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.

Based on observation, interview, record review, policy review, and review of video surveillance, the hospital failed to follow their policies and did not provide one patient (#14) out of 31 sampled records reviewed between 09/21/20 to 02/22/21, with an appropriate (timely) medical screening examination (MSE). Review of hospital video showed that Patient #14 had an emergency medical condition based on a prudent layperson observer standard. Patient #14 appeared to have labored breathing and was wheeled outside the hospital by Staff M, Registered Nurse and Staff N, Patient Safety Officer, in 17 degree temperatures, wearing only a short sleeve t-shirt, to wait unattended for a medical screening examination. The patient remained outside and unattended over nine minutes. The patient was found unresponsive, and subsequently died after life saving measures were unsuccessful. The hospital also failed to provide a MSE within the capability of the hospital for one patient (#31), who presented to the hospital's ED seeking care for an emergency psychiatric (relating to mental illness) condition. Patient #31 presented twice on the same day with suicidal ideations (thoughts of causing one's own death) and a psychiatric consult was not completed prior to his discharge, to determine if an emergency medical conditions (EMC) existed. The hospital's ED average monthly census over the past five months was 5,853.

Please refer to A-2406 for details.

Based on observation, interview, record review, policy review, and review of video surveillance, the hospital failed to provide one patient (#14) out of 31 sampled records reviewed between 09/21/20 to 02/22/21, with an appropriate (timely) medical screening examinations (MSE), after he presented with an emergency medical condition (EMC). The patient repeatedly stated that he could not breathe, was placed outside in a t-shirt in 17 degree weather, left unattended, and died . The hospital also failed to provide one patient (#31) with an MSE within the hospital's capability, when the patient presented twice to the ED in one day with a psychiatric emergency. The patient reported that he wanted to kill himself, stating that he had a plan to jump off of a bridge or be struck by a car, and was discharged to himself on both presentations without a psychiatric evaluation. The hospital's Emergency Department (ED) average monthly census over the past five months was 5,853.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," dated 08/2019 showed:
- The hospital will attend to the emergency needs of patients who request, or by reasonable appearance, request such emergency care and/or treatment.
- Individuals who come to the ED and request examination or treatment will receive an appropriate medical screening examination (MSE) beyond medical triage (process of determining the priority of a patient's treatment based on the severity of their condition), provided by qualified medical personnel.
- The MSE was a means to determine if an EMC exists and is within the scope of the hospital's capabilities. Such a determination shall be provided to any individual regardless of financial status, race, color, national origin, or handicap.
- The MSE includes ancillary services routinely available to determine whether or not an EMC exists, and the ED must honor all requests for examination or treatment.
- An EMC is a medical condition manifesting itself by symptoms of [DIAGNOSES REDACTED]
- When an individual is determined to have an EMC, the hospital 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 hospitals nurse education document titled, "Emergency Medical Treatment and Labor Act (EMTALA)," dated 09/2020, showed the following:
- Hospitals were required to provide stabilizing treatment for patients with emergency medical conditions (EMC).
- EMTALA was a federal law that ensured everyone would receive a medical screening exam (MSE), and treatment of an EMC.
- The MSE was an examination sufficient enough to indicate the presence or absence of an EMC.
- A patient with suicidal (SI, thoughts of causing one's own death) or homicidal (HI, thoughts or attempts to cause another's death) thoughts/gestures and dangerous to themselves or others would be considered to have an EMC.

Review of the hospital's policy titled, "Triage," (process of deterring the priority of a patient's treatment based on the severity of their condition) dated 01/2019, showed the following:
- All patients who present to the ED would be assessed by a Registered Nurse (RN) in a prompt manner dependent upon the urgency of the patient's chief complaint, clinical status, initial findings and patient volume.
- Based upon the patient's chief complaint, a brief and/or comprehensive (subjective/objective) assessment and acuity (the severity of a patient's illness and the level of service needed) will be designated. The triage nurse would then direct the patient to the appropriate care area to receive treatment.
- Patients assigned a level two acuity were determined to have a high risk situation, and included those who may be in severe distress.
- Patients who were awaiting further evaluation, should be reassessed as per nursing judgement.

Review of Patient #14's medical record from Hospital B (a nearby hospital), showed that the patient was admitted on [DATE] for congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues) and elevated levels of liver enzymes (indicating possible liver disease). Documentation on the patient's day of discharge, 02/15/21, showed that the patient had a cirrhotic liver (liver damage from scarring of the liver), CHF which further affected his liver, and a weakened, enlarged heart, which affected his heart's blood pumping ability.

Review of Patient #14's medical record dated 02/17/21, showed the patient was a [AGE]-year-old male who presented to the ED at 10:31 PM, with complaints of shortness of breath (SOB) and cough. The patient's recent admission to Hospital B for SOB with CHF was documented in the medical record, and the patient reported in triage that he felt the same way upon presentation. In triage, he appeared jaundice (yellowing of the skin or whites of the eyes, often associated with liver disease) was grunting (sign associated with respiratory distress), "refuse to wear mask" and had been coughing all day. The patient denied fevers, but reported feeling as if he was freezing, with loss of taste (symptom of COVID-19, highly contagious and sometimes fatal virus). The patient's medical history included CHF, [DIAGNOSES REDACTED] (heart muscle disease which causes an enlarged heart), hypertension (HTN, high blood pressure), polysubstance (the consumption of more than one drug at once) abuse and an above the knee amputation (removal of an injured or diseased body part). His vital signs as documented were within normal limits, except for the patient's elevated pulse rate (the number of heart beats per minute, normal range for adults is 60 to 100 bpm) of 106. He was assigned an acuity of 2-Emergent, based on the Emergency Severity Index (ESI, a numerical value one [most urgent] to five [least urgent], which shows the priority of medical evaluations, as well as resources needed to treat patients). At 10:40 PM, nine minutes after his presentation, nurse documentation showed that the patient continued to yell out in triage and refused to wear a mask. An electrocardiogram (EKG, test that checks for problems with the electrical activity within the heart) was completed at 10:46 PM. It was interpreted by Staff S, ED Physician, as a moderate risk for acute coronary syndrome (ACS, any condition brought on by a sudden reduction or blockage of blood flow to the heart, as with a heart attack, for example). Recommendation was further workup in the ED. Labs and a chest x-ray were ordered at 10:58 PM, but were not completed, and at 11:13 PM, Zofran was ordered to be administered to the patient for nausea and vomiting. At 11:30 PM, Staff M, RN, documented that the patient was a distraction, caused a scene, and was informed that he would be "escorted outside to wait for a room." The patient was subsequently escorted outside when he refused to cooperate, and was later found unresponsive, was not breathing and had no pulse. Resuscitation was initiated but was unsuccessful, and the patient was pronounced dead on 02/18/21 at 12:20 AM. Review of Patient #14's blood specimens obtained during resuscitation, showed that the patient had a critically high Troponin level of 279 (indicates a problem with the heart, and may be experiencing a heart attack), abnormal chemistries (measurement of electrolytes, fats, proteins, glucose and enzymes), a significantly elevated b-type natriuretic peptide (diagnostic blood test for CHF) of 9,038 (acute heart failure likely), and an elevated white cell count of 16.0 (can indicate infection, disease or injury).

Review of three hospital video recordings titled, "South ED Visitor Waiting Room South Side," dated 02/17/21, showed a view of the ED waiting room, and part of the nurses' triage desk. The review showed:
- 10:26 PM, A (unidentified) Public Safety Officer (PSO) pushed Patient #14 by wheelchair into the waiting room, and placed him near the triage desk. The patient wore a surgical face mask (standard protocol during COVID-19 public health emergency), as well as a sweatshirt with a hood.
- 10:27 PM, Staff M, RN, took the patients vital signs, and covered him with a blanket.
- 10:46 PM, The patient was wheeled to the waiting room and out of camera view.
- 10:50 to 10:52 PM, The patient wheeled back into camera view. He appeared to have labored breathing (shortness of breath with increased effort to breathe), removed his mask, appeared to make attempts to catch his breath, and placed his mask back on. His labored breathing continued, and the patient pulled down his mask and wheeled out of camera view.
- 11:02 PM, An unidentified patient in the waiting room stood up, pointed in the direction of Patient #14 and appeared to speak to someone at the triage desk. Another unidentified patient stood up and moved to a seat further away from Patient #14.
- 11:03 PM, Staff M, RN, walked toward Patient #14 and off camera. She appeared back in camera view and wheeled the patient out of the main waiting room to a partitioned area next to the waiting room. The patient's mask covered his nose and mouth.
- 11:18 PM, Staff M and Staff N, PSO, appeared back in camera view. Staff M wheeled the patient toward the ED entrance while Staff N followed behind with the patient's belongings. The patient no longer had a blanket, or his sweatshirt on, and only wore a short-sleeved t-shirt.

Review of a video camera recording titled, "South ED Drive Entrance South," dated 02/17/21, showed the view outside the main ED entrance. The video showed:
- 11:19 to 11:20 PM, Staff M, RN, wheeled Patient #14 out of the ED entrance and placed his wheelchair next to the ED entrance doors (outside of the hospital). Patient #14's breathing was visibly labored. Staff M placed the patient's belongings next to the wheelchair and she and Staff N, left the patient unattended, and re-entered the building. The patient wore only a short-sleeved t-shirt. The patient's labored breathing continued.
- 11:20 to 11:22 PM, the patient's labored breathing intensified. He appeared to be gasping for air, his body began to jerk, his head thrust backwards several times before the patient stopped moving and his head remained tilted back.
- 11:25 PM, Staff R, Sergeant Charge Officer, appeared in camera view and entered the ED doors (walking past the patient). The patient appeared to have shallow breaths at that time.
- 11:28 PM, the patient's arm slipped off the arm rest and the patient's body slumped over the left side of the wheelchair.
- 11:29 PM, Staff L, Assistant Nurse Manager (ANM), appeared in camera view, outside the ED, and approached the patient. He attempted to rouse the patient but was unsuccessful. He appeared to check for a pulse and performed a sternal rub (painful pressure, applied with the knuckles, to the center of the chest of a patient who is not alert to elicit a response), then left the patient outside, unattended, and walked back into the ED.
- 11:30 to 11:31 PM, Staff L, ANM, and Staff M, RN, exited the ED entrance an appeared to assess the patient. Staff M attempted to sit the patient upright, but his body immediately slumped back over. She wheeled the patient toward the ED trauma entrance and out of camera view.

Review of the hospital's document titled, "Patient Safety & Quality Department Event Summary," dated 02/22/21, confirmed that at 11:20 PM, when Staff M wheeled the patient outside the ED entrance, his breathing was labored. Staff R, Sergeant Charge Officer; Staff O, PSO; Staff P, PSO and Staff Q, Charge Officer, were at the security desk at the time the patient was wheeled outside. At 11:21 PM, the patient appeared to be distressed, gasping with shallow/irregular breathing, head tilted back, with no staff present. At 11:22 PM, the patient turned red with slight head movement, and was pale by 11:27 PM. At 11:28 PM, Staff L, ANM, arrived and shook the patient, checked for his pulse, and performed a sternal rub before he walked away. He returned with Staff M, RN, after approximately 30 seconds, and at 11:31 PM, Staff M wheeled the patient into the hospital.

Observation on 02/22/21 at 3:40 PM, showed that the ED's exterior entrance was open to the elements of weather, with the exception of an awning directly over the entrance doors. Upon entering the ED, there was a vestibule area separating the entrance from the waiting room. Within the vestibule area was a security station, staffed with PSOs, and a desk occupied by a unit secretary, used for COVID-19 screenings.

Review of the National Weather Service's local weather record for 02/17/21 at 11:30 PM, showed that the temperature was 17 degrees Fahrenheit (F, unit of temperature), with a wind chill of 11 degrees and light snow.

During a telephone interview on 03/04/21 at 11:00 AM, Patient #14's father stated that the patient was diagnosed with [DIAGNOSES REDACTED]"fluid on his lungs." When the patient was discharged from Hospital B, he wasn't feeling any better, and by the evening of 02/17/21, he could hardly breathe. When the patient asked to be taken to a hospital, Patient #14's father encouraged him to call an ambulance because "they could get him there faster and would probably be able to give him some oxygen." The patient refused and asked to be driven, and when he took the patient to the ED, the patient "was in bad shape." He was later notified by the hospital that there was an "issue" with the patient, and learned his son had passed away, as well as the details of the event. He stated he didn't understand why his son was forced to wear mask when he couldn't breathe, or why he was pushed outside in the cold after he told the nurse he was freezing. "How could a nurse look at him and think he is going to be ok outside alone?"

During a telephone interview on 02/23/21 at 1:37 PM, Staff M, ED RN, stated that when she triaged Patient #14, she believed his presenting symptoms were not related to his heart. The patient was grunting and only gave short answers during triage, but he "did not strike me as a critical patient." The patient was placed in the corner of the waiting room, but was "uncooperative" and would not keep his mask on, which upset other patients, so he was placed behind the partitioned wall. She stated she asked Staff S, ED Physician, if Patient #14 should be placed in an examination room before other patients, and Staff S responded that the only reason would be to "reduce other patients' risk of possible COVID exposure." The patient called out for help, stated he was going to vomit, vomited, and then laid down on the floor in his vomit. When he continued to refuse to wear a mask, she told him that if he didn't calm down, "he would have to sit outside." A PSO (name unknown) who stood next to her, said that the patient couldn't sit in the vestibule because he wouldn't wear a mask, so she placed him outside because he was belligerent and she had "no other choice." She informed Staff L, ANM, that the patient was placed outside the building, and Staff L responded that her actions "sounded reasonable." She returned to the triage desk and found that there were four examination rooms available for waiting patients, when Staff L, ANM, approached her and asked her to come outside. When she and Staff L went outside, the patient was not breathing.

During a telephone interview on 02/23/21 at 3:00 PM, Staff N, PSO, stated that when he approached the patient, he was lying face down on the floor. Staff M, RN, asked the patient to get up and he stated he couldn't, because he could not breathe. He then said he was "shitting" himself. He asked Staff M how he could help and she stated that "she needed him to wear a face mask." The patient stated he couldn't get up on his own so he and Staff M went to get gloves to assist him. When they returned the patient was standing and leaning over the wheelchair. Staff M, placed a new mask on the patient, assisted him into the wheelchair, placed the patient's previously worn sweatshirt on the side of the wheelchair, and wheeled the patient outside the building. As the patient was wheeled outside, Staff M said to the patient, "Sir, do you know why you're being placed outside?" and the patient said, "I can't breathe." Staff M then stated, "You're being uncooperative and won't wear your mask. I don't know what kind of disease you have or if you have COVID, so you're going to have to wait out here until it's time to be seen." Staff N did not question Staff M's actions because "she's a nurse." When Staff N returned inside, he reported the incident to his supervisor, who told him to write up a report because "this is going to be a situation." He stated that he looked out the window five minutes later, and the patient's head was lying back, and when he reported this to his supervisor, he was told to continue with the report. When Staff M was asked why did not bring the patient back into the building, he responded that he "was following the chain of command."

During a telephone interview on 02/24/21 at 8:40 AM, Staff R, Sergeant Charge Officer, stated that he witnessed Staff M, RN, wheel Patient #14 outside the ED entrance while the patient repeatedly stated that he could not breathe. He left the area, and when he walked around to the ED entrance, he saw Patient #14 still sitting outside. He reported the incident to Staff L, ANM, and asked him, "Since when do we place patients outside?" Staff L responded that he had spoken with Risk Management and they were ok with it. Staff R told Staff L it was cold outside and the patient didn't belong out there, when Staff L replied that he would take the patient a blanket. He stated that "problem patients" were typically placed by the security desk, not outside the building. Staff R stated that he did not bring the patient back into the building because PSOs were not to interfere with patient care.

During a telephone interview on 02/23/21 at 1:15 PM, Staff L, ANM, stated that he was in his office when he was notified by Staff M, of Patient #14's medical presentation and "behavioral issues." Staff M reported to him that the patient had placed himself on the floor, self-induced vomiting, and threatened to urinate on himself. He stated Staff M told him that Patient #14 had been placed outside by security, which was a common practice for disruptive patients, but he was under the impression that the patient was inside the building. After about 10 minutes, Staff R, Sergeant Charge Officer, reported to him that there was a patient outside in a wheelchair with a t-shirt on. Staff L went outside to check on Patient #14 after he finished a task he was working on, "approximately one or two minutes later." When he saw the patient, he shook him, performed a sternal rub, and checked for a pulse. He stated that the patient had respirations and a pulse so he left the patient and went inside "to get another set of hands." He and Staff M arrived back outside and she wheeled the patient into the ED. He stated that no patient should ever be placed outside and he felt that there could have been a better solution.

During a telephone interview on 02/23/21 at 12:17 PM, Staff I, ED RN, stated she overheard Staff M, RN, tell the patient that she was "going to take him outside," but she thought that meant in the vestibule by security, where "combative patients" had been placed before. Security however, did not want the patient placed there because he kept coughing without a mask on. Staff I stated she wouldn't have put the patient outside, she would have put him out in the vestibule by the security desk.

During a telephone interview on 02/23/21 at 1:00 PM, Staff K, ED RN, stated that while Patient #14 was in the waiting room, he kept yelling out, "I can't breathe," and was yelling something while he laid on the floor that she couldn't recall, because she was "trying to block it out." She heard Staff M, RN, and Staff S, ED Physician, discuss whether the patient should receive the next available bed, but the conversation ended when the patient placed himself on the floor and Staff M had to respond. She witnessed Staff M wheel the patient toward the vestibule area, and when Staff M returned, she said she was going to notify Staff L, ANM, of what transpired. She stated that the protocol had been to place patients who wouldn't wear masks in the vestibule area (located by security).

During a telephone interview on 02/23/21 at 6:20 PM, Staff O, PSO, stated that Staff M, RN, informed security that Patient #14 could "potentially become a problem," so he approached the patient and asked the patient to pull his mask back up (over his mouth and nose). The patient stated he didn't know why he had to wait because he was having trouble breathing and had thrown up, when Staff M responded to the patient that he had only been waiting for 40 minutes. The patient then laid on the floor, and stated that it was the only thing that would help him breathe. He then saw Staff M wheel the patient past security and out the doors, but no one stopped her. Staff M told the patient that since he wouldn't wear a mask, he would have to wait outside, and although he had never witnessed a patient being placed outside the building, he thought the nurse was making the best decision at the time.

During a telephone interview on 02/24/21 at 8:48 AM, Staff S, ED Physician, stated that she was working as the triage physician, interpreted Patient #14's EKG results, marked the EKG as moderate risk, and added that it was "not unusual for patients with moderate risk EKGs to wait a while in the ED." She stated she did speak with Staff M about placing Patient #14 in an examination room, and told her that the only reason the patient would need to be roomed next would be due to a possible COVID risk (exposure to other patients), as he was "snorting" and not wearing a mask.

During an interview on 02/23/21 at 10:45 AM, Staff D, ED Executive Director, stated that all patients and visitors had the right to refuse a mask, and that it would never be acceptable for a patient to be placed outside or asked to wait outside the building.

The hospital failed to provide a timely MSE, after Patient #14 presented to the hospital's ED seeking medical treatment. The patient presented with SOB, complaints of difficulty breathing, grunting respirations and repeatedly stated, "I can't breathe." He had a history of CHF, HTN and his EKG was marked as moderate risk for acute coronary syndrome. Staff M disregarded the patient's safety and medical condition, when she wheeled him outside in below freezing temperatures to await a MSE, wearing only a t-shirt, because the patient would not wear a mask. Only one minute after the patient was left outside, unmonitored, his labored breathing intensified and the patient became unresponsive. Multiple staff were aware of the patient's placement outside and all allowed him to be left out in the elements without medical oversight for over nine minutes. The patient was found unresponsive, and subsequently died after life saving measures were unsuccessful.

2. Review of the hospital's policy titled, "Suicide Precautions," dated 08/2019, showed that it was recommended that any patient threatening suicide or at risk for self-harm be evaluated with a psychiatric (relating to mental illness) consultation to further clarify the severity of suicidal risk and guide the level of observation required to reduce risk factors.

Review of the hospital's document titled, "ED Physician On-Call Specialties Psychiatry," dated 11/20/20, showed Psychiatry as one of the specialties available for consultation.

Review of Patient #31's medical record showed he was a [AGE]-year-old male male who (MDS) dated [DATE], with complaints of suicidal ideation. Further review of his medical record history showed that he received a psychiatric consult during three previous ED visits, when he presented with complaints of suicidal ideation.

Review of Patient #31's ED record record showed that on 11/20/20 at 3:36 AM, the patient presented with complaints of hearing voices that were telling him to hit stuff and kill people, and planned to kill himself. He answered "yes" to questions that asked if he wished he were dead, had suicidal thoughts, and suicidal intent, which prompted nursing staff to initiate suicidal precautions (SP, precautions taken to ensure patients are safe and free of self injury or self-harm). Physician documentation showed that Patient #31 had a plan to jump off a bridge or get hit by a car. Patient #31 was last seen by psychiatry during an ED visit on 11/08/20, and it was noted that he had risk/protective factors, that he did not have significant impairment due to his psychosis (a disorder characterized by false ideas about what is taking place or who one is) and he had not had any new or acute (sudden onset) additional stressors. During the visit on 11/20/20, Patient #31 did not have any new additional stressors. Patient #31 showed no signs of intoxications (to be affected by alcohol or drugs where physical and mental control was markedly diminished) such as slurred speech, [DIAGNOSES REDACTED] (an involuntary eye movement which may cause the eye to rapidly move from side to side, up and down, or in a circle and may slightly blur vision) or abnormal gait (a person's manner of walking). The physician contacted social services to make them aware that the patient was in the ED. Patient #31 was offered a call for resources from social services, which he declined, and was discharged from the ED at 6:18 AM.

During an interview on 02/24/21 at 12:20 PM, Staff V, Psychiatry Resident, stated that ED physicians would consult psychiatry on SI patients unless they were intoxicated. In that case, they would wait until the patient was clinically sober and if they were still suicidal, then the patient would receive a Psychiatric consult. If the patient was no longer suicidal, then they could be discharged . Psychiatry was available 24-hours a day, seven days a week for consultation in the ED.

During an interview on 02/24/21 at 1:45 PM, Staff Y, ED Physician, stated that she examined Patient #31 on his first visit to the ED on 11/20/20, and she felt that based on his complaint, symptoms, and past medical history, that he was not a danger to himself. She could not recall specifically why she did not do a psychiatry consult. If a patient was intoxicated and had SI, she would not consult psychiatry until that patient was clinically sober. If the patient was sober and had SI, she would then consult psychiatry. Patient #31 did not appear to be under the influence of drugs or alcohol during his visit.

Review of Patient #31's ED medical record (second presentation), showed that on 11/20/20 at 8:11 PM, the patient presented with complaints of going crazy because people were yelling at him and trying to rape him. He had SI with a plan to jump off a bridge. He was visibly upset and told the nurse that he knew they were not going to help him. He answered "yes" to questions that asked if he wished he were dead, had suicidal thoughts, and suicide intent with a specific plan, which prompted nursing staff to initiate suicidal precautions. Physician documentation showed that Patient #31 presented to the ED for SI with a plan to jump off a bridge or get hit by a car. Those plans were unchanged from his numerous prior visits, and he was seen earlier that morning with similar complaints. Patient #31 had visual and auditory hallucinations (seeing and hearing things that are not there) that told him to hurt himself and others, and made statements that were similar to those made during his ED visit on 11/08/20. He had been evaluated by psychiatry multiple times during similar complaints with the most recent evaluation on 11/10/20, and he did not require admission at that time. Patient #31 was provided a bus pass by social services and was discharged at 9:26 PM.

There was no indication in the ED records for Patient #31'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 02/24/21 at 3:05 PM, Staff Z, ED Physician, stated that he was not aware of any type of policy for Psychiatry consultation for SI patients in the ED. Psychiatry was available to the ED for consultation 24-hours a day, seven days a week. He would only consult psychiatry if the patient needed to be admitted to the behavioral health unit (BHU). He did not do a psychiatric consult with Patient #31 based on their conversation because he felt that the patient was a low risk for self-harm, and he did not feel he needed admitted to the BHU. He did not remember for sure, but based on his documentation, he determined that Patient #31 was not intoxicated or under the influence of drugs or alcohol at that visit.

Patient #31 presented to the ED with SI and a plan to jump off of a bridge or jump in front of a car. Due to his frequent ED visits, staff did not feel that he needed a Psychiatry consult, which was recommended for every clinically sober patient who presented to the ED with SI. The patient did not appear to be under the influence of drugs or alcohol during either ED visit on 11/20/20. Psychiatry was an available service to the ED, and they were never consulted. The hospital failed to provide an appropriate MSE within the capability and capacity of the hospital's ED, which included ancillary services routinely available to them.