and the patient said she was, and the nurse told the officer that they were unable to care for the patient, and that the Detention Order was worthless to them, and they would only accept the patient if the officer obtained an Order of Protective Custody. The officer asked to speak with a supervisor who concurred with the nurse. The officer subsequently took the patient (Patient #1) to another facility across town, who accepted her."

Review of Facility Policy and Procedure entitled Texas EMTALA-Medical Screening Examination and Stabilization Policy, last revised 05/2017, revealed but was not limited to the following: " An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and 1. The individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition ; or 2. a prudent layperson observer would conclude form the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition. Psychiatric Qualified Medical Personnel (QMP): The ED physician shall consult the QMP providing behavioral assessment for psychiatric purposes but shall remain the primary decision-maker with regards to transfer and discharge of the individual presenting to the DED (Dedicated Emergency Department) with psychiatric or behavioral emergencies. Should an individual with a psychiatric or behavioral emergency present to a behavioral department of a hospital that meets the requirements of a DED, that department is responsible for ensuring that the individual has the appropriate MSE, including any behavioral examination , and providing stabilizing treatment."

Review of Facility Policy and Procedure entitled Emergency Detention BH (Behavioral Health), last revised 03/2011, revealed but was not limited to the following: "Facility will ensure that the laws are followed and the rights of the patients are protected in the event that law enforcement is required to take into custody a person who is exhibiting behaviors that constitute a danger to themselves or others. A patient on an emergency detention will be advised by staff of the following: A. The right not to be detained for no more than 48 hours after the hour of initial detention unless an order of for further detention is obtained. A physician must evaluate a patient as soon as possible within 12 hours after the apprehension by the peace officer under an emergency detention. The patient shall be released after completion of the preliminary physician evaluation unless the patient is admitted to the facility."

Record review of Patient #1's Medical Record revealed but was not limited to the following:

"Notification of Emergency Detention, dated 11/17/2017 at 0638 and signed by a Peace Officer, revealed Patient #1 had cuts on left arm and destruction of house, assaulting boyfriend. Patient #1 suffers from Schizophrenia, Bipolar depression, and Borderline Personality Disorder."

Review of Patient #1's Emergency Provider Report, dated 11/07/17 at 0728 and electronically signed by the attending ED physician revealed but was not limited to the following: "Initial Greet Date Time: 11/07/17 at 0635; Assumed Care at 0640 11/07/17; [AGE] year old female is brought to ED for emergency detention secondary to SI (Suicidal Ideation). Police states the Patient got into an altercation with her fiance last night. Patient's fiance left the house to go to the hospital. While he was out, she broke some glass and sent him a picture holding a shard of glass up to her throat, gesturing that she was going to kill herself, so he called 911. Patient states she has a history of schizophrenia, personality disorder, and bipolar disorder. A physical exam was documented by the attending ED physician. Re-Evaluation and MDM: Patient seen for SI. At this time patient states she wants to go home. Refuses to sign AMA form. Escorted out by police. Patient Discharge and Departure: Clinical Impression: Suicidal Ideation."

Review of Patient #1's Physician Orders, dated 11/07/2017 at 0643 and signed by attending ED physician, revealed but was not limited to the following: "Psych Evaluation", Suicide Precautions at Level 1: Standard Observation - Monitor and observe minimally every 15 minutes.

Continued review Patient #1's Emergency Patient Record , recorded on 11/07/2017 at 0714 by facility nursing staff, revealed but was limited to the following: "Patient arrived to the ED at 0632 in handcuffs along with police. When I went to meet the patient, she was hysterical in tears and raising her voice. Patient stated she just wanted to go home and she knows her right to refuse. Police took handcuffs off patient at this time. I attempted to placate patient and explain the risks and benefits of treatment versus going AMA. I educated the patient on her right to go against medical advice if she wished. Police contacted their supervisor for clarity. Informed police he must stay with patient while she is still here. Police said he could not stay with patient for us to conduct testing and that he would take her with him to another facility. Patient escorted off campus in handcuffs by police."

Interview on 11/29/ during the entrance conference and ongoing during the survey process with the facility Director of Clinical Outcomes revealed but was not limited to the following: "She indicated that police officers from surrounding jurisdictions often bring patients into the facility emergency room on an emergency detention order due to mental health issues. She stated the emergency department provides a medical screening exam and treatment to the extent that is available in the emergency department. She stated the facility does not have mental health beds. She stated the emergency department physician orders a psychiatric evaluation of the patient and that is provided by telemedicine. She stated that if it is determined by the telemedicine psychiatrist that these patients need inpatient mental health treatment, they are transferred to an inpatient mental health facility as soon as a bed is available. Continued interview with the Director of Clinical Outcomes confirmed the police officer who brought Patient #1 to the emergency department was not willing to remain in the emergency department with Patient #1 until her psychiatric evaluation could be completed. She stated the facility does not have the authority to hold the patient if the patient does not want to remain in the emergency department to complete a psychiatric evaluation. She stated the facility security guards are not police officers; therefore, they do not have the legal authority to enforce the emergency detention order. She stated they do not restrain a patient who is on an emergency detention order if police have left. They allow the patient to leave and then call the police She described this as an ongoing issue when police officers bring patients into the emergency department on an emergency detention order who need a medical/psychiatric screening and/or treatment and the police officer refuses to stay with the patient. She stated the facility has consulted with their corporate attorney regarding this issue but they have not received an answer to the issue at this point in time."