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.

BARNES JEWISH HOSPITAL ONE BARNES-JEWISH HOSPITAL PLAZA SAINT LOUIS, MO 63110 April 28, 2020
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interview, record review, and policy review the hospital failed to provide a complete Medical Screening Examination (MSE) to one patient (#21), within the hospital's capability to determine if an Emergency Medical Condition (EMC) existed during an Emergency Department (ED) visit. There were 30 patients' medical records reviewed who presented to the hospital's ED seeking care, out of a sample selected from October 2019 to April 2020. As a result of not providing a MSE sufficient enough to determine the presence of an EMC, within 20 minutes of the patient's discharge, Patient #21, was seen falling from the eighth level of a parking garage and died . This failure had the potential to affect all patients who presented to the ED. The hospital's ED had an average of 7,590 emergency visits per month and of those visits, an average of 724 per month were psychiatric patients.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," dated 08/2019, showed that:
- Individuals will receive an appropriate MSE by qualified medical personnel as determined by the hospital's board of directors.
- A MSE is an examination sufficient enough to reasonably indicate the presence or absence of an EMC.
- The MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether or not an EMC exists.
- Psychiatric patients who are suicidal or homicidal are considered unstable.

Review of the hospital's policy titled, "Suicide Precautions," dated 08/2019, showed that:
- All patients in the ED who are being evaluated or treated for behavioral health conditions as their primary reason for care, will be screened for Suicidal Ideation (SI, thoughts of causing one's own death).
- A Registered Nurse (RN) is to assess patients for other symptoms that may affect the patient's behavior health condition, which includes the ability to cooperate and cognitive ability.
- The patient's mood and pertinent verbatim statements should be documented in the Electronic Medical Record (EMR).

Review of Patient #21's 04/16/2020 EMS (emergency medical services) run report showed that the ambulance crew member documented they were dispatched because a male was walking naked on a bridge and that local law enforcement on the scene reported that "patient has not talked to any responders and has just looked at them." The ambulance crew member documented "Psychiatric Problems" as the primary complaint. Further documentation showed the ambulance crew member asked the patient if he would be willing to go to the hospital ED and the patient stated "Don't give me choices," and that "any information he gives will be totally wrong." The ambulance crew member documented they asked the patient "why he would want to give EMS the wrong information , but patient just looks at EMS, smiles, and then looks away." Further documentation showed the ambulance crew member's "Impression" was "Suicidal ideations." "Upon arrival at Barnes Jewish Hospital, security met EMS at doors and escorted EMS and patient to the behavioral health unit at Barnes-Jewish's emergency room ." The ambulance crew member documented they arrived at the ED at 4:04 PM.

Review of Patient # 21 04/16/2020 medical record showed that he arrived in the ED at 4:11 PM. Documentation labeled "ED Provider Note" showed that the patient presented to the ED "by EMS for bizarre behavior." "Reportedly found by bystanders naked on a bridge." "Will not give history, states 'Anything I say will be the wrong answer.'" "Will not give name, age, circumstances." "At times endorses intent to kill himself." Further documentation showed "Unable to perform ROS [review of systems]." "Mental status change." Further documentation showed the patient was found to be intoxicated (to be affected by alcohol or drugs where physical and mental control is markedly diminished) with methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) and fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use) and that the plan was to discharge when he sobered up. The patient was assessed by the primary ED RN/triage RN, and refused to give any information about himself or his history and was made a "Doe" (a name assigned to an unidentified patient), in the electronic medical record (EMR). The patient answered no questions in triage that related to suicidal or homicidal thoughts. The patient continued to make comments that were bizarre, would inappropriately laugh or giggle at times, and then he would have a flat affect (absence or near absence of emotional expression). The patient became agitated at one point which required the use of medications to chemically restrain him. The next morning 04/17/2020 the ED physician determined the patient was awake and sober. The hospital did not perform a psychiatric examination to determine patient # 21's suicidality prior to discharge. The hospital's capabilities included an on-call psychiatrist and 40 available psychiatric inpatient beds.

During a telephone interview on 04/28/20 at 4:00 PM, Staff Q, ED RN, stated that:
- She assisted the patient to the restroom and she saw him on the ground, cradling himself like a baby, and could hear him as he talked to himself, "You know you don't want to hurt anyone," a statement the patient had repeated a couple times.
- She was asked by the patient, "What do you think happens when you die?"
- She found that question somewhat odd, but it was not reported to the physician.

During a telephone interview on 04/27/20 at 3:35 PM, Staff J, ED Physician, stated that he asked all the questions of what happened, why his clothes were off, etc. There was never a report of SI or that he had tried to jump off the bridge and he refused to answer any of the questions; in retrospect, Patient #21 was on a bridge.

During a telephone interview on 04/28/20 at 9:15 AM, Staff N, ED Physician, stated that if a patient had a diagnosis of a mental illness or a previous psychiatric admission, this would have been approached differently after the patient reached sobriety, which may have included a psychiatric consult; they had no medical history for this patient because he had refused to answer any questions and there was no EMR found for any previous visits.

During a telephone interview on 04/29/20 at 3:00 PM, both Staff V, Psychiatry Chair Physician, and Staff U, Psychiatry Vice-Chair Physician, were present; Staff U, stated that:
- He agreed that a patient may have said they were suicidal while intoxicated because their inhibitions were down and may have not said it when they were sober and had a clear mind for fear that someone may have taken their statement seriously and possibly taken action to keep them safe.
- If a patient had posed the question to a nurse, "What do you think happens when you die?" He would have found that statement worrisome and would have expected that nurse to have reported that to the attending physician.
- He agreed that just because a patient did not have a previous history of a mental health issue, did not mean they did not have one; every patient had to have had their "first episode" or time to have been seen.

Review of the on call log showed a psychiatric physician was on call on 04/16/20 and 04/17/20, when the patient was treated and discharged from the ED. The hospital had the capability to provide psychiatric services to individuals evaluated in the ED that presented with a mental health concern. The hospital chose to discharge Patient #21 in care of himself without a psychiatric evaluation.

Please refer to 2567 for details.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interview, record review, policy review, and review of video surveillance, the hospital failed to provide a complete Medical Screening Examination (MSE) to one patient (#21), within the hospital's capability to determine if an Emergency Medical Condition (EMC) existed during an Emergency Department (ED) visit. There were 30 patients' medical records reviewed who presented to the hospital's ED seeking care, out of a sample selected from October 2019 to April 2020. As a result of not providing a MSE sufficient enough to determine the presence of an EMC, within 30 minutes of the patient's discharge, Patient #21, was seen falling from the eighth level of a parking garage and died . This failure had the potential to affect all patients who presented to the ED. The hospital's ED had an average of 7,590 emergency visits per month and of those visits, an average of 724 per month were psychiatric patients.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," dated 08/2019, showed that:
- Individuals will receive an appropriate MSE by qualified medical personnel as determined by the hospital's board of directors.
- A MSE is an examination sufficient enough to reasonably indicate the presence or absence of an EMC.
- The MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether or not an EMC exists.
- Psychiatric patients who are suicidal or homicidal are considered unstable.

Review of the ED's policy titled, "Triage," dated 01/2019, showed that:
- The ED should involve other health team members as appropriate.
- Patients that are assigned as a level two acuity are determined to have a high risk situation that includes, danger zone vital signs, a new onset of confusion, and disorientation.
- There should be documentation of nursing care provided, assessment including all pertinent information related to the patient's visit.

Review of the hospital's policy titled, "Suicide Precautions," dated 08/2019, showed that:
- All patients in the ED who are being evaluated or treated for behavioral health conditions as their primary reason for care, will be screened for Suicidal Ideation (SI, thoughts of causing one's own death).
- A Registered Nurse (RN) is to assess patients for other symptoms that may affect the patient's behavior health condition, which includes the ability to cooperate and cognitive ability.
- The patient's mood and pertinent verbatim statements should be documented in the Electronic Medical Record (EMR).

Review of the police report, dated 04/17/20, showed that St. Louis Police Department (STLPD) documented that, STLPD, District Four had received approximately four radio assignments on 04/16/20 at approximately 3:24 PM for a white male that was, "taking off his clothes and crying in traffic on the Poplar Street Bridge." Patient #21 was transported at that time by ambulance to BJH's ED for treatment.

Review of the ambulance crew's emergency medical services (EMS) Care Summary, dated 04/16/20, at 3:48 PM, showed that EMS arrived on the scene and found that Patient #21 was sitting on the side of the outside lane, leaned against the median, with no clothes on, and wrapped in a plastic sheet. When the patient was asked questions by the EMS staff and the police on the scene, the patient would not respond and would look away. When the EMS staff and the police asked Patient #21 if he was willing to be taken to the hospital, the patient told them, don't give me choices. In route to BJH, the patient states, that any information he provided would have been totally wrong. When asked why he would give the wrong information to EMS, the patient smiled and looked away. When EMS assessed the patient, he was found to have dilated, non-reactive pupils, and was tachycardic with a heart rate of 140 beats per minute (bpm). EMS was instructed to take the patient to the Psych Pod (a locked unit within the ED for treatment of psychiatric patients) of the ED. A verbal report was given to an ED nurse. The dispatch reason documented on the report was, psychiatric problem/abnormal behavior/suicide attempt. The impression indicated on the EMS Care Summary was, "suicidal ideations."

Review of Patient # 21 04/16/2020 medical record showed that he arrived in the ED at 4:11 PM. Documentation labeled "ED Provider Note" showed that the patient presented to the ED "by EMS for bizarre behavior." "Reportedly found by bystanders naked on a bridge." "Will not give history, states 'Anything I say will be the wrong answer.'" "Will not give name, age, circumstances." "At times endorses intent to kill himself." The patient was found to be intoxicated (to be affected by alcohol or drugs where physical and mental control is markedly diminished) with methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) and fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use). The patient was assessed by Staff H, ED RN/Triage RN, and refused to give any information about himself or his history and was made a "Doe" (a name assigned to an unidentified patient), in their electronic medical record (EMR). The patient answered no questions in triage related to SI or homicidal ideations (HI, thoughts or attempts to cause another's death). Patient #21 stated to Staff H, "I will give you the worst answer for every question," and laughed inappropriately. A psychosocial assessment, performed by Staff H while the patient was intoxicated, showed that the patient had an anxious facial expression, was guarded and withdrawn, his behavior exhibited disorganization and paranoia (excessive suspiciousness without adequate cause) and interaction was minimal. There was documentation by both Staff J, ED Physician and Staff R, ED Resident Physician, that showed the patient's behavior as, "intermittently crying, responding to internal stimuli, kneeling down and praying," and the patient stated, "Anything I say will be the wrong answer." A psychiatric consult was mentioned initially by Staff J, ED Physician, if the patient's behavior was not improved when he reached sobriety. A psychiatry consult was never mentioned again within the patient's EMR. The patient required chemical restraints after an episode of severe agitation where he swung a pole used to hold medications and intravenous (IV, in the vein) fluids, and broke a fire alarm light. Staff P, ED RN, documented just prior to the patient's discharge, the patient was tearful and said, "I am just thinking of the bad choices that led me here." Staff L, Social Worker (SW), made a visit and provided the patient with clothes, transportation to an Illinois rest stop, and homeless resources, but did perform a mental health examination to assess the patient for depression or thoughts of suicide or homicide prior to discharge. The patient was repeatedly assessed as not having SI prior to becoming sober.

During a telephone interview on 04/30/20 at 1:35 PM, Staff W, emergency medical technician (EMT), stated that:
- She recalled the patient that they were dispatched to that was reportedly naked on a bridge.
- Upon their arrival to the scene, they found Patient #21 naked and wrapped in a yellow plastic sheet, sat on the ground, on the inside of the bridge and against a two foot concrete barrier.
- The patient was cradling himself like a baby and they got down to his level and attempted to speak to him, but he refused to talk.
- The patient was placed on a stretcher, put in the ambulance, and taken to BJH ED, where they were instructed to take the patient to the Psych POD for assessment.

During a telephone interview on 04/30/20 at 1:40 PM, Staff X, EMT, stated that:
- She recalled the patient that they were dispatched to that was reportedly naked and walking on a bridge.
- Her role was in the back of the ambulance to care for the patient, but that she also assessed the patient at the scene.
- Upon their arrival the patient was seen sitting on the side of the bridge, against a concrete barrier, naked and wrapped in a plastic sheet, cradling himself like a baby.
- When they attempted to ask the patient questions, he looked away and refused to answer.
- When she asked the patient if he wanted to go to the hospital, the patient replied, "You shouldn't give me choices."
- He was noted to have had tears in his eyes, but was not actually crying.
- When she assessed the patient in the back of the ambulance, the patient was found to have been tachycardic.
- She reported all of the patient's comments and behavior to the ED nurse when they arrived with the patient.
- Her impression was that something was just not right, that she had seen this type of behavior with someone on drugs where they were not aware of what they were doing, but this felt different by the way he acted; she felt the patient could have wanted to use the bridge to hurt himself.

The ED Triage Note, dated 04/16/20 at 4:16 PM, showed that the patient arrived to the ED via EMS after he was found on a bridge, naked, sitting on the ground. The Illinois Department of Transportation (IDOT) called the report into the police. The patient refused to answer any questions for the ED staff. Staff H, ED RN/Triage RN, was unable to assess for any SI or HI, due to the patient's refusal to answer any questions. The patient was assigned as a level two acuity (determined to have a high risk situation) and was made an elopement (when a patient makes an intentional, unauthorized departure from a medical facility) risk.

During an interview on 04/27/20 at 1:53 PM, Staff H, ED RN/Triage RN, stated that:
- She recalled that Patient #21 stated, "I don't know the answers to the questions," and "I'm going to give you the worst answers."
- When she asked the patient about SI and HI, the patient giggled and did not give a verbal answer.
- He made odd and bizarre comments and then said, "I don't know."
- He knelt on the floor as if he were praying, then got back up and sat on the bed.
- If a nurse assessed a patient with a questionable behavior, a patient's statement, or something a nurse observed that was of concern, a physician would have listened to the nurse's concern and could have changed the treatment plan if they felt it was necessary.

The ED Provider Note, dated 04/16/20 at 4:20 PM, documented by both Staff J, ED Physician, and Staff R, ED Resident Physician, showed that the patient came in with a chief complaint of bizarre behavior and was found by bystanders naked on a bridge. The patient refused to give any history and had stated that, "Anything I say will be the wrong answer." The patient refused to give his name, age, or circumstances of the events that occurred. The note showed, "At times endorses intent to kill himself." During the patient's review of systems (ROS), the patient was found to have been tachycardic, alert and oriented to person, place, and time. Speech was documented as, "non-communicative." Assessment of behavior showed the patient was not agitated and was "cooperative, briskly awake and alert, nonverbal other than brief statements, and speech was not pressured, rapid." At 4:28 PM, the Provider Note was updated with an assessment of behavior that documented, "intermittently crying, responding to internal stimuli, kneeling down and praying." Per the medical decision making (MDM), the impression was that the patient's bizarre behavior was a drug induced mania or psychosis (a disorder characterized by false ideas about what is taking place or who one is) and a psychiatry consult was to have been considered.

During a telephone interview on 04/27/20 at 3:35, Staff J, ED Physician, stated that:
- He recalled the patient that had come in by EMS after he was found naked on a bridge.
- The patient had presented with bizarre behavior and refused to answer any questions; he was unsure how much the patient was unable to answer or just unwilling to answer.
- The patient was in a "zone" from substance intoxication.
- The patient refused to give his name, any medical history, or an explanation of the circumstances.
- The patient would inappropriately and intermittently laugh and then weep; at one point, the patient was on his knees praying.
- He may have said something to EMS about SI or HI, but he had denied SI and HI every time he was asked by all of the providers at the hospital.
- The patient had laughed and said, "Anything I tell you is going to be wrong," so he felt that anything given by the patient would have been unreliable.
- The patient had tested positive for methamphetamine and fentanyl.
- When a patient was deemed no longer intoxicated, the patient would have been reassessed again and determined if a psychiatric consult was appropriate.
- He asked all the questions of what happened, why his clothes were off, etc. There was never a report of SI or that he had tried to jump off the bridge and he refused to answer any of the questions; but in retrospect, Patient #21 was on a bridge.

During a telephone interview on 04/28/20 at 4:50 PM, Staff R, ED Resident Physician, stated that:
- His documentation on 04/16/20 at 4:20 PM that included, "At times endorses intent to kill himself," came from a conversation with EMS; he had not heard the patient say that to him directly.
- The patient's thoughts were disorganized and he had delirium for sure.
- The primary driver was substance abuse and wait until the patient is sober to call psych.

During a follow up telephone interview on 04/28/20 at 4:25 PM, Staff J, ED Physician, stated that:
- Staff R, ED Resident Physician, never told him that the patient, "At times endorses intent to kill himself"; he assumed that may have been reported by EMS when they arrived to the ED.
- The patient's behavior was erratic, evasive, and difficult at times, which he seemed like he enjoyed.
- Some patients have said things when they were intoxicated, and then would take it back when they became sober.
- It concerned him, "That a patient may say only what I want to hear when they are sober; we have to make judgements."

ED Physician Re-evaluation Note, dated 04/16/20 at 10:38 PM, Staff J, ED Physician documentation showed a summary of the assessment made when the patient had arrived to the ED as well as showed, "At times endorses intent to kill himself." Significant labs and vital signs were documented as, a urine drug screen positive for methamphetamine and fentanyl and the patient continued to be tachycardic with a HR of 110 bpm. There was no reassessment of SI or HI documented.

The ED Physician Re-Evaluation Note, dated 04/17/20 at 5:58 AM, Staff I, ED Physician documented that the patient conversed normally, did not recall the night prior and the plan was an anticipated discharge later that morning. There was no reassessment of SI or HI documented.

Review of the ED Physician Note, dated 04/17/20 at 6:17 AM, Staff I, ED Physician documented that the patient was observed for intoxication with fentanyl and methamphetamine. Patient #21 was initially cooperative, then became agitated and damaged a light in his room by waving the IV pole around. The patient was given medication that calmed and sedated him, then he was placed in seclusion. The patient eventually calmed and was moved out of seclusion to a patient room. The patient was assessed by Staff I as calm and cooperative when awake, otherwise was tired, but woke easily. The patient was alert and oriented to person, place, and time and had, no SI, HI, or hallucinations. A differential diagnosis was given as, "high probability of possible substance abuse (PSA) with intoxication and a low probability of self-harm risk, psychosis." The patient was unable to remember the events of the night prior that had brought him into the ED. The plan documented was to have given the patient a meal and fluids, complete a reassessment for sobriety and gait, with an anticipated discharge later that morning.

During a telephone interview on 04/27/20 at 2:50 PM, Staff I, ED Physician, stated that:
- The patient was found on a bridge but there was no indication that he had planned to jump.
- As a general rule, a psychiatric consult would not have been placed until reassessment of the patient was made after sobriety was reached; patients have said things when they were intoxicated and then when they became sober, the statements would have been denied and they were not sure why they had made them.
- Patients that come in intoxicated, either on drugs or alcohol, would not have automatically received a psychiatric consult; they would have been reassessed after they had become sober, and if the symptoms had resolved, they would have been discharged .
- The patient may have been assessed differently if they had reports from family that the patient had talked about suicide for days prior, had a psychiatric history, or had previous high risk behaviors; we had no medical or psychiatric history for this patient.
- The patient was tired and tearful, but no obvious signs of depression.
- There were no red flags seen for this patient, he seemed safe to have gone home.

ED Physician Re-Evaluation Note, dated 04/17/20 at 7:06 AM, Staff N, ED Physician, documented that the patient was seen for, "intoxicated on meth and opioids, needs sobriety." There was no reassessment of SI or HI documented.

ED Nurse Note, dated 04/17/20 at 10:13 AM, Staff P, ED RN, documented that the patient was alert and oriented to person, place, and time, and that the patient was tearful and stated, "I am just thinking of the bad choices that led me here." The patient stated to Staff P, that his immediate goal was to make his way to Las Vegas to start a new life. There was no reassessment of SI or HI documented.

During an interview on 04/28/20 at 10:10 AM, Staff P, ED RN, stated that:
- The patient woke when he had taken his vital signs at the start of his shift; the patient became tearful and stated that he was upset about the choices he had made that brought him to the ED.
- The patient had planned to start a new life in Las Vegas and seek a better future.
- He was unsure if those plans were realistic and asked the patient how he would have gotten there, and the patient replied, "By bus."
- Initially the patient was tearful.
- The protocol was for the patient to have become sober before a reassessment was performed and it was determined if a patient required a psychiatric consult; you would not have gotten true answers from a patient that was intoxicated.
- He assessed the patient for SI prior to discharge (this was not documented).

During a telephone interview on 04/28/20 at 4:00 PM, Staff Q, ED RN, stated that:
- She recalled the patient had said, "Whatever I say is not right, I'm always wrong."
- She assisted the patient to the restroom, where there was a little hole that staff used to visualize patients to keep them safe. She saw him on the ground, cradling himself like a baby, and could hear him as he talked to himself, "You know you don't want to hurt anyone," a statement the patient had repeated a couple times.
- She was then asked by the patient, "What do you think happens when you die?"
- She found that question somewhat odd, but it was not reported to the physician; she thought Staff H was aware of the patient's statement.
- Psychiatric consults were not typically placed until a patient was sober and could have had a meaningful conversation.
During a telephone interview on 04/28/20 at 3:40 PM, Staff O, ED RN, stated that:
- He recalled the patient and that it was reported to him that he had come in by EMS after he was found running naked on a bridge.
- He never received a report that the patient was ever suicidal.
- He initially assessed the patient and he had denied SI and HI (this was not documented) and he had only endorsed drug usage, but gave little detail.
- There was very little conversation and the patient only gave one or two word statements; it was difficult to have gotten anything out of him.
- The process was to await for sobriety in a patient prior to the assessment for a psychiatric consult.

Progress Note, dated 04/17/20 at 10:25 AM, Staff L, SW, showed that SW had responded to the patient's bedside
and assisted with discharge planning. The patient reportedly engaged with her minimally and stated that he planned to meet a friend at a rest stop in Illinois after he was discharged . The patient refused to share if he had any type of support system or where he had stayed prior to his ED visit. The SW provided the patient with a bus pass and a list of homeless shelters. There was no documentation of an SI or HI assessment at the time SW had visited just prior to the patient's discharge.

During a telephone interview on 04/27/20 at 4:40 PM, Staff L, SW, stated that:
- She recalled the patient; she had received a consult to assist with discharge planning and was told he was homeless, needed clothing, and transportation.
- He had refused to tell her anything about any support systems he had, family, or where he lived prior to his ED visit; he would not give any previous addresses.
- He told her he had planned to meet a friend at a rest stop in Illinois and needed a ride there.
- The ED physicians would usually listen to a SW if we went to them with an assessment that concerned us about a patient's discharge or wellbeing.
- She did not assess the patient for SI or HI prior to his discharge.

During a telephone interview on 04/28/20 at 9:15 AM, Staff N, ED Physician, stated that:
- He recalled the patient that had come in by EMS and reportedly had been found naked on a bridge with bizarre behavior.
- He had cared for the patient the morning that he was discharged .
- It was not their practice to get psychiatry involved until the patient had become sober and was reassessed, then it would have been determined if the patient required a psychiatric evaluation (there was no documentation after sobriety was reached that showed Patient #21 was reassessed and determined to not require a psychiatric evaluation).
- The ED has seen a lot of patients that were intoxicated that have said they had SI or HI, but that would have been questionable if the patient was intoxicated because those statements were so common.
- If a patient had a diagnosis of a mental illness or a previous psychiatric admission to a hospital, this would have been approached differently after the patient reached sobriety; maybe a psychiatric consult, but a psychiatric admission would have been doubtful with his denial of SI, HI, and depression.
- If a SW had assessed a patient prior to their discharge and felt something was off or they had a concern, the ED physician would have possibly changed their plan; SW was often good at the retrieval of pertinent information from a patient, but there was no report from the SW that she was concerned after her visit.

During a telephone interview on 04/27/20 at 4:25 PM, Staff K, PCT, stated that the patient had a flat affect and did not say anything when they walked to the front door.

Review of the hospital's video surveillance on 04/17/20, post discharge, showed the patient walk from the front door of the ED, through the grounds of BJH, and eventually ended at a BJH parking garage about an half mile away from the hospital. The patient was not visible again until the video showed him falling to the ground outside the garage approximately 30 minutes after he was discharged from BJH ED.

During an interview on 04/27/20 at 2:00 PM, Staff E, ED Executive Director, stated that:
- When staff were given his name, as reported by the patient, the patient could not be found in their EMR or in the Care Everywhere system, therefore, there was no past medical or psychiatric history for the patient that could have been used to treat him;
- If a patient presents with bizarre behavior, which may or may not have included SI, and was intoxicated, the protocol was to wait for the patient to have reached sobriety and was reassessed before an order for a psychiatric consult was made.
- He felt his staff and physicians followed their standard of care and procedures for any patient that came into the ED and was determined to be intoxicated.

During an interview on 04/27/20 at 2:35 PM, Staff A, Director of Regulatory Risk Management and Patient Safety, stated that when the event was investigated, it was found that the staff followed the protocol and waited for the patient to have reached sobriety before a reassessment was completed; it was determined that the patient required no psychiatric evaluation.

During a joint telephone interview on 04/29/20 at 3:00 PM, Staff V, Psychiatry Chair Physician, and Staff U, Psychiatry Vice-Chair Physician, staff U stated that:
- Protocol for a psychiatric consult would have been determined after reassessment of a patient when the patient had reached sobriety.
- Patients have said things when they were intoxicated that they would not have said when they were sober, therefore re-evaluations were to have been performed after sobriety was reached; he agreed that a patient may have said they were suicidal while intoxicated because their inhibitions were down and may have not said it when they were sober and had a clear mind for fear that someone may have taken their statement seriously and possibly taken action to keep them safe.
- If the attending physician felt there was an underlying reason or condition, a psychiatric consult would have been appropriate.
- If a patient had posed the question to a nurse, "What do you think happens when you die?" He would have found that statement worrisome and would have expected that nurse to have reported that to the attending physician.

Review of the police report, dated 04/17/20, showed that:
- Video surveillance of the patient leaving BJH ED through to the arrival to the BJH parking garage, was reviewed by police.
-"Witnesses" were interviewed by police and it was determined that no one saw the patient in the garage and he was not seen until he was falling from the garage to the ground.
- The incident was classified as, "Noncriminal Incident - Suicide."
- When the patient was looked up in the Regional Justice Information System (REJIS), provides a nationwide data base to the state of Missouri and Illinois and gives a rapid access to any criminal history and possible verification of a person's identity), Patient #21's information was unable to be found and verified.
- An addendum, dated 04/21/20, was attached at the end of the police report and indicated the medical examiner had contacted STLPD by email to inform them he had identified the victim by fingerprints.

The hospital failed to provide Patient #21 with a MSE within its capabilities and capacity for a patient that presented with bizarre behavior after he was found naked on a bridge and reportedly, "At times endorses intent to kill himself," the insufficient MSE did not include a mental health evaluation after the patient became sober, even though the hospital had the capabilities of an on-call psychiatrist to perform the mental health examination. As the result of the hospital not providing a complete MSE to identify an EMC existed, within approximately 20 minutes of the patient's discharge from the ED, the patient was seen falling from the eighth floor of a parking garage and died .



Please refer to the 2567 for details.