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.

UNIV. OF VERMONT - FLETCHER ALLEN HEALTH CARE 111 COLCHESTER AVE BURLINGTON, VT 05401 Jan. 12, 2021
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the hospital failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services (psychiatry) for 1 of 20 applicable patients (Patient #1). Findings include:

Per record review Patient #1 has a history of self-mutilation, pulmonary embolism (blood clot in lung), overdose, hemorrhagic shock (body shuts down due to blood loss), dissociative identity disorder (A disorder characterized by the presence of two or more distinct personality states.), depression, borderline personality disorder (A mental disorder characterized by unstable moods, behavior, and relationships.), anxiety, and anemia (deficiency of red blood cells). Patient #1 was admitted and discharged from the Emergency Department (ED) five times over a period of three days from 12/23/20 to 12/26/20. On 12/23/20, S/He was admitted at 4:12 PM with a chief complaint of "Self Injury" and was discharged home at 11:39 PM. On 12/24/20, S/He was admitted at 10:04 AM with a chief complaint of a "Laceration (deep cut)" and was discharged home at 10:54 AM; and at 5:32 PM came back to the ED with a chief complaint of "psychiatric (mental) evaluation" and was discharged home at 11:29 PM. On 12/25/20, S/He was admitted at 11:10 AM with a chief complaint of a "Laceration" and discharged home at 2:30 PM; and at 8:22 PM came back to the ED with a chief complaint of a self-inflicted "arm injury" and was discharged home at 12:38 AM on 12/26/20. On 12/27/20 at 6:35 PM, Patient #1 presented to the ED unresponsive after a drug overdose and subsequently died on [DATE].

Per review of a provider's note from 12/23/20, Patient #1 presented to the ED for self-injury. Per the patient's report, the self-mutilation was caused by another identity. This personality found a razor blade and cut him/her-self and caused eight lacerations across the left forearm. Per the physician's physical exam, Patient #1 had "7 lacerations on the left forearm ...All lacerations are parallel to each other". S/He was "alert and oriented" and had "no agitation or thought disorder". Upon further review of the provider's note, "The patient does have a care plan in place which states provider may consult crisis for new concerns, but to only treat lacerations as medically necessary". The patient had "seven lacerations repaired ...40 sutures total". At 10:35 PM "Spoke to crisis who evaluated the patient". Patient #1 was "recently moved from a crowded homeless shelter where staff constantly checked up on" him/her "to an isolated hotel room. Crisis feels that" s/he "injured" him/her-self "again given the opportunity because" s/he "was isolated. They are comfortable with discharge because" s/he "will have full ......services soon". "The patient was discharged home" and was provided instructions to follow up with his/her primary physician and outpatient mental health provider.

Per review of a crisis note from 12/23/20 at 11:19 PM, Patient #1 reported to the Crisis Clinician that s/he was moved from one residence to another because the newer residence (a hotel) had increased supervision. S/He stated that his/her alter personality was "mad" about moving and had told Patient #1 that s/he would "die" at the hotel. Patient #1 reported that s/he "disassociated" and his/her alter went out and bought razors; and "disassociated" again and his/her alter cut his/her forearm seven times. It had been about a month since Patient #1's last episode of self-harm and s/he remarked that "it was the first time they have really been alone". Patient #1 reported that s/he felt "depressed and anxious" and that was because s/he was off his/her medications and was "doing everything alone". S/He stated that s/he did not have insurance until the first of the year; however, did have access to a couple of his/her medications. S/He expressed that s/he had not picked them up from the pharmacy because s/he feared the alter would use them to "overdose". The Crisis Clinician's mental exam revealed that Patient #1 was "Well-groomed", "Cooperative", "Alert and Oriented" with "Fair" insight and "Poor" judgment. Per the Crisis Clinician's risk assessment, Patient #1 as him/her-self did not have thoughts of suicide or self-harm; however, his/her alter caused harm to him/her today. The alters in the past had also caused extensive and severe lacerations, which necessitated skin grafting, medical admission, and blood transfusions. S/He also had a history of a drug overdose in 2018 and in the spring of 2020. The crisis clinician's clinical impression was that Patient #1's alters severely self-harm; however, Patient #1 as him/her-self denied any safety concerns. Patient #1 was "agreeable and able to properly safety plan". Patient #1 "has historically shown that inpatient admission due to self harm only causes and increase in severity and frequency of self harming upon d/c, therefore it is recommended that" Patient #1 "not be supported through inpatient admission at this time". The plan for Patient #1 was to discharge from the ED and to follow-up with his/her "provider" and "outpatient safety plan". S/He would be provided a "lock box for medications"; s/he "felt" that s/he was "able to dispose of razors"; and was "agreeable to talk to staff about checking in .... twice daily".

Per review of a psychiatry update note from 12/23/20 at 10:53 PM, "Psychiatry did not formally consult on this patient tonight due to a previously established explicit and extensively documented plan created in collaboration with the Psychiatry Consult Service", outpatient mental health provider, "Ethics, and Surgery during" Patient #1's "4/12/2020 hospital admission". The psychiatrist's assessment and plan revealed that s/he was "in agreement with the Crisis Clinician's assessment and plan" for Patient #1 from 12/23/20.

Per interview on 1/7/21 at 4:34 PM with ED Provider #1, s/he stated that if a patient presented with self-harm, the patient would be put on (suicide) "precautions" until s/he figured out what was going on with the patient. A medical screening would be done and then if the patient were cleared medically, a consult for a crisis counselor to evaluate the patient would be made. Regarding the case with Patient #1 on 12/23/20, Patient #1 had a history of self-harm behavior and that in his/her experience, cutting was a form of release and typically did not involve deep lacerations. In this case, Patient #1's lacerations were deep and when s/he had assessed Patient #1 for suicidality s/he "denied any suicidal ideation flatly". S/He stated that "one of" his/her "personalities engaged in these behaviors". ED Provider #1 stated that Patient #1 was a "frequent visitor to the ED" and that s/he had "read a care plan that said the patient would have these acute episodes when discharging would get worse". S/He stated that crisis had seen the patient, things were getting set up for him/her as an outpatient, and that they "were comfortable sending" him/her "home". S/He stated that Patient #1 was "re-assessed for suicidality multiple times" during his/her time in the ED. ED Provider #1 stated that S/He often involved "ancillary services" as s/he expressed, we "do not have the time to spend" discerning the best course of action and/or treatment for a psychiatric emergency and that crisis and psychiatry were the experts to help guide that process.

Per review of a provider's note from 12/24/20 at 10:16 AM, Patient #1 presented to the ED for a laceration. The patient had a significant history of self-mutilation by cutting requiring repairs, and this was his/her "third presentation in three days". Patient #1 was unaware of what happened, s/he remembered going to bed and noticed a large laceration on his/her left lower leg at 9:30 this morning. Patient #1 did not know what type of object was used to inflict the injury. Patient #1 shared with the provider that "'he' has been very suicidal as of late, this 'he'" Patient #1 "speaks of is presumed to be a dissociative identity". The physician's exam revealed that there was a "25 cm linear laceration to the left lower leg through the dermis". The patient had "no agitation or overt thought disorder". The physician had asked if Patient #1 had a plan in place for future episodes of self-mutilation and s/he stated "'he' has been pretty suicidal"; however, Patient #1 stated that s/he "is not suicidal". The patient also reported that s/he had outpatient counseling and could follow up with them. Patient #1's laceration was repaired, and s/he was discharged with instructions to follow-up with his/her doctor and outpatient counselor. S/He was also given instructions regarding wound care and pain control. The patient was re-evaluated by the physician immediately prior to discharge with "improved symptoms, normal vital signs .... discharged with a clear plan for outpatient follow-up".

Per review of a provider's note from 12/24/20 at 7:10 PM, Patient #1 presented to the ED for a psychiatric evaluation. S/He had been seen twice in the last 24 hours with several lacerations on right forearm and left lower leg both needing extensive repair. S/He had a crisis consultation last night and "ultimately felt like this was not a safety concern and patient was discharged in the ED on both occasions". S/He came back to the ED and stated that his/her alter told him/her that s/he would "cut to kill". Patient #1 contacted his/her outpatient support program and they referred him/her to the ED for an evaluation. Patient #1 reported to the provider that s/he "is feeling safe". Per the provider's exam, the patient was "alert and oriented. No agitation or overt thought disorder". The patient was evaluated by Crisis and the "Crisis Clinician felt that the patient behaviors were likely result of recent move from a shelter that had more support staff and more people around to a place there is more isolated". Patient #1 was also evaluated by psychiatry and "does not need hospitalization at this time". S/He "will be discharged back to" his/her "established living arrangement. I discussed with patient" and s/he "is agreeable to this plan".

Per review of a crisis note from 12/24/20 at 8:15 PM, Patient #1 had presented to the ED hours later than when the outpatient counseling service had encouraged him/her to do so and had arrived with two packed bags. S/He had told the Crisis Clinician that s/he was not sure what type of help s/he needed but stated that when his/her alter "'makes threats follows through'" "'this morning was a warning'" and that s/he would expect "either another OD or more deep cutting". And that the other personality's goal was allegedly to "'destroy the body'" as s/he "'doesn't want to be alive'". S/He "reported being scared of the next thing to happen" from his/her alter. Patient #1's mental status exam showed that s/he was "Well groomed", "Cooperative", "Alert and Oriented" with "Fair" insight ("puts up barriers to suggestions, recommendations to help") and "Fair" judgement ("cutting is excessively deep"). Per the Crisis Clinician's risk assessment regarding suicidality, Patient #1 "reportedly disposed of razors but found something this am to cut" him/her-self "with". "At this time, states with certainty that" his/her "alter will cut to kill ....as soon as ...is alone". The Crisis Clinician's interpretation was that Patient #1 had been "engaging in deep self harm cutting in the context of dissatisfactory housing with noisy roommate and less staffing". Patient #1 "may very well cut again tomorrow and end up in the ED". S/He "initially seemed to be seeking admission by coming with two packed bags ...Remains at chronic risk" to him/her-self. The plan for Patient #1 was to "discharge from the ED to Follow Up Provider" and for the outpatient crisis center to follow-up with housing about changing units.

Per review of a psychiatry note from 12/24/20 at 10:27 PM, the psychiatrist confirmed what the Crisis Clinician had reported that the incidents of self-mutilation were "just warnings" and that next time the alter would "cut to kill". Patient #1 expressed to the psychiatrist that s/he did not want to go to a higher level of outpatient care/support and/or stay in the ED overnight. Patient #1 was "calm, linear, organized, .... but ...demonstrated obvious black-and-white thinking and help seeking help rejecting behavior". Per review of the psychiatrist's mental status exam for Patient #1, s/he was "cooperative and apathetic"; mood was "neutral, mildly restricted, appropriate social reactivity"; oriented to "person, place, time"; with "fair" insight and "poor" judgment. Per review of the psychiatrist's assessment, "It has been previously established by the Psychiatry Consult Service, Ethics" and outpatient mental health provider "(during ...4/12-4/20/20 hospitalization )" that Patient #1 "does not benefit from inpatient psychiatric hospitalization and in fact demonstrates worsened self-mutilation after discharge. The patient will not be placed on an involuntary hold ...While the patient has what can be considered terminal psychiatric illness and has persistently high baseline risk of death by self-mutilation" S/He "clearly demonstrates symptoms of borderline personality disorder ...and should be allowed to discharge home from the ED, knowing that" his/her "self-mutilation will recur".

Per interview on 1/7/21 at 1:18 PM with ED Provider #2, s/he stated that there were several components to a safe discharge; the patient would be "medically stable to leave", there would be a "safety" plan to mitigate "self-harm risk", and there would be a "safe place to stay". S/He stated that determining a patient's capacity would be "case-by-case" and that crisis and psychiatry teams were heavily relied upon to help make the determination for patients if there was a question. S/He stated that regarding Patient #1 s/he had seen him/her on 12/23/20 and was only involved in helping to repair the patient's lacerations. Patient #1 had presented on the following day, 12/24/20, and had wanted to speak to crisis. ED Provider #2 stated that s/he spoke to psychiatry and crisis on that date and that Patient #1 was at her "baseline" and that s/he did not need "hospitalization ". Patient #1 "tended to escalate when more services were added". S/He stated that there was an "ED care plan" in place for Patient #1 and that "unless new change would not warrant a crisis clinician evaluation". The plan was for Patient #1 was to be discharged from the ED and for him/her to go back to the hotel s/he was residing in. ED Provider #2 stated that Patient #1's presentation was like times when s/he had presented to the ED in the past. Upon his/her evaluation of Patient #1 on 12/24/20, s/he was "calm, cooperative, pleasant, reasonable". S/He had a "linear thought pattern, did not seem off" his/her "baseline from when I had met" him/her "previously". S/He stated that for Patient #1, it was "up to the provider's discretion whether or not crisis was called".

Per interview on 1/7/21 at 2:31 PM with a Second Year Resident Physician (A stage of graduate medical education.), s/he stated that his/her role was to evaluate patients, write notes, make recommendations, admit, and discharge patients; and that all these processes were evaluated and approved by an Attending Physician (A physician who has completed residency and practices medicine in a clinic or hospital). S/He stated that the psychiatry service only evaluated patients after they had been assessed by a Crisis Clinician. S/He stated that a patient's capacity was based on their mental status exam and whether the patient was able to make a "single medical decision". S/He stated that s/he had first heard about Patient #1 on 12/23/20 from crisis. On 12/24/20, s/he evaluated Patient #1 and that s/he was "very well put together". S/He had his/her "hair done" and was dressed in "casual clothes". S/He had exhibited "linear, organized thinking". S/He "denied suicidal ideations, wanted to go home".
During an interview at that time with the Medical Director of ED Psychiatry, s/he stated that historically when Patient #1 presented to the ED s/he was not suicidal, his/her "alter" was suicidal. S/He stated that when Patient #1 had increased supports his/her condition had "worsened". S/He was "not able to be kept safe as an inpatient" and when s/he was discharged s/he had "escalated to a dangerous degree of self-harm". S/He stated that "further hospitalization s would be dangerous for the patient". S/He stated that the patient would typically present several days in a row with a "little escalation" and then the behavior would taper off, referring to this as an "extinction burst". S/He stated that s/he "came in all the time with very bad wounds". The "more support" s/he "got the worse" s/he "did". S/He stated that patients care plans were always "in flux" and that "every time they come in; they are re-assessed". S/He stated that in April of 2020 a multidisciplinary team (to include Ethics) meeting was held to discuss whether to involuntarily commit Patient #1 to receive further treatment. "They did not have a way to keep" him/her "safe". "Nothing to offer the patient". S/He stated that "Because overall nothing had changed globally, ultimately did not change the treatment recommendations". There was an "overall chronic risk in death by self-lacerations".

Per review of a provider's note from 12/25/20 at 12:21 PM, Patient #1 presented to the ED with a nine (cm) centimeter laceration with six branching lacerations, one centimeter perpendicular to the main laceration: and 4 cm, 3 cm, and 2 cm lacerations on his/her right ankle. Patient #1 reported that S/He took and uber to the ED and that S/He "disassociated and cut" him/her-self. S/He denied any "current SI (suicidal ideation) but states that" his/her "'other person' desires to hurt her". Per the provider's physical exam, Patient #1 was "alert and oriented, appears comfortable". The provider contacted Crisis and they stated that Patient #1 would not be accepted to the higher level of outpatient care and that the "patient declined any further assessment from crisis. Crisis agreed to do a phone check ...later today". The patient's condition at departure from the ED was "Stable".

Per interview on 1/7/21 at 3:27 PM with ED Provider #3, s/he stated that when a patient presents as suicidal and/or with self-harm, the main goal was to "assess risk to harm to self or others". If it is "determined" that there is a risk of harm to self and/or others, then s/he would "get crisis involved". S/He further stated that a safe discharge plan would reflect how the patient could be discharged safely and that "everyone is on the same page". S/He stated that s/he had seen Patient #1 a "number of times". S/He stated that s/he "can't think of a time that" Patient #1 "did not present without the same complaint"; and that Patient #1 was "adamant" s/he "was not suicidal". ED Provider #3 stated that s/he had spoken to crisis while Patient #1 was in the ED and that they "did not feel that they needed to see" him/her. ED Provider #3 had asked crisis to call the patient at home. S/He stated that both crisis and psychiatry advised that Patient #1 was "ok" to be discharged . They "all agreed that it was a reasonable plan". S/He stated that s/he "knew looking at previous psychiatry documentation" that Patient #1 did not "benefit" from hospitalization .

Per review of a provider's note from 12/25/20 at 8:25 PM, Patient #1 presented to the ED via Emergency Medical Service for an arm injury. S/He has been seen in the ED multiple times in the past as well as earlier today and multiple times yesterday for self-inflicted wounds. Patient #1 reported that his/her "alter" was threatening to "kill" and that s/he "disassociated" and cut him/her-self. Per the physician's physical exam, Patient #1 was "Well appearing, in no acute distress"; his/her skin was with "multiple injuries in various stages of healing"; and s/he had "Normal speech, gait wnl (within normal limits), strength and sensation to light touch wnl". Patient #1 reported to the physician that his/her "injuries have been increasing lately because ...has been alone more often, which allows ...other personalities to injure ... more often". Upon exam his/her "tendon is clearly visible, no tendon injury and range of motion .... though limited at baseline due to ...multiple injuries, is not acutely worse". His/her wound was repaired, and crisis was consulted. "Crisis met with the patient, discussed with psychiatry, and agreed that the patient was appropriate for discharge". The patient was discharged with instructions for suture removal and to "return for any new or worsening symptoms".

Per review of a crisis note from 12/26/20 at 12:23 AM, Patient #1 explained to the Crisis Clinician that his/her "behaviors of late as being driven by one of" his/her "alters". And that the alter "'wants to be dead' and on some level there is a sense of resignation and hopelessness that" Patient #1 "does not have the capacity to subdue" their "intent". Patient #1 was scheduled to have an appointment with his/her outpatient case manager on 12/28/20 and then a psychiatrist on 1/12/20. Patient #1 reported that s/he was in "full control" and that s/he "denies current suicidality and dose not evidence plan or intent". S/He reported that his/her housing had changed because "they could not keep" his/her "safe". "Earlier in the year a treatment team from Psychiatry", Outpatient provider, and "ethics met to discuss protocol for ongoing care" due to the patients "level of self-harm that has led to the need for medically based admissions .... the team had decided to treat further occurrences in a more medically based palliative manner". The crisis clinician consulted with on-call psychiatry to include the attending physician, and "both doctors felt that discharge from the ED was appropriate course of action". "This writer will schedule twice daily phone checks over the next two days until" s/he "meets with Case Manager". S/He "is also encouraged to seek medical care at the ED if as needed which to date" s/he "has followed through with". Per review of the Crisis Clinician's mental status exam, Patient #1 was "Well groomed", "Alert and Oriented", with "Poor" insight and "Poor" judgment. The Crisis Clinician's risk assessment revealed that Patient #1's suicidality was "High for continuing acts of self-harm however no current stated intent or intent to die". The Clinician's interpretation was that "past history and current treatment states that inpatient admission and intensive OP (outpatient)therapy appears counter-productive for" Patient #1 "moving forward .... Historically" Patient #1 "has sought and accessed medical care as needed ....in consultation with psychiatry ..., it is recommended that" Patient #1 "discharge to follow up with established treatment team".

Per interview on 1/7/21 at 3:11 PM with ED Provider #4, s/he stated that when a patient presented to the ED with self-harm, a medical evaluation would be done to identify any acute medical issues. Once the medical issues were identified and addressed, a psychiatric evaluation would be done. S/He stated that Patient #1 presented to the ED with a "left arm laceration". The patient was "calm" and s/he "answered questions". S/He had other lacerations on the same arm as well as on both legs. ED Provider #4 stated that s/he closed the laceration, and that Patient #1 had no other medical issues. S/He stated that s/he "got the crisis person involved"; and stated that "what was unusual, crisis person told" him/her "that" Patient #1 "was a palliative case". S/He stated that s/he had been an ED provider for "27 years" and had "never heard that term applied to a psychiatric case before". S/He further stated that "crisis had spoken to the psychiatric resident" and "together made a decision did not need emergency hospitalization ". "Everyone felt that the patient was ok to be discharged ".

The above documentation demonstrates that Patient #1 had an emergency medical condition. S/He presented to the ED 5 times over the course of 3 days with suicidal ideations and significant self-harm injures. S/He had a change in housing, was living alone with limited supervision, had no health insurance, and a lack of appropriate medications. During numerous interviews and review of Patient #1's record, the providers continued to refer to a discussion that had taken place approximately eight months ago (April 2020) with a multidisciplinary group regarding the patient's care. There was no evidence that the patient's status was reassessed and no evidence of a written care plan and/or evidence of the patient's involvement in that plan during any of his/her visits to the ED on 12/23/20 through 12/26/20. There was also no further updated safety and/or treatment plan for Patient #1 that ensured Patient #1's stability and/or safety from self-harm. As such, the evaluation of Patient #1's emergency medical condition was incomplete by psychiatry.

Per review of the hospital policy "EMTALA-Medical Screening Examination & Stabilization Policy"-effective 1/1/2019, it states, "Emergency Medical Condition means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: (A) Placing the health of the individual ( ...) in serious jeopardy, (B) Serious impairment of bodily functions, or (C) Serious dysfunction of any bodily organ or part ....Medical Screening Examination is the process required to determine with reasonable clinical confidence that an emergency medical condition exits or a woman is in labor. With respect to an individual with psychiatric symptoms, a medical screening exam consists of both a medical and psychiatric screening. The medical screening examination is an ongoing process and the medical records must reflect continued monitoring based on the individual's needs and must continue until the individual is either stabilized or appropriately transferred."
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the hospital failed to provide, within the capabilities of the staff and facilities available, stabilizing treatment for an emergency medical condition prior to discharge and/or transfer for 1 of 20 applicable patients (Patient #1). Findings include:

Per record review Patient #1 has a history of self-mutilation, pulmonary embolism (blood clot in lung), overdose, hemorrhagic shock (body shuts down due to blood loss), dissociative identity disorder (A disorder characterized by the presence of two or more distinct personality states.), depression, borderline personality disorder (A mental disorder characterized by unstable moods, behavior, and relationships.), anxiety, and anemia (deficiency of red blood cells). Patient #1 was admitted and discharged from the Emergency Department (ED) five times over a period of three days from 12/23/20 to 12/26/20. On 12/23/20, S/He was admitted at 4:12 PM with a chief complaint of "Self Injury" and was discharged home at 11:39 PM. On 12/24/20, S/He was admitted at 10:04 AM with a chief complaint of a "Laceration (deep cut)" and was discharged home at 10:54 AM; and at 5:32 PM came back to the ED with a chief complaint of "psychiatric (mental) evaluation" and was discharged home at 11:29 PM. On 12/25/20, S/He was admitted at 11:10 AM with a chief complaint of a "Laceration" and discharged home at 2:30 PM; and at 8:22 PM came back to the ED with a chief complaint of a self-inflicted "arm injury" and was discharged home at 12:38 AM on 12/26/20. On 12/27/20 at 6:35 PM, Patient #1 presented to the ED unresponsive after a drug overdose and subsequently died on [DATE].

Per review of a provider's note from 12/23/20, Patient #1 presented to the ED for self-injury. Per the patient's report, the self-mutilation was caused by another identity. This personality found a razor blade and cut him/her-self and caused eight lacerations across the left forearm. Per the physician's physical exam, Patient #1 had "7 lacerations on the left forearm ...All lacerations are parallel to each other". S/He was "alert and oriented" and had "no agitation or thought disorder". Upon further review of the provider's note, "The patient does have a care plan in place which states provider may consult crisis for new concerns, but to only treat lacerations as medically necessary". The patient had "seven lacerations repaired ...40 sutures total". At 10:35 PM "Spoke to crisis who evaluated the patient". Patient #1 was "recently moved from a crowded homeless shelter where staff constantly checked up on" him/her "to an isolated hotel room. Crisis feels that" s/he "injured" him/her-self "again given the opportunity because" S/He "was isolated. They are comfortable with discharge because" s/he "will have full ......services soon". "The patient was discharged home" and was provided instructions to follow up with his/her primary physician and outpatient mental health provider.

Per review of a crisis note from 12/23/20 at 11:19 PM, Patient #1 reported to the Crisis Clinician that s/he was moved from one residence to another because the newer residence (a hotel) had increased supervision. S/He stated that his/her alter personality was "mad" about moving and had told Patient #1 that s/he would "die" at the hotel. Patient #1 reported that s/he "disassociated" and his/her alter went out and bought razors; and "disassociated" again and his/her alter cut his/her forearm seven times. It had been about a month since Patient #1's last episode of self-harm and S/He remarked that "it was the first time they have really been alone". Patient #1 reported that s/he felt "depressed and anxious" and that was because s/he was off his/her medications and was "doing everything alone". S/He stated that s/he did not have insurance until the first of the year; however, did have access to a couple of his/her medications. S/He expressed that s/he had not picked them up from the pharmacy because s/he feared the alter would use them to "overdose". The Crisis Clinician's mental exam revealed that Patient #1 was "Well-groomed", "Cooperative", "Alert and Oriented" with "Fair" insight and "Poor" judgment. Per the Crisis Clinician's risk assessment, Patient #1 as him/her-self did not have thoughts of suicide or self-harm; however, his/her alter caused harm to him/her today. The alters in the past had also caused extensive and severe lacerations, which necessitated skin grafting, medical admission, and blood transfusions. S/He also had a history of a drug overdose in 2018 and in the spring of 2020. The crisis clinician's clinical impression was that Patient #1's alters severely self-harm; however, Patient #1 as him/her-self denied any safety concerns. Patient #1 was "agreeable and able to properly safety plan". Patient #1 "has historically shown that inpatient admission due to self harm only causes and increase in severity and frequency of self harming upon d/c, therefore it is recommended that" Patient #1 "not be supported through inpatient admission at this time". The plan for Patient #1 was to discharge from the ED and to follow-up with his/her "provider" and "outpatient safety plan". S/He would be provided a "lock box for medications"; S/He "felt" that s/he was "able to dispose of razors"; and was "agreeable to talk to staff about checking in .... twice daily".

Per review of a psychiatry update note from 12/23/20 at 10:53 PM, "Psychiatry did not formally consult on this patient tonight due to a previously established explicit and extensively documented plan created in collaboration with the Psychiatry Consult Service", outpatient mental health provider, "Ethics, and Surgery during" Patient #1's "4/12/2020 hospital admission". The psychiatrist's assessment and plan revealed that s/he was "in agreement with the Crisis Clinician's assessment and plan" for Patient #1 from 12/23/20.

Per interview on 1/7/21 at 4:34 PM with ED Provider #1, s/he stated that if a patient presented with self-harm, the patient would be put on (suicide) "precautions" until s/he figured out what was going on with the patient. A medical screening would be done and then if the patient were cleared medically, a consult for a crisis counselor to evaluate the patient would be made. Regarding the case with Patient #1 on 12/23/20, Patient #1 had a history of self-harm behavior and that in his/her experience, cutting was a form of release and typically did not involve deep lacerations. In this case, Patient #1's lacerations were deep and when s/he had assessed Patient #1 for suicidality s/he "denied any suicidal ideation flatly". S/He stated that "one of" his/her "personalities engaged in these behaviors". ED Provider #1 stated that Patient #1 was a "frequent visitor to the ED" and that s/he had "read a care plan that said the patient would have these acute episodes when discharging would get worse". S/He stated that crisis had seen the patient, things were getting set up for him/her as an outpatient, and that they "were comfortable sending" him/her "home". S/He stated that Patient #1 was "re-assessed for suicidality multiple times" during his/her time in the ED. ED Provider #1 stated that s/he often involved "ancillary services" as s/he expressed, we "do not have the time to spend" discerning the best course of action and/or treatment for a psychiatric emergency and that crisis and psychiatry were the experts to help guide that process.

Per review of a provider's note from 12/24/20 at 10:16 AM, Patient #1 presented to the ED for a laceration. The patient had a significant history of self-mutilation by cutting requiring repairs, and this was his/her "third presentation in three days". Patient #1 was unaware of what happened, s/he remembered going to bed and noticed a large laceration on his/her left lower leg at 9:30 this morning. Patient #1 did not know what type of object was used to inflict the injury. Patient #1 shared with the provider that "'he' has been very suicidal as of late, this 'he'" Patient #1 "speaks of is presumed to be a dissociative identity". The physician's exam revealed that there was a "25 cm linear laceration to the left lower leg through the dermis". The patient had "no agitation or overt thought disorder". The physician had asked if Patient #1 had a plan in place for future episodes of self-mutilation and s/he stated "'he' has been pretty suicidal"; however, Patient #1 stated that s/he "is not suicidal". The patient also reported that s/he had outpatient counseling and could follow up with them. Patient #1's laceration was repaired, and s/he was discharged with instructions to follow-up with his/her doctor and outpatient counselor. S/He was also given instructions regarding wound care and pain control. The patient was re-evaluated by the physician immediately prior to discharge with "improved symptoms, normal vital signs .... discharged with a clear plan for outpatient follow-up".

Per review of a provider's note from 12/24/20 at 7:10 PM, Patient #1 presented to the ED for a psychiatric evaluation. S/He had been seen twice in the last 24 hours with several lacerations on right forearm and left lower leg both needing extensive repair. S/He had a crisis consultation last night and "ultimately felt like this was not a safety concern and patient was discharged in the ED on both occasions". S/He came back to the ED and stated that his/her alter told him/her that s/he would "cut to kill". Patient #1 contacted his/her outpatient support program and they referred him/her to the ED for an evaluation. Patient #1 reported to the provider that s/he "is feeling safe". Per the provider's exam, the patient was "alert and oriented. No agitation or overt thought disorder". The patient was evaluated by Crisis and the "Crisis Clinician felt that the patient behaviors were likely result of recent move from a shelter that had more support staff and more people around to a place there is more isolated". Patient #1 was also evaluated by psychiatry and "does not need hospitalization at this time". S/He "will be discharged back to" his/her "established living arrangement. I discussed with patient" and s/he "is agreeable to this plan".

Per review of a crisis note from 12/24/20 at 8:15 PM, Patient #1 had presented to the ED hours later than when the outpatient counseling service had encouraged him/her to do so and had arrived with two packed bags. S/He had told the Crisis Clinician that s/he was not sure what type of help s/he needed but stated that when his/her alter "'makes threats follows through'" "'this morning was a warning'" and that s/he would expect "either another OD or more deep cutting". And that the other personality's goal was allegedly to "'destroy the body'" as s/he "'doesn't want to be alive'". "She reported being scared of the next thing to happen" from his/her alter. Patient #1's mental status exam showed that s/he was "Well groomed", "Cooperative", "Alert and Oriented" with "Fair" insight ("puts up barriers to suggestions, recommendations to help") and "Fair" judgement ("cutting is excessively deep"). Per the Crisis Clinician's risk assessment regarding suicidality, Patient #1 "reportedly disposed of razors but found something this am to cut" him/her-self "with". "At this time, states with certainty that" his/her "alter will cut to kill ....as soon as ...is alone". The Crisis Clinician's interpretation was that Patient #1 had been "engaging in deep self harm cutting in the context of dissatisfactory housing with noisy roommate and less staffing". Patient #1 "may very well cut again tomorrow and end up in the ED". S/He "initially seemed to be seeking admission by coming with two packed bags ...Remains at chronic risk" to him/her-self. The plan for Patient #1 was to "discharge from the ED to Follow Up Provider" and for the outpatient crisis center to follow-up with housing about changing units.

Per review of a psychiatry note from 12/24/20 at 10:27 PM, the psychiatrist confirmed what the Crisis Clinician had reported that the incidents of self-mutilation were "just warnings" and that next time the alter would "cut to kill". Patient #1 expressed to the psychiatrist that s/he did not want to go to a higher level of outpatient care/support and/or stay in the ED overnight. Patient #1 was "calm, linear, organized, .... but ...demonstrated obvious black-and-white thinking and help seeking help rejecting behavior". Per review of the psychiatrist's mental status exam for Patient #1, s/he was "cooperative and apathetic"; mood was "neutral, mildly restricted, appropriate social reactivity"; oriented to "person, place, time"; with "fair" insight and "poor" judgment. Per review of the psychiatrist's assessment, "It has been previously established by the Psychiatry Consult Service, Ethics" and outpatient mental health provider "(during ...4/12-4/20/20 hospitalization )" that Patient #1 "does not benefit from inpatient psychiatric hospitalization and in fact demonstrates worsened self-mutilation after discharge. The patient will not be placed on an involuntary hold ...While the patient has what can be considered terminal psychiatric illness and has persistently high baseline risk of death by self-mutilation" s/he "clearly demonstrates symptoms of borderline personality disorder ...and should be allowed to discharge home from the ED, knowing that" his/her "self-mutilation will recur".

Per interview on 1/7/21 at 1:18 PM with ED Provider #2, s/he stated that there were several components to a safe discharge; the patient would be "medically stable to leave", there would be a "safety" plan to mitigate "self-harm risk", and there would be a "safe place to stay". S/He stated that determining a patient's capacity would be "case-by-case" and that crisis and psychiatry teams were heavily relied upon to help make the determination for patients if there was a question. S/He stated that regarding Patient #1 s/he had seen him/her on 12/23/20 and was only involved in helping to repair the patient's lacerations. Patient #1 had presented on the following day, 12/24/20, and had wanted to speak to crisis. ED Provider #2 stated that s/he spoke to psychiatry and crisis on that date and that Patient #1 was at her "baseline" and that s/he did not need "hospitalization ". Patient #1 "tended to escalate when more services were added". S/He stated that there was an "ED care plan" in place for Patient #1 and that "unless new change would not warrant a crisis clinician evaluation". The plan was for Patient #1 was to be discharged from the ED and for him/her to go back to the hotel s/he was residing in. ED Provider #2 stated that Patient #1's presentation was like times when s/he had presented to the ED in the past. Upon his/her evaluation of Patient #1 on 12/24/20, s/he was "calm, cooperative, pleasant, reasonable". S/He had a "linear thought pattern, did not seem off" his/her "baseline from when I had met" him/her "previously". S/He stated that for Patient #1, it was "up to the provider's discretion whether or not crisis was called".

Per interview on 1/7/21 at 2:31 PM with a Second Year Resident Physician (A stage of graduate medical education.), s/he stated that his/her role was to evaluate patients, write notes, make recommendations, admit, and discharge patients; and that all these processes were evaluated and approved by an Attending Physician (A physician who has completed residency and practices medicine in a clinic or hospital). S/He stated that the psychiatry service only evaluated patients after they had been assessed by a Crisis Clinician. S/He stated that a patient's capacity was based on their mental status exam and whether the patient was able to make a "single medical decision". S/He stated that s/he had first heard about Patient #1 on 12/23/20 from crisis. On 12/24/20, s/he evaluated Patient #1 and that s/he was "very well put together". S/He had his/her "hair done" and was dressed in "casual clothes". S/He had exhibited "linear, organized thinking". S/He "denied suicidal ideations, wanted to go home".
During an interview at that time with the Medical Director of ED Psychiatry, s/he stated that historically when Patient #1 presented to the ED s/he was not suicidal, his/her "alter" was suicidal. S/He stated that when Patient #1 had increased supports his/her condition had "worsened". S/He was "not able to be kept safe as an inpatient" and when s/he was discharged s/he had "escalated to a dangerous degree of self-harm". S/He stated that "further hospitalization s would be dangerous for the patient". S/He stated that the patient would typically present several days in a row with a "little escalation" and then the behavior would taper off, referring to this as an "extinction burst". S/He stated that s/he "came in all the time with very bad wounds". The "more support" s/he "got the worse" s/he "did". S/he stated that patients care plans were always "in flux" and that "every time they come in; they are re-assessed". S/He stated that in April of 2020 a multidisciplinary team (to include Ethics) meeting was held to discuss whether to involuntarily commit Patient #1 to receive further treatment. "They did not have a way to keep" him/her "safe". "Nothing to offer the patient". S/He stated that "Because overall nothing had changed globally, ultimately did not change the treatment recommendations". There was an "overall chronic risk in death by self-lacerations".

Per review of a provider's note from 12/25/20 at 12:21 PM, Patient #1 presented to the ED with a nine (cm) centimeter laceration with six branching lacerations, one centimeter perpendicular to the main laceration: and 4 cm, 3 cm, and 2 cm lacerations on his/her right ankle. Patient #1 reported that s/he took an Uber to the ED and that s/he "disassociated and cut" him/her-self. S/he denied any "current SI (suicidal ideation) but states that" his/her "'other person' desires to hurt her". Per the provider's physical exam, Patient #1 was "alert and oriented, appears comfortable". The provider contacted Crisis and they stated that Patient #1 would not be accepted to the higher level of outpatient care and that the "patient declined any further assessment from crisis. Crisis agreed to do a phone check ...later today". The patient's condition at departure from the ED was "Stable".

Per interview on 1/7/21 at 3:27 PM with ED Provider #3, s/he stated that when a patient presents as suicidal and/or with self-harm, the main goal was to "assess risk to harm to self or others". If it is "determined" that there is a risk of harm to self and/or others, then s/he would "get crisis involved". S/He further stated that a safe discharge plan would reflect how the patient could be discharged safely and that "everyone is on the same page". S/He stated that s/he had seen Patient #1 a "number of times". S/He stated that s/he "can't think of a time that" Patient #1 "did not present without the same complaint"; and that Patient #1 was "adamant" s/he "was not suicidal". ED Provider #3 stated that s/he had spoken to crisis while Patient #1 was in the ED and that they "did not feel that they needed to see" him/her. ED Provider #3 had asked crisis to call the patient at home. S/He stated that both crisis and psychiatry advised that Patient #1 was "ok" to be discharged . They "all agreed that it was a reasonable plan". S/He stated that s/he "knew looking at previous psychiatry documentation" that Patient #1 did not "benefit" from hospitalization .

Per review of a provider's note from 12/25/20 at 8:25 PM, Patient #1 presented to the ED via Emergency Medical Service for an arm injury. S/he has been seen in the ED multiple times in the past as well as earlier today and multiple times yesterday for self-inflicted wounds. Patient #1 reported that his/her "alter" was threatening to "kill" and that s/he "disassociated" and cut him/her-self. Per the physician's physical exam, Patient #1 was "Well appearing, in no acute distress"; his/her skin was with "multiple injuries in various stages of healing"; and s/he had "Normal speech, gait wnl (within normal limits), strength and sensation to light touch wnl". Patient #1 reported to the physician that his/her "injuries have been increasing lately because ...has been alone more often, which allows ...other personalities to injure ... more often". Upon exam his/her "tendon is clearly visible, no tendon injury and range of motion .... though limited at baseline due to ...multiple injuries, is not acutely worse". His/her wound was repaired, and crisis was consulted. "Crisis met with the patient, discussed with psychiatry, and agreed that the patient was appropriate for discharge". The patient was discharged with instructions for suture removal and to "return for any new or worsening symptoms".

Per review of a crisis note from 12/26/20 at 12:23 AM, Patient #1 explained to the Crisis Clinician that his/her "behaviors of late as being driven by one of" his/her "alters". And that the alter "'wants to be dead' and on some level there is a sense of resignation and hopelessness that" Patient #1 "does not have the capacity to subdue" their "intent". Patient #1 was scheduled to have an appointment with his/her outpatient case manager on 12/28/20 and then a psychiatrist on 1/12/20. Patient #1 reported that s/he was in "full control" and that s/he "denies current suicidality and dose not evidence plan or intent". S/He reported that his/her housing had changed because "they could not keep" his/her "safe". "Earlier in the year a treatment team from Psychiatry", Outpatient provider, and "ethics met to discuss protocol for ongoing care" due to the patients "level of self-harm that has led to the need for medically based admissions .... the team had decided to treat further occurrences in a more medically based palliative manner". The crisis clinician consulted with on-call psychiatry to include the attending physician, and "both doctors felt that discharge from the ED was appropriate course of action". "This writer will schedule twice daily phone checks over the next two days until" s/he "meets with Case Manager". S/He "is also encouraged to seek medical care at the ED if as needed which to date" s/he "has followed through with". Per review of the Crisis Clinician's mental status exam, Patient #1 was "Well groomed", "Alert and Oriented", with "Poor" insight and "Poor" judgment. The Crisis Clinician's risk assessment revealed that Patient #1's suicidality was "High for continuing acts of self-harm however no current stated intent or intent to die". The Clinician's interpretation was that "past history and current treatment states that inpatient admission and intensive OP (outpatient)therapy appears counter-productive for" Patient #1 "moving forward .... Historically" Patient #1 "has sought and accessed medical care as needed ....in consultation with psychiatry ..., it is recommended that" Patient #1 "discharge to follow up with established treatment team".

Per interview on 1/7/21 at 3:11 PM with ED Provider #4, s/he stated that when a patient presented to the ED with self-harm, a medical evaluation would be done to identify any acute medical issues. Once the medical issues were identified and addressed, a psychiatric evaluation would be done. S/He stated that Patient #1 presented to the ED with a "left arm laceration". The patient was "calm" and s/he "answered questions". S/He had other lacerations on the same arm as well as on both legs. ED Provider #4 stated that s/he closed the laceration, and that Patient #1 had no other medical issues. S/He stated that s/he "got the crisis person involved"; and stated that "what was unusual, crisis person told" him/her "that" Patient #1 "was a palliative case". S/He stated that s/he had been an ED provider for "27 years" and had "never heard that term applied to a psychiatric case before". S/He further stated that "crisis had spoken to the psychiatric resident" and "together made a decision did not need emergency hospitalization ". "Everyone felt that the patient was ok to be discharged ".

The above documentation demonstrates that the patient had a change in status and was not stabilized. S/He presented to the ED 5 times over the course of 3 days with significant self-harm injures. S/He had a change in housing, was living alone with limited supervision, had no health insurance, and a lack of appropriate medications. During numerous interviews and review of Patient #1's record, the providers continued to refer to a discussion that had taken place approximately eight months ago (April 2020) with a multidisciplinary group regarding the patient's care. There was no evidence that the patient's status was reassessed and no evidence of a written care plan and/or evidence of the patient's involvement in that plan during any of his/her visits to the ED on 12/23/20 through 12/26/20. There was also no further updated safety and/or treatment plan for Patient #1 that ensured Patient #1's stability and/or safety from self-harm.

Per review of the hospital policy "EMTALA-Medical Screening Examination & Stabilization Policy"-effective 1/1/2019, it read, "Stabilization of Psychiatric Emergencies: If an individual is expressing suicidal or homicidal thoughts or gestures and it is determined that he or she presents a danger to themselves or others, he or she is deemed to have an 'emergency medical condition'. Such an individual is stable when he or she is protected or prevented from injuring or harming himself or others .... Stable for Discharge .... For the purpose of discharging an individual with psychiatric condition(s), the individual is considered to be stable when he or she is no longer considered to be a threat to himself or herself or others".