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.

OZARKS MEDICAL CENTER 1100 KENTUCKY AVE WEST PLAINS, MO 65775 Aug. 8, 2019
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and policy review, the facility failed to follow policy and provide within its capability, an adequate Medical Screening Exam (MSE) on two separate Emergency Department (ED) visits for one patient (#22) of 22 ED records reviewed from February 2019 through August 2019. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an Emergency Medical Condition (EMC). The ED had an average of 2352 visits per month.

Findings included:

1. Review of the facility's policy titled, "Emergency Medical Treatment & Active Labor Act," revised 12/2005 showed the following:
- An EMC is a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, psychiatric (relating to mental illness) disturbances and/or symptoms of substance abuse (misuse of alcohol and other drugs), such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy.
- A MSE is the process required to reach, with reasonable clinical confidence, the point at which a medical emergency does or does not exist.
- A screening exam in the ED includes all necessary and available testing and use of on-call services to determine the presence or absence of an EMC.
- Patients will not be denied evaluation, treatment or stabilization on the basis of their presenting complaint or condition.

Review of the facility's policy titled, "Suicide (to cause one's own death) Risk Assessment," dated 07/2016, showed the following directives for staff:
- Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide.
- Address the patient's immediate safety needs and most appropriate setting for treatment.
- When a patient is at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as a crisis hotline) to the patient and his or her family.
- All patients who present to the facility for treatment are screened for risk of suicide according to the suicide assessment (evaluation used to determine suspected suicide risk) trigger question protocol.
- Three trigger questions are asked, "Have you had little interest or pleasure in doing things over the past two weeks?" "Have you been feeling down, depressed [extreme sadness that doesn't go away] or hopeless over the past two weeks?" and "Have you had suicidal thoughts?". A positive response to the trigger questions will prompt a Columbia Suicide Severity Rating Screen (C-SSRS, a tool used to assess the severity of suicidal ideation [SI, thoughts of causing one's own death] and behavior).
- Affirmative responses to questions asked on the C-SSRS direct staff to provide patients with a referral to Behavioral Healthcare (BHC) or psychiatric review.
- If Psychiatric Review is indicated, options were to contact the BHC crisis office, psychiatric consult or admit to the psychiatric unit.

Review of the facility's policy titled, "Suicide Precaution and 1:1 Continuous Observation," dated 10/2018, showed the following:
- An RN may initiate suicide precautions based upon assessment and the order is obtained from a physician as soon as possible.
- Patients at risk for suicide are placed in an appropriate care area with continuous direct observation by appropriately trained staff.
- Patients are undressed and placed in a hospital gown after completing a skin assessment.

Review of the facility's document titled, "Hospital Database Worksheet," revised 08/06/19, showed the facility's capabilities included a psychiatric adult inpatient unit and psychiatric outpatient services.

Review of the facility's document titled, "On-Call List," showed that Psychiatry was listed as one of the specialties available for consultation.

Review of the facility's policy titled, "Leaving Against Medical Advice (AMA)," dated 11/2014, showed that the hospital has a duty to warn the patient of the risks entailed in leaving before it is medically indicated. If the physician is unable to convince the patient to stay, they will be asked to sign a waiver before leaving.

Review of Patient #22's ED records showed that this [AGE] year old male had presented to the ED four different times between 07/25/19 and 07/26/19.

Review of Patient #22's first ED encounter medical record, showed that he was a [AGE] year old male with a past medical history and problem list of neck surgery in 2017, mental illness, previous psychiatric treatment, depression, heart disease, stents in heart (a tiny wire mesh tube placed in a heart artery to keep it open), chest pain, hypertension (high blood pressure [BP, a measurement of the pressure of blood flow in two different parts of the heart, normal is approximately 90/60 to 120/80]) and hypotension (low blood pressure). He (MDS) dated [DATE] at 5:03 PM with head and neck pain and he rated his pain an eight out of 10. He had no previous ED encounters for neck or head pain. He answered no to all of the suicide assessment trigger questions. He was assessed by a nurse practitioner and was given 60 milligrams (mgs, a measure of dosage strength) of Toradol (nonsteroidal anti-inflammatory drug used to treat moderate to severe pain) intramuscular (IM, in the muscle) at 6:18 PM. He was discharged to home from the ED at 6:24 PM with a pain rating of six out of 10.

Review of the second ED encounter medical record, showed that on 07/25/19 at 10:25 PM, Patient #22 returned to the ED, accompanied by his spouse, with neck pain and back pain. The triage nurse documented that the patient was alert, but in distress. His blood pressure was 183/109, and his pain level was a 10 out of 10. The self-harm assessment was performed and the patient answered yes to feeling down, depressed or hopeless, noticing less interest or pleasure in doing things, having thoughts of harming or killing himself, and having dangerous items in his possession. He was evaluated by Staff R, ED Physician who documented that the patient wanted the pain to stop or he would stop it. At 11:18 PM Patient #22 was given Morphine (a narcotic used to treat moderate to severe pain) intravenous push (to manually administer a dose of medication through a tube into a vein), Reglan (a medication used to treat nausea and vomiting) IV push, and Benadryl (a medication used to treat allergy symptoms that also can cause drowsiness) IV push. On 07/26/19 at 12:30 AM, Patient #22 told Staff R he was not suicidal or homicidal (desire to harm or kill another person) and his pain was improved. He was stable for discharge with a pain level of three out of 10, and he was discharged from the ED with a prescription for Robaxin (a medication use to treat muscle spasms and pain).

Review of the third ED encounter medical record, showed that on 07/26/19 at 3:25 PM, Patient #22 returned to the ED, accompanied by his spouse, and stated he was there for neck pain. His blood pressure was 196/109, with a pain level of eight out of 10. He answered no to all of the suicide assessment trigger questions. Documentation showed that on 07/26/19 at 4:39 PM, Patient #22 left AMA when he was told he would not receive narcotics.

Review of the fourth ED encounter medical record, showed that on 07/26/19 at 5:35 PM, Patient #22 was found unresponsive in the parking lot, in front of the emergency room door, with blunt trauma from a self-inflicted gunshot wound. He was pronounced dead on 07/26/19 at 5:42 PM.

During an interview on 08/07/19 at 4:15 PM, Staff R, ED Physician, stated the following:
- He saw Patient #22 on 07/25/19 and asked him twice if he was suicidal and he said no.
- He asked Patient #22 if he wanted to be admitted to the Psychiatric unit and the patient said no (this was not documented in the medical record).
- He looked at a patient's history prior to examining them.
- He knew about Patient #22's history of depression.
- When a patient stated they would harm themselves, it was a red flag for physicians.
- He did not feel that Patient #22 was a threat to himself.

During an interview on 08/07/19 at 9:30 AM, Staff M, ED Physician, stated the following:
- He was trained not to look at a patient's previous visits and only looked at previous visits if the patient could not give a good history.
- He typically read the triage and nursing notes, would get his scribe and go into the patient's room.
- He did not know about Patient #22's previous psychiatric history.
- Patient #22 did not want to see a Nurse Practitioner because only certain medications would help his pain, and a nurse practitioner could not give him those.
- Patient #22 did not say what those medications were.
- He never got the chance to determine if Patient #22 needed a MSE.
- He never got a chance to examine Patient #22.
- He told Patient #22 that the ED did not prescribe narcotics for chronic pain control.
- When Patient #22 informed Staff M that he was leaving, Staff M said "Ok," and walked out of the room.

During an interview on 08/07/19 at 10:05 AM, Staff N, ED Medical Director, stated the following:
- Patient #22 was not a "frequent flier" (a patient that goes to the ED often).
- Patient #22 was always "super compliant."
- Psychiatry was on call 24 hours a day, seven days a week, but were primarily utilized for admissions.
- He would expect the ED Physicians to order a Psychiatric evaluation or admit patients if there were any question about suicidal ideation or other psychiatric issues.
- He would expect the ED Physicians to perform a thorough history and physical on each patient.
- He would expect the ED Physicians to look at a Patient's medical history prior to the examination.

During an interview on 08/07/19 at 5:00 PM, Staff S, Psychiatrist, stated the following:
- He was the on call psychiatrist on 07/25/19 and 07/26/19 for the ED and Psychiatric unit.
- The psychiatrists were on call 24 hours a day, seven days a week.
- He did not receive a phone call regarding Patient #22 on 07/25/19 or 07/26/19.
- A thorough and appropriate Mental Health Screen would consist of several personal questions and should cover means and opportunity for self-harm.

The facility had the capacity and capability to provide an adequate MSE for Patient #22 on two separate ED encounters and failed to follow their own internal policies. The facility's policy titled, "EMTALA," showed that an EMC includes severe pain, psychiatric disturbances and/or symptoms of substance abuse, such that the absence of immediate medical attention could place the health of the individual in serious jeopardy. A screening exam included all necessary and available testing and use of on-call services to determine the presence of an EMC and patients will not be denied evaluation and treatment on the basis of their presenting complaint or condition. Patient #22 presented on the first through third visits with severe pain, rating his pain from an eight to a 10 out of 10. There was no indication in the ED records during the first or second encounter, that diagnostic or laboratory studies were ordered or completed, related to the patient's presenting complaints. Additionally, on his second ED encounter, he had suicidal thoughts, Staff R, ED Physician, did not complete an adequate behavioral health screening exam and did not include the on call psychiatrist to determine the presence or absence of an emergency medical condition related to his psychiatric health. On Patient #22's third ED encounter he was denied evaluation and treatment because he stated he wanted medication that a nurse practitioner could not prescribe, and Staff M, ED Physician, told the patient that he would not give him narcotics for chronic pain. Staff M, informed the patient he would not receive any narcotics prior to doing a MSE to determine if Patient #22 had an EMC.

The facility's policy titled, "Suicide Risk Assessment," showed directive for staff to provide patients with a referral to BHC or psychiatric review if they answered yes to questions asked on the C-SSRS. On Patient #22's second ED encounter, he stated that he was suicidal to the triage nurse and he had a history of depression, mental illness and previous psychiatric treatment. The psychiatrist on call was not notified and the patient was not referred or given any information regarding his mental health.

The facility's policy titled, "Leaving AMA," showed that the hospital had a duty to warn the patient of the risks entailed in leaving before it was medically indicated and the physician should convince the patient to stay. On Patient #22's third ED encounter, Staff M, ED physician, did not inform the patient of any risks to leaving and did not convince him to stay.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and policy review, the facility failed to provide a complete Medical Screening Examination (MSE) within its capability and capacity to determine if an Emergency Medical Condition (EMC) existed on two separate Emergency Department (ED) visits for one patient (#22) of 22 patients who presented to the facility ED seeking care, out of a sample selected from February 2019 to August 2019. The ED had an average of 2352 visits per month.

Findings included:

1. Review of the facility's policy titled, "Emergency Medical Treatment & Active Labor Act," revised 12/2005 showed the following:
- An EMC is a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, psychiatric (relating to mental illness) disturbances and/or symptoms of substance abuse (misuse of alcohol and/or other drugs), such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy.
- A MSE is the process required to reach, with reasonable clinical confidence, the point at which a medical emergency does or does not exist.
- A screening exam in the ED includes all necessary and available testing and use of on-call services to determine the presence or absence of an EMC.
- Patients will not be denied evaluation, treatment or stabilization on the basis of their presenting complaint or condition.

Review of the facility's policy titled, "Suicide Risk Assessment," dated 07/2016, showed the following directives for staff:
- Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide (to cause one's own death).
- Address the patient's immediate safety needs and most appropriate setting for treatment.
- When a patient is at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as a crisis hotline) to the patient and his or her family.
- All patients who present to the facility for treatment are screened for risk of suicide according to the suicide assessment (evaluation used to determine suspected suicide risk) trigger question protocol.
- Three trigger questions are asked (1. Have you had little interest or pleasure in doing things over the past two weeks? 2. Have you been feeling down, depressed [extreme sadness that doesn't go away] or hopeless over the past two weeks? 3. Have you had suicidal thoughts?). A positive response to the trigger questions will prompt a Columbia Suicide Severity Rating Screen (C-SSRS, a tool used to assess the severity of suicidal ideation [SI, thoughts of causing one's own death] and behavior).
- Affirmative responses to questions asked on the C-SSRS direct staff to provide patients with a referral to Behavioral Healthcare (BHC) or psychiatric review.
- If Psychiatric Review is indicated, options are to contact the BHC crisis office, psychiatric consult or admit to the psychiatric unit.

Review of the facility's policy titled, "Suicide Precaution and 1:1 Continuous Observation," dated 10/2018, showed the following:
- An registered nurse (RN) may initiate suicide precautions based upon assessment and the order is obtained from a physician as soon as possible.
- Patients at risk for suicide are placed in an appropriate care area with continuous direct observation by appropriately trained staff.
- Patients are undressed and placed in a hospital gown.

Review of the facility's document titled, "Hospital Database Worksheet," revised 08/06/19, showed the facility's capabilities included a psychiatric adult inpatient unit and psychiatric outpatient services.

Review of the facility's document titled, "On-Call List," showed that Psychiatry was listed as one of the specialties available for consultation.

Review of the facility's policy titled, "Leaving Against Medical Advice (AMA)," dated 11/2014, showed that the hospital has a duty to warn the patient of the risks entailed in leaving before it is medically indicated. If the physician is unable to convince the patient to stay, they will be asked to sign a waiver before leaving.

Review of Patient #22's ED record showed that he had presented to the ED four different times between 07/25/19 and 07/26/19.

Review of Patient #22's first ED encounter medical record showed the following:
- He was a [AGE] year old male, with a past medical history and problem list of neck surgery in 2017, mental illness, previous psychiatric treatment, depression, heart disease, stents in heart (a tiny wire mesh tube placed in a heart artery to keep it open), chest pain, hypertension (high blood pressure [BP, a measurement of the pressure of blood flow in two different parts of the heart, normal is approximately 90/60 to 120/80]) and hypotension (low blood pressure).
- He (MDS) dated [DATE] at 5:03 PM with head and neck pain and he rated his pain an eight out of 10.
- There were no previous ED encounters for neck pain or head pain.
- He was assessed by a nurse practitioner and was given 60 milligrams (mgs, a measure of dosage strength) of Toradol (nonsteroidal anti-inflammatory drug used to treat moderate to severe pain) intramuscular (IM, in the muscle) at 6:18 PM.
- He was discharged to home from the ED at 6:24 PM with a pain rating of six out of 10.

Review of Patient #22's second ED encounter medical record showed the following Nursing Triage Documentation:
- He (MDS) dated [DATE] at 10:25 PM and was triaged at 10:46 PM
- His complaint was severe neck pain and back pain that started two days ago.
- At 10:46 PM, the patient's blood pressure was 183/109, and he rated his pain a 10 out of 10.
- He appeared to be in pain.
- The patient was seen in the ED earlier today (07/25/19 at 5:03 PM) for the same symptoms and the patient stated whatever they gave him did not help at all.
- A self harm assessment was performed and the patient answered yes to the questions "Have you recently felt down, depressed or hopeless?", "Have you noticed less interest or pleasure in doing things?", "Do you have thoughts of harming or killing yourself?" and "Do you have any dangerous items in your possession?"

Review of Patient #22's second ED encounter medical record showed the following Physician Documentation:
- The patient was seen on 07/25/19 at 11:00 PM by Staff R, ED Physician.
- The chief complaint was a headache that started two days ago and was still present.
- The patient rated the pain a 10 out of 10.
- The patient stated that he wanted the pain to stop or he would stop it.
- The patient stated that he had neck surgery at the base of his skull and had a history of pain.
- The patient stated he was not suicidal.
- A physical exam was completed and Staff R ordered Morphine (a narcotic used to treat moderate to severe pain) four mgs. intravenous push (IVP, to manually administer a dose of medication through a tube into a vein), Reglan (anti vomiting medication used to treat nausea and vomiting) 10 mgs IVP and Benadryl (a medication used to relieve symptoms of allergy, hay fever, common cold and also used to prevent and treat nausea, vomiting and as a sleep aid) 50 mgs IVP.
- These medications were administered at 11:18 PM by Staff K, ED RN.
- At 12:30 AM on 07/26/19 course of care was that the patient presented with a headache and neck pain, chronic in nature, the patient was not suicidal or homicidal (desire to injure or kill another person), and pain was improved. He was stable for discharge.
- He ordered a prescription for Robaxin (muscle relaxant) 750 mgs to be taken by mouth every six hours as needed for muscle spasm, for the patient to take at home.

There was no physician documentation of a behavioral health screening exam and no X-Rays or lab work were ordered.

Review of Patient #22's second ED encounter medical record showed the following Nursing Documentation:
- The patient was assessed on 07/25/19 at 11:06 PM by Staff K, ED RN.
- There was no documentation of suicide precautions (interventions used to provide a safe environment for patients identified as exhibiting suicidal behavior and/or ideations, which may include the patient changing into a hospital gown, personal belongings checked for weapons or other harmful items, assessing the patient's room for potentially harmful items and initiating continuous observation).
- The patient appeared to be in pain.
- Staff K administered the ordered medications of Morphine, Reglan and Benadryl at 11:18 PM.
- At 12:02 AM on 07/26/19, the patient's blood pressure was 166/81, and his pain level was a 3 out of 10.
- Staff K reviewed discharge instructions with Patient #22 and his wife, and provided information related to acute (sudden onset) headache and chronic (greater than six months, long term) neck pain.
- There was no assessment of suicide risk prior to discharge.
- He was discharged to home from the ED on 07/26/19 at 12:04 AM.

Discharge instructions did not include information on suicide or any referrals to behavioral health care.

There was no indication in the ED records for Patient #22's first or second encounter, that diagnostic or laboratory studies were ordered or completed, related to the patient's presenting complaints.

During an interview on 08/07/19 at 8:30 AM, Staff F, ED RN, stated the following:
- She was the triage nurse on 07/25/19 from 7:00 PM to 7:00 AM the following morning.
- Patient #22 appeared to be in pain.
- When Patient #22 answered yes to suicide assessment questions, she informed Staff R, ED physician, Staff K, ED RN assigned to Patient #22 and the charge nurse.
- The patient's wife informed her that she was concerned about her husband because he had been making comments of wanting to kill himself.
- She escorted Patient #22 and his wife to Room 9, which was a psych safe room (a room that has been cleared of any objects a patient might use to harm themselves or others), and Staff R met them at the door.
- He remained in street clothes, and was not placed in a hospital gown by ED staff.
- The ED physician made the decision on whether a patient needed to be admitted to the psychiatric unit. If a patient stated he wanted to hurt themselves and was a danger to himself, then that patient would need inpatient care.

During an interview on 08/07/19 at 8:00 AM, Staff K, ED RN, stated the following:
- He worked in the ED on 07/25/19 from 7:00 PM to 7:00 AM the following morning.
- Staff F triaged Patient #22 and was concerned about suicidal ideations.
- Psychiatry was on call 24 hours a day, seven days a week.
- He listened outside the closed curtain as Staff R, ED Physician, talked to Patient #22 and asked the patient if he was suicidal. The patient said he was hurting and wanted it to stop, but did not remember if the patient told Staff R if he was suicidal or not.
- He did not complete a suicide assessment while he took care of the patient, or before the patient's discharge.
- He gave the patient the ordered pain medications and when he reassessed him, Patient #22's pain was a 3 out of 10, and the patient hopped out of bed and moved with ease.

During an interview on 08/07/19 at 4:15 PM, Staff R, ED Physician, stated the following:
- He saw Patient #22 on 07/25/19 and asked him twice if he was suicidal, and he said no.
- He asked Patient #22 if he wanted to be admitted to the Psychiatric unit and the patient said no (This was not documented in the medical record).
- He knew about Patient #22's history of depression, because he reviewed a patient's histories before he examined them.
- When a patient stated they would harm themselves, it was a red flag for physicians.
- He did not feel that Patient #22 was a threat to himself.

During an interview on 08/07/19 at 5:00 PM, Staff S, Psychiatrist, stated the following:
- He was the on call psychiatrist on 07/25/19 and 07/26/19 for the ED and Psychiatric unit.
- The psychiatrists were on call 24 hours a day seven days a week.
- He did not receive a phone call regarding Patient #22 on 07/25/19 or 07/26/19.
- A thorough and appropriate mental health screen would consist of several personal questions and should cover means and opportunity for self-harm.

Review of Patient #22's third ED encounter medical record showed the following Nursing Triage Documentation:
- He (MDS) dated [DATE] at 3:26 PM and was triaged at 3:31 PM.
- His complaint was neck pain.
- The patient told the triage nurse that he went to a pain clinic but was let go for a "dirty pee test."
- At 3:31 PM, the patient's blood pressure was 196/109, and he rated his pain an eight out of ten.
- He was alert.
- This was a recurrent problem and there was no new injury.
- Columbia Suicide Severity Rating Screen was negative.

Review of Patient #22's third ED encounter medical record showed the following Physician Documentation:
- The patient was seen on 07/26/19 at 4:31 PM by Staff M, ED Physician.
- The chief complaint was neck pain and chronic neck pain that started today and was still present.
- The patient described the pain as moderate in the area of the cervical (the seven vertebrae that make up the neck) spine.
- Patient #22 left the ER AMA when he was told he would not receive narcotics.
- Patient #22 left in stable condition.
- Documentation was provided by a scribe (a person who transcribes information during clinical visits in real time into electronic health records under physician supervision). Information recorded by the scribe was reviewed and validated by Staff M, ED Physician on 07/26/19 at 7:23 PM.

Review of the facility's document titled Addenda for Patient #22 dated 08/07/19 showed that on 08/07/19 Staff M, ED Physician, reviewed the chart and realized that a physical exam had been documented. Patient #22 had left the ED while they were still in the "History" phase of his ED visit and therefore the physical exam was documented in error.

Review of Patient #22's third ED encounter medical record showed the following Nursing documentation:
- The patient was assessed on 07/26/19 at 4:39 PM by ED RN.
- Patient #22 appeared to be in pain.
- The patient left the ED against medical advice.
- Patient #22 was alert and oriented and coherent.
- Patient #22 notified the ED staff that he was leaving the ED (wanted narcotics).
- Prior to leaving the ED he was advised to return if needed.
- Patient #22 was informed of the risks of leaving and verbalized understanding of these risks.
- There was no indication that the patient's elevated blood pressure was reassessed.
- Patient #22 refused to sign a form prior to leaving the ED.
- Patient #22 left the ED by private vehicle.


During an interview on 08/07/19 at 11:30 AM Staff G, Chief Nursing Officer (CNO), stated the following:
- After an internal investigation and video review, the ED nurse who care for Patient #22 on 07/26/19 at 4:39 PM, had no interaction with Patient #22, and never entered into his room.
- On 07/26/19 at 4:39 PM, the RN assigned to care for Patient #22 documented a full physical exam but never actually saw Patient #22.
- The RN assigned to care for Patient #22 was terminated following their internal investigation for false documentation.
- His expectation for nursing staff would be to do an assessment on all patients, and not document things they did not do.
- His expectation would be the same for physicians, to document only what they performed.
- He would not expect a physician's physical examination to be documented if the physician did not have an opportunity to complete a MSE.

During an interview on 08/07/19 at 9:30 AM Staff M, ED Physician, stated the following:
- He remembered Patient #22 very well.
- He was trained not to look at patient's previous visits, and he only looked at previous visits if the patient could not give a good history.
- He typically read the triage and nursing notes, would got his scribe and went into the patient's room.
- He did not know about Patient #22's previous psychiatric history.
- He almost never consulted with psychiatry.
- Patient #22 did not want to see a Nurse Practitioner because only certain medications would help his pain, and a nurse practitioner could not give him those medications.
- Patient #22 did not say what those medications were.
- He told Patient #22 that the ED did not prescribe narcotics for chronic pain.
- He read the nursing triage note, which was why he went in and told Patient #22 the ED did not give narcotics for chronic pain.
- Patient #22 said there was no help there and he was leaving.
- Staff M did not offer Patient #22 any other suggestions or attempt to get him to stay, instead Staff M got up and left the room.
- He never did a MSE or physical exam on Patient #22.

During an interview on 08/07/19 at 10:05 AM, Staff N, ED Medical Director, stated the following:
- Patient #22 was not a "frequent flier" (a patient that goes to the ED often).
- Patient #22 was always "super compliant."
- Psychiatry was on call 24 hours a day, seven days a week, but they were primarily utilized for admissions.
- He would expect the ED Physicians to order a Psychiatric evaluation or admit patients if there were any question about suicidal ideation or other psychiatric issues.
- He would expect the ED Physicians to perform a thorough history and physical on each patient.
- He would expect the ED Physicians to look at a patient's medical history, prior to the examination, to verify if a patient had any mental health issues.

Review of the fourth ED encounter medical record, showed that on 07/26/19 at 5:35 PM, Patient #22 was found unresponsive for blunt trauma from a gunshot wound. He was found in the parking lot in front of the emergency room door with a self-inflicted gunshot wound from a handgun to the right and left temple. Patient #22 was pronounced dead on 07/26/19 at 5:42 PM.

The facility failed to provide Patient #22 with a MSE that included laboratory or radiology studies based on the patient's presenting complaints. Also, during the second ED encounter, the facility failed to provide an adequate MSE that included a mental health screening exam to rule out an EMC, after the patient expressed concerns about the potential for self harm, which was confirmed by the patient's spouse. The patient's care was compromised and he returned to the ED 15 hours later requesting help for pain. Again, the facility failed to provide Patient #22, during the third ED encounter, an adequate MSE. The patient left AMA, came back to the facility an hour later and committed suicide in the ED parking lot.