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 HEALTHCARE 1100 KENTUCKY AVE WEST PLAINS, MO 65775 May 12, 2021
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interview, record review, policy review, and review of recorded video surveillance showed the hospital failed to follow its policies and procedures when they did not provide an appropriate medical screening examination (MSE) within its capability and capacity, to rule out an emergency medical condition (EMC) for one patient (#29) out of 31 Emergency Department (ED) sampled cases from November 2020 through May 2021. Patient #29 presented to Ozarks Healthcare ED seeking care for dehydration and refusal to eat. During his triage, he was found to be at risk for suicide, but was placed in the ED waiting room and left unattended by staff. Patient #29 waited over three hours before he left the hospital without a MSE, and the following morning, walked into traffic and died . The hospital's average monthly ED census over the past six months was 1,895.

Findings included:

Review of the facility's policy titled, "Emergency Medical Treatment & Active Labor Act, (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition)" revised 10/2019 showed the following:
- An EMC is a medical condition that manifests itself by acute symptoms of sufficient severity, including psychiatric (relating to mental illness) disturbances, 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.
- The MSE must provide evaluation and stabilizing treatment within the capabilities of the hospital, which may include all necessary and available testing and use of on-call services to determine the presence or absence of an EMC.

Review of the hospital's policy titled, "Suicide Precaution," revised 04/2021, showed the following:
- Patients who presented to the hospital would be screened upon arrival to identify those patients that are at risk for suicide.
- A registered nurse (RN) may initiate suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) based upon assessment, and the order would be obtained from a physician as soon as possible.
- Patients at risk for suicide would be placed in an appropriate care area with continuous direct observation by appropriately trained staff.

Review of the hospital's policy titled, "Suicide Risk Assessment," revised 04/2021, showed the following directives for staff:
- Address the patient's immediate safety needs and most appropriate setting for treatment.
- Positive responses to questions (such as if the patient has active suicidal thoughts with method and intent) asked on the 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) directed staff to provide ED patients with a psychiatric review.
- If a psychiatric review was indicated, options would be to provide a psychiatric consult or admit to the Neuropsychiatric Department.

Review of the hospital's document titled, "On-Call List," showed that a psychiatrist was available and on-call to the ED on 04/28/21.

Review of the hospital's undated document titled, "Inpatient Units," showed that the hospital services available for inpatient treatment included a Neuro-Psychiatric Unit (NPU).

Review of the hospital's website showed that the hospital's NPU was staffed 24 hours-a-day with trained psychiatrists and nursing personnel, who provided intensive, inpatient psychiatric care for patients between the ages of 18 and 64.

Review of the hospital's document titled, "NPU Daily Staffing Sheet," showed that there were 13 beds available for psychiatric admissions on 04/28/21.

Review of Patient #29's ED medical record dated 04/28/21, showed that staff failed to follow the hospital's policy and did not provide the patient with an appropriate MSE, when he presented to the ED with his wife at 6:26 PM, with complaints of dehydration and no desire to eat. He reported that he "wanted to starve to death," and had been "doing this for 12 years." The patient was 5 foot 8 inches tall, and weighed only 105 pounds. During triage, and while using the C-SSRS, the patient reported he thought about suicide almost daily, was actively suicidal, and had intentions to act upon suicide. The patient's assessment indicated he was at risk for psychiatric elopement, which triggered a recommendation that the patient be placed close to the nurses' station, and for nursing to contact a physician for a psychiatric consult order. The record showed no indication that the ED physician was contacted, or that a psychiatric consult was ordered, and no documentation that the patient was monitored continuously for elopement or suicide risk. At 10:24 PM, over three hours after the patient presented, the patient could not be found.

During an interview on 05/10/21 at 3:45 PM, Staff I, ED Triage Registered Nurse (RN), stated that she did not identify that the patient needed to be placed on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm), placed the patient in the ED waiting room, and provided a brief patient report to the charge nurse at the end of her shift (7:00 PM).

During an interview on 05/11/21 at 12:10 PM, Staff J, ED Charge RN, stated that the report he received from the triage nurse did not include details of the patient's assessment that triggered the need for a psychiatric evaluation. The patient was not monitored by staff, and when he called out for Patient #29 in the waiting room around 10:00 PM, there was no response.

Review of recorded video surveillance dated 04/28/21, showed that the patient waited in the waiting room hall and nearby lobby, without continuous, direct observation by staff from 6:55 PM until 9:28 PM, when the patient then walked to the lobby and appeared off-balance. The patient appeared to balance himself against a wall while several staff walked past the patient but offered no assistance. At 10:00 PM, the patient and his spouse exited the hospital, and there was no attempt made by staff to prevent the patient from leaving.

During an interview on 05/10/21 at 3:30 PM, Staff D, ED Manager, stated that in her review of the events, video recording of the ED waiting room showed that Patient #29 left after waiting for over three hours. She was informed by the patient's spouse on 04/29/21, that Patient #29 had walked into traffic that morning around 9:00 AM, and had died .

See A-2406 for additional information.
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 hospital failed to provide an appropriate medical screening examination (MSE) within its capability and capacity, to determine if an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment) existed for one patient (#29) of 31 patients who presented to the hospital Emergency Department (ED) seeking care, out of a sample selected from November 2020 to May 2021. The ED had an average of 1,895 visits per month, for the last six months.

Findings included:

Review of Patient #29's ED medical record showed that he was a [AGE] year old male, who (MDS) dated [DATE] at 6:26 PM, with complaints of dehydration and no desire to eat. He was triaged by Staff I, RN, at 6:45 PM. The patient was 5 foot 8 inches tall, and weighed 105 pounds, and although he reported he was able to eat and drink, he had no desire to do so. He stated, "I want to starve to death" and added that he had been starving himself for 12 years. During his Suicide Risk Assessment, when asked if over the previous two weeks if he had little interest or pleasure in doing things, if he was feeling down, depressed or hopeless, or if he had suicidal thoughts, he responded, "nearly every day." His Suicide Risk Assessment was documented at a nine (anything over a score of three prompted a complete Columbia Suicide Severity Rating Scale [C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life]) which prompted additional questions using the C-SSRS. When asked if he wished he were dead, if he had thoughts of killing himself, thoughts of how he might kill himself, and if he had intentions of acting upon those thoughts, he responded, "yes." The answers to the C-SSRS questions created a prompt for the nurse to "contact attending physician for psychiatric consult order." He was assessed to be at risk for psychiatric elopement (when a patient makes an intentional, unauthorized departure from a medical facility), which triggered elopement precautions (EP, interventions to prevent someone from leaving who may be at risk for self-harm or injury), with suggestions to place the patient close to the nurses' station. There was no indication in the record that the ED physician was contacted, that a psychiatric consult was ordered, or that the patient was was monitored by staff for elopement or suicidal risk. At 10:24 PM, over three hours after the patient presented, the patient could not be found.

Review of the hospital's document titled, "On-Call List," showed that there was a psychiatric provider available to the ED for consultation on 04/28/21.

During an interview on 05/10/21 at 3:45 PM, Staff I, ED Triage Registered Nurse (RN), stated that when Patient #29 arrived to the ED, his spouse voiced that he would not eat or drink. The patient had reported that he wanted to starve himself to death and that he had been starving himself for the past 12 years. He voiced to her that he did not want a psychiatric evaluation, because they did not work. The patient's responses to the C-SSRS questions indicated that he needed a psychiatric consult, but she did not identify that the patient needed to be placed on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm). She placed the patient in the waiting room because all 16 ED rooms were occupied, and because she did not know if she was able to place additional patients inside the ED, such as in a chair in the hall. She documented the patient's need for a psychiatric evaluation in the comments section, which was visible to all ED nursing staff and providers, and provided a brief report to the charge nurse around 7:00 PM.

During an interview on 06/07/21 at 2:45 PM, Patient #29's spouse stated that the main reason she brought the patient to the ED was because he was having suicidal ideations (thoughts of casuing one's own death), wasn't eating or drinking, and she wanted him to get help in a hospital setting. She stated that he was disabled due to his psychosis (serious mental illness with loss of reality) with paranoia (excessive an unrealistic suspiciousness), was not taking his psychiatric medications or seeing his psychiatrist, and after their son died in January (four months earlier), she felt he was becoming more depressed. He told the triage nurse that he had a plan to kill himself, but she made light of the conversation, didn't seem concerned, and placed him in the waiting room, where no one checked on them.

Review of recorded video surveillance dated 04/28/21, showed that the patient waited in the waiting room hall and nearby lobby, without continuous, direct observation by staff from 6:55 PM until 9:28 PM, when the patient then walked to the lobby and appeared off-balance. The patient appeared to balance himself against a wall while several staff walked past the patient but offered no assistance. At 10:00 PM, the patient and his spouse exited the hospital, and there was no attempt made by staff to prevent the patient from leaving.

During an interview on 05/11/21 at 12:10 PM, Staff J, ED Charge RN, stated that report from Staff I did not include the details of the patient's assessment which had triggered the patient's need for a psychiatric evaluation, but observed the comment that she documented indicating the need for one. Staff J stated that (in addition to his charge nurse responsibilities) he was responsible for triaging walk-in patients as well as ambulance patients, because there was not a triage nurse scheduled that night, and because of this, no staff monitored the patient while he waited. Around 10:00 PM, when Staff J called out for Patient #29 in the waiting room, there was no response.

During an interview on 05/10/21 at 3:30 PM, Staff D, ED Manager, stated that on 04/29/21, she identified that Patient #29 had triggered a psychiatric evaluation, and that he had left without being seen. Staff D stated that she would have expected staff to initiate SP if the patient's responses triggered a psychiatric evaluation. She reviewed video of the waiting room from the evening before, and was able to determine that Patient #29 had left the ED around 10:00 PM, accompanied by his spouse. Her attempts to contact the patient and the patient's spouse that morning were unsuccessful, but was notified by the patient's spouse later in the day that the patient had walked into traffic that morning around 9:00 AM, and died .

During an interview on 05/12/21 at 9:15 AM, Staff M, Chief Operating Officer (COO)/Chief Nursing Officer (CNO), stated that he expected staff to implement suicide interventions (this would include SP) based on the patient's assessment, and to follow the hospital's policy.

The patient presented to the hospital ED with thoughts of killing himself, and intention to act upon those thoughts. The hospital staff failed to identify the patient's suicide risk, failed to observe the patient while he waited, and failed to contact the ED physician for a psychiatric consult. The patient was left to wait in the waiting room, unsupervised by staff for over three hours. He departed the hospital around 10:00 PM, without a MSE, and on the following morning, walked into traffic and died .