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Based on observation and interview, the hospital failed to post the patient rights signage in required areas for patients seen at the Emergency Department (ED).

This failure had the potential for individuals to be uninformed of their rights to receive emergency medical care under the Emergency Medical Treatment and Labor Act (EMTALA -the law requiring treatment of all patients requesting care at the ED.

Findings:

During an observation on 4/28/25 at 10:18 AM, at the ED pediatric waiting room, there was no visible EMTALA sign posted.

During an observation and concurrent interview on 4/28/25 at 10:28 AM, with the Emergency Department Manager (EDM), in triage rooms A and B, there were no visible EMTALA sign posted. EDM stated, "We don't have any inside the rooms. They're up front, they're only in the waiting room so the public can see them. I've been here for forty years; I've never seen them in triage (rooms)."

During an observation on 4/28/25 at 10:30 AM, there were patients inside treatment rooms 1, 2, and 4. There was no visible EMTALA sign posted in the rooms. When queried if there were EMTALA signs posted in any of the treatment rooms, EDM stated, "No."

During an interview on 5/1/25 at 9:30 AM, with Registered Nurse (RN)1, RN 1 said, patients brought in by ambulance are triaged in the Emergency Medical Services (EMS -system that responds to emergencies in need of highly skilled pre-hospital clinicians) bay or the outside rooms. RN 1stated, "They would not go to the waiting room prior to triage."

During an interview on 4/30/25 at 9:23 AM, the Accreditation and Licensure Manager (ALM) stated, "We don't have a policy on the ED postings."

Based on interview and record review the facility to complete a Medical Screen Examination (MSE-screening used to determine whether a patient has an emergent medical or psychiatric condition and treatment for one out of 20 sampled patients (Patient 20) when Pt 20 was brought in by ambulance after attempting suicide by ingesting 60-70 pills and was not supervised until an MSE had been performed and left the facility while unattended prior to being screened by a doctor.

This failure had the potential of Pt 20 for delay in psychiatric treatment, ability for second suicide attempt and potential death.

Findings:


During a record review of Patient 20's, ED (Emergency Department Notes) and Timeline, dated 3/26/25, with Informatics Coordinator was reviewed. The ED patient care timeline, indicated per RN 2 Pt 20 was brought into the ED by ambulance on 3/26/25 at 3:45 p.m., due to an attempted suicide by taking 60-70 pills of hydroxyzine (medication used to help control anxiety and tension caused by nervous and emotional conditions, overdose symptoms (may include drowsiness, uncontrolled muscle movements or seizures)). RN 2, on 3/26/25 at 3:51 pm. completed, Pt 20's, Columbus Suicide Severity Rating Scale" (a unique suicide risk assessment tool that supports suicide risk assessment through a series of simple plain-language questions where the assessment would be graded from low, moderate, high and extremely high) Pt 20 scored, "High Risk" on the assessment tool. RN 2 on 3/26/25 at 3:52 p.m. completed the triage for Pt 20 and determined Acuity Level 2 (1-5 level acuity with 1 being immediate treatment required for life saving interventions, 2. Emergent, pt should be seen as soon as possible by a doctor and so on). RN 4 on 3/26/25 at 3:52 pm. called for security to come to the ED. RN 2 on 3/26/25 at 4:03 pm. had indicated Pt 20 had verbalized there was no immediate intent to hurt herself was placed on a bed in the hallway and had observed Pt 20 leave the ED with a "steady gait" and no further documentation regarding communication with Pt 20 was observed in the medical record. RN 4 on 3/26/25 at 4:06 pm was notified that Pt 20 had left the ED without being seen by MD and per the medical record, no further actions were taken by the facility. The medical record did not indicate that security had presented to the ED before Pt 20 had left or that Pt 20 had returned to the ED after the encounter on 3/26/25.

During a concurrent interview and record on 4/30/25 at 9:29 a.m. with RN 2, "ED Triage RN Note" dated 3/26/25 at 3:45 pm. was reviewed and RN 2 stated Pt 20 was brought into the ED by ambulance for attempted to commit suicide but did not have an 5150 hold (72- hour emergency psychiatric hold which would allow for involuntary detention as initiated by a qualified mental health professional) by reviewing the nursing notes and from memory. RN 2 reviewed, "ED Note", dated 3/26/25 at 4:03 pm. which indicated RN 2 had observed Pt 20 leave the ED without being seen or evaluated by a doctor. RN 2 stated Pt 20 was not on a legal 5150 hold and could not be held so there was nothing to be done to make the patient stay in the ED. RN 2 stated if Pt 20 was on a legal 5150 hold then she would have been on a one-to-one watch with security to observe and if she had left then the police would need to have been called but this wasn't the case here.

During a interview on 4/30/25 at 10:39 am. with RN 3, RN 3 stated if a patient had an intentional overdose of a medication and wanted to leave before being evaluated by a doctor, the doctor would be called right away. RN 3 stated, "we would not just let the patient walk out, oh God no!". RN 3 stated especially with medications in the patient's system, there could be a delayed effect so the policy would be followed of not letting the patient be alone and requiring a physician to evaluate them before they leave. RN 3 stated the doctor would make the final decision in determining capacity if they (the patient) would be trying to further harm themselves and might place them on a 5150 hold or allow them to leave if the patient had capacity to make that decision. RN 3 stated that they would talk with the patient and to try and get them to stay while trying to get the doctor in the room to evaluate the patient as soon as possible.

During a concurrent interview and record review on 4/30/25 at 12:40 pm. with RN 4, RN 4 stated after reviewing, "ED Note", dated 3/26/25 at 3:52 pm that security was called to watch Pt 20 until the Pt 20 could be evaluated by an ED doctor or psychiatry doctor. RN 2 reviewed the nursing note dated 3/26/5 at 4:03 pm., stated in this situation, security had not come to the unit, the Pt had left before the doctor was able to evaluate and usually there would be an attempt to try and prevent the patient from leaving. RN 4 could not explain why this did not happen in this case.

During an interview on 4/30/25 at 1:29 pm. with Lead Security Guard (LSG), LSG stated, the ED nurses would call the security department to come and watch a psychiatric patient who had not been evaluated by a doctor or psychiatrist yet because they do not want the patient to leave or do not want the patient to hurt themselves until they had been evaluated. LSG stated if a psychiatric patient had been placed on a 5150 hold, then the security department would provide 24-hour one-to-one observation until the patient had been discharged or transferred from the ED. LSD stated usually when the call would come in from the ED to request an observation guard, it takes about 5 minutes to get to the unit, unless we are in the middle of doing something else. LSG could not explain when the security guard arrived to the ED since there was no documentation and Pt 20 had left without being evaluated by a doctor (documentation for the security guard starts with observing the patient).

During an interview on 5/1/25 at 10:00 with MD3, MD3 stated if a psychiatric patient wants to leave before being evaluated then the nursing staff would "grab one of us quickly to evaluate them to see if it would be safe for them to leave, we can perform a quick assessment". MD3 stated that sometimes we try and get them to stay with meals, while we are waiting for the results of tests and try and de-escalate and talk to them about why they should stay. MD3 stated the ED can be a busy and chaotic place where things change within seconds and sometimes the nurses can't find us to evaluate, it just depends.

During a concurrent interview and record review on 5/1/25 at 1:08 pm with Emergency Department Manager (EDM), EDM stated the expectations for the nursing staff in the ED would be for patients with a psychiatric complaint of suicidal ideation (contemplation about ending ones' own life) or attempted suicide or homicidal ideation (thoughts about harming or killing another person) to be to have security at the bedside to provide 1:1 supervision or ensure the nurse remains until security was at the bedside and ensure the patient had been evaluated by the doctor and or psychiatry (doctor) after the medical screening for determination of a 5150 hold screening status. Patients are not allowed to leave until the doctor can evaluate them and if there was an escalation then the doctor would need to get in there to evaluate. The nurse would need to document the attempt to have them stay because they can't do the medical screening. A review of Pt 20's ED notes dated 3/26/25 at 4:03 pm. was reviewed and EDM stated she did not know who RN2 was as the name was not familiar and the nurse did not document the attempt to have Pt 20 remain in the ED until the medical screen could take place. EDM stated she could not explain why this did not happen as it was the expectation of the nurses in the ED.

During a review of the facility's policy and procedure titled, "Policy-Care of the Behavioral Health Patient," dated 10/19/23, indicated "Patient's who present on a voluntary basis who are a danger to themselves, others, or gravely disabled ...High risk patients will be under constant visual observation, unless the Emergency Department physician or physician from the psychiatry service is in the patient's room and chooses to close the door ...All high-risk voluntary behavioral health patients in the Emergency Department), will also remain under direct visual observation by Security unless the ED physician or physician from the psychiatry service is in the patient's room and chooses to close the door for privacy. A qualified clinical designee may be chosen to observe the patient, in lieu of Security, as long as the patient is deemed to non-violent and a Security officer is located in the department. A high-risk voluntary behavioral health patient includes the following: ...Any patient with behaviors, symptoms, or history identified by any evaluating nurse, physician, or clinician suggesting that they are potential danger to self, danger to others, or gravely disabled will identified as high-risk behavioral health patient ...Guidelines for the care of these patients include: 1. Immediately room the patient in a private room ...4. Initiate 1:1 continuous monitoring ...5. Contact Security for assistance ...8. The patient must be under constant visual observation. This may be accomplished by the presence of a security officer, or clinical staff member. This includes the use of the bathroom. The clinical staff will inform the patient of the process and purpose of constant visual observation. 9. The Security officer, or clinical staff designee, assigned to the patient will be given a brief report by the patient's primary nurse upon the officer's arrival. The security officer (or designee) will have primary responsibility for keeping the patient in sight and keeping the patient safe ...B. If the patient on a high-risk behavioral health patient elopes: 1. The Charge RN will notify the Police Department immediately and provide a physical description. 2. If there is a reasonable belief the patient may be in the immediate area of the Medical Center, a search may be made by Security ...".

During a review of the facility's policy and procedure titled, "Policy-Leaving Hospital Against Medical Advice," dated 4/21/22, indicated, "An adult patient who has capacity *(if patient lacks capacity see policy "Leaving Against Medical Advice-Incapacitated Patient") has the right to decide whether or not to submit to medical treatment. However, before a patient is discharged prior to the completion of treatment or contrary to medical".

Based on interview and record review, the facility failed to provide the stabilizing treatment for an emergency medical condition (EMC) within its capabilities for one of 20 sampled patients (Patient 11) when Patient 11 presented to the emergency department for suicidal ideation (thoughts or plans of ending one's own life) and was discharged (sent/leave to) home without any physician reassessment after she was observed by nursing staff to be "screaming and ramming her head into the wall repeatedly," immediately prior to discharge.

This failure has the potential for patients with unstabaliazed EMCs to be discharged resulting in deterioration of the patient's condition.

Findings:

A review of facility policy and procedure titled "Policy - Medical Emergencies on the Van Ness, Davies, and Mission Bernal Campuses and in Outpatient Clinics and Departments Not Contiguous with the Main Campus (EMTALA)", dated as effective 04/17/25, indicated, "Patients with Emergency Medical conditions will receive evaluation and treatment within the capability of the facility and the avaialable qualified medical personnel necessary to assure, within reasonable medical probability that the Emergency Medical Condition has been relieved and/or no material deterioration [worsening] to the condition is likely to result from, or occur during, a transfer, transport, or discharge."

A review of a facility provided ambulance report, dated 02/14/25, indicated the San Francisco Fire Department (SFFD) responded to a call for Patient 11. The ambulance report indicated that upon arrival by the Emergency Medical Services (EMS, pre-hospital medical care and transportation often by ambulance), "patient [11] is in handcuffs because she attempted to cut her wrists in front of PD [Police Department]. The patient has as Hx [medical history] of PTSD [Post-traumatic Stress Disorder, a mental health condition due to experiencing an extremely stressful event] and depression with previous suicide attempts ...the patient is placed on a 5150 hold [a 72-hour involuntary psychiatric evaluation and temporary detention for individuals who may be a danger to themselves, to others, or gravely disabled due to a mental health disorder] by SFPD [San Francisco Police Department].

A review of a facility provided document titled "APPLICATION FOR UP TO 72-HOUR ASSESSMENT, EVALUATION, AND CRISIS INTERVENTION OR PLACEMENT FOR EVALUATION AND TREATMENT [5150]", dated 02/14/25, indicated a police officer detained Patient 11. The document further indicated Patient 11 "stated she was depressed and had PTSD," and the police officer "witnessed [Patient 11] take out a knife and attempt to cut her wrist".

During a concurrent interview and record review on 05/01/20 at 9:29 AM with Registered Nurse (RN) 1, Patient 11's ED triage RN Note, dated 02/14/25, was reviewed. The ED triage RN note indicated that Patient 11 "with several recent SI [suicidal ideation] attempts ... 5150 placed for SI, patient attempted to self cut [sic]. No abrasions [damage to skin caused by scraping] or lacerations [break in skin] as bystander intervened. Calm, cooperative." RN 1 stated most of his assessment came from EMS report and he only recalls what is in his note about how the patient presented to the ED.

A review of Emergency Department (ED) Provider Note written by Medical Doctor (MD) 1, dated 02/14/25, indicated that "Psychiatry who evaluated the patient [Patient 11] in the emergency department and feels that the patient does not currently meet 5150 criteria however given her history of cognitive [memory, thinking, and/or reasoning] impairment and significant psychiatric history he [psychiatrist] recommends that the patient be seen by social worker prior to discharge in order to facilitate a safe discharge ... given the patient's cognitive decline, there is some concern for her return to her facility. Psychiatry is advising that she discuss with the daytime social worker a safe discharge plan."

A review of a psychiatric consult note written by MD 2, dated 02/14/25, indicated MD 2 assessed patient as having a "baseline elevated risk level for suicide." The psychiatric consult note further indicated, "Despite an elevated baseline risk, she [Patient 11] does not appear above this risk today, and there is insufficient evidence to warrant inpatient psychiatric hospitalization or an LPS [Lanterman-Petris-Short Act, similar terminology to indicate an involuntary psychiatric evaluation and temporary detention like a 5150] ...Primary focus should tailor towards enhancing her ability to navigate psychosocial stressors." The psychiatric consult note by MD 2 indicated under the plan section, "SW [social work] has been consulted ...Psychiatry Reassessment in the AM [morning], SW to continue to see weekend care options who can help facilitate re-orienting her back home."

During a concurrent phone interview and record review on 05/01/25 at 4:27 PM with Social Worker (SW) 1, a care team social services note for Patient 11, dated 02/14/25, was reviewed. The note indicated, "The case had been discussed with [MD 2] ...Pt [patient] is linked to [behavioral health clinic], but the [sic] are only available during regular business hours. Psychiatry may consider re-assessing the patient in the morning if clinically indicated [appropriate]. Pt will board [stay] in the ED overnight." SW 1 stated Patient 11 was "not able to participate in conversation ...that's why we decided to board her in the emergency room." SW 1 further stated Patient 11's "therapists in the community were not available ... her assigned APS [Adult Protective Services, agency that responds to reports of abuse, neglect, exploitation, and self-neglect involving older adults and adults with disabilities] social worker was not available...that's why we decided to observe her." SW 1 stated Patient 11 was to stay in the ED over the weekend as Patient 11's community resources were unavailable.

A review of a care team social services note for Patient 11 written by SW 2, dated 02/15/25, indicated SW 2 reassessed Patient 11 at 11:41 AM "to meet with patient to assist with discharge planning, as per psych [psychiatry]." The note further indicated, "Throughout >1.5 hour conversation with these SWs, patient [11] repeated her desire to return home to commit suicide at least 10 times. She was unwavering in her SI with plan and intent. This SW's attempts to safety plan with [Patient 11] were entirely unsuccessful. Patient expressed strong desire to die by suicide either by stabbing herself in the heart or slitting her throat ...she is intent on carrying through with this plan." The note further indicated, "After consulting with psych resident [MD 4], psych re-evaluated and does not recommend inpatient hospitalization ...he [MD 4] recommended someone meet patient at her housing to remove knives from her possession." The note also indicated SW 2 called an APS SW who reiterated to SW 2 that "she feels it would be unsafe to discharge patient given her current presentation." The note also indicated SW 2 called EMS personnel who also "feels it would be unsafe to discharge patient given her current presentation." Finally, the note indicated SW 2 called the SFPD non-emergency line and was told that "they [SFPD] would need a warrant to remove someone's knives."

During a phone interview on 04/30/25 12:09 PM with SW 2, SW 2 was asked about her assessment of Patient 11. SW 2 stated, "it was quite a long assessment ...I was working with her for a couple of hours ...she [Patient 11] reiterated that she was feeling suicidal ... she had a plan of how to do it ... she told me about the reasons why she was in that mindset ..." When asked if safety planning [a patient-centered process to create a plan to enhance safety in settings of crisis or potential harm] with Patient 11 was successful, SW stated, "it was unsuccessful ... she [Patient 11] was not able to say how she was going to keep herself safe." SW 2 further stated that she "consulted with community agencies" to see if anyone could meet with Patient 11 after discharge. SW 2 stated she spoke to an APS SW and an EMS agency, but they were unable to meet with patient immediately after discharge. SW 2 concluded that Patient 11 "was consistent in her inability to safety plan with me [SW 2] ...She did not want to go home and keep herself safe."

During a concurrent interview and record review on 04/30/25 at 3:00 PM with MD 4, Patient 11's psychiatric progress note written by MD 4, dated 02/15/25, was reviewed. The psychiatric progress note indicated Patient 11 "made statements about using a knife to cut herself, but there were no signs of actual injury on evaluations made by EMS or the ED ...The patient's capacity to leave the hospital is: Marginal ...Though they [Patient 11] are unlikely to harm themselves and suicide is mitigated [made less severe], they are not actively willing to participate in conversation about safe discharge and active help. They are emotionally motivated and upset, near their psychiatric baseline ..." When asked what MD 4 meant by marginal capacity to leave, MD 4 stated, "part of the discussion I had with safety planning with our social work team is that there is a lot of fear that they [Patient 11] are safe to go home." MD 4 went on to state that Patient 11 was able to communicate a choice of wanting to go home and per his assessment she continued to be at her baseline elevated risk for suicide as indicated by prior admissions. When asked what type of assessment or behavior would change Patient 11 from baseline that would warrant admission, MD 4 stated Patient 11 currently has "Contingent [dependent on] SI [suicidal ideation] versus non-contingent SI ... her [Patient 11's] suicidal ideation was largely contingent ... if she was allowed to change apartments ...another factor we were thinking ...if there was a wound or active bleeding ... it would make us more inclined [likely] to keep her [admit patient into the hospital]."

A review of a care team social services note for Patient 11 written by SW 1, dated 02/15/25, indicated "SW team worked on this case yesterday and today ... [Patient 11] does not have any support at home to be included into her safety plan ...Pt is unable to remain safely at home at this time. Pt's outpatient provider ar [sic] only available during regular business hours: On-site CM [case manager] ...APS SW ... [behavioral health clinic] Outpatient Team ...I am unable to secure Pt's safe DC [discharge] this weekend d/t [due to] to [sic] this particular set of circumstances."
During a concurrent interview and record review on 05/01/25 at 2:27 PM with SW 3, SW 3's social work note titled "ED Case Management Transition of Care Plan" for Patient 11, dated 02/16/25 was reviewed. The social work note indicated, "SW met with patient at bedside ...Pt unable to engage in safety planning at this time as she remains fixated on sharing her story ... at this time, pt still unable to engage in solution focused discussion (moving to a different apartment, engaging in support from friends, caregiver support) and continues to verbalize desire to go home so she can end her life ...Discussed case with [RN 5] who noted that pt is cleared by psychiatry and attending. SW left for a brief period of time, but was requested by RN to return to bedside as pt was 'banging her head on the wall.' Pt emotionally elevated and screaming that she wants to kill herself now and that she no longer wants to go home ...[RN 5] discussed with psychiatry team who maintains no further evaluation is needed ...SFPD noted plan to assist with discharging pt and helping her re-present to [other hospital] for further evaluation." SW 3 stated she met with Patient 11 and, "essentially spent the whole day with her ... she was initially calm ... she was expressing SI the whole time ...I wasn't able to engage or have a discussion on safety planning." SW 3 recalled that RN 5 messaged her to return to bedside as Patient 11 was banging her head against the wall; when SW 3 came to bedside she saw that the patient was back in bed and "she was much more escalated in her emotions."

During a concurrent interview and record review on 05/02/25 at 8:39 AM with MD 5, MD 5's ED Note for Patient 11 titled, "ED OBSERVATION PROGRESS NOTES - Psychiatric care" dated 02/16/25 at 6:58 AM was reviewed. The note indicated, "The patient's current clinical status is not changed ...patient seen by social worker who arranged for safe disposition." MD 5 stated typically for psychiatric patients, once psychiatry has discharged a patient, he would "eye-ball them" [quickly observe] prior to writing his observation note.

During a concurrent interview and record review on 05/02/25 at 8:39 AM with MD 5,
RN 5's nursing note, titled "ED Notes Addendum", dated 02/16/25 at 1:29 PM was reviewed. RN 5's note indicated "This RN was attempting to discharge pt [Patient 11] at this time. This RN asked pt where she would like to go and would she like to go home. PT starting to have incongruent thought stating she wants us to call police. PT screaming and ramming her head into the wall repeatedly. Nursing staff helped pt back to bed to protect patient from hurting herself. Security and social worker at bedside trying to placate [make less angry] patient." MD 5 stated he was not notified or aware of Patient 11's actions at time of discharge. MD 5 further stated "it would have been nice to inform me if something like this happens ... it's definitely not normal behavior."

During a concurrent interview and record review on 04/30/25 at 3:00 PM with MD 4, RN 5's nursing note, titled "ED Notes Addendum", dated 02/16/25 at 1:29 PM was reviewed. RN 5's note indicated "This RN was attempting to discharge pt [Patient 11] at this time ... PT screaming and ramming her head into the wall repeatedly." MD 4 stated he was not the psychiatrist that was paged about Patient 11's actions at time of discharge. When asked if this behavior would warrant an admission, MD 4 stated the behavior "may warrant a reassessment ... [it] could be an admission ... or not an admission ...I think it would be reasonable to come evaluate them [Patient 11] ...at least we can lay eyes on them again ... feel the similar confidence when we signed the [psychiatric] note."

A review of a nursing note, tilted "ED notes", dated 02/16/25 at 1:35 PM by RN 5 indicated "This RN paging Psych at this time."

A review of a nursing note, tilted "ED notes", dated 02/16/25 at 1:51 PM by RN 5 indicated "SFPD at bedside at this time."

A review of a nursing note, tilted "ED notes", dated 02/16/25 at 1:57 PM by RN 5 indicated "Per Psych MD there is no need to further evaluate patient and is fine with PD escorting patient off of the property."

During an interview on 05/01/25 at 1:34 PM with MD 6, MD 6 stated he "got paged by an RN sometime in the afternoon ...asking me if the patient [11] was okay to be discharged ... although they were banging their head ..." MD 6 stated, "based on what I gleaned ... she was at her baseline." When asked what information he used to make the decision that Patient 11 was at her baseline, MD 5 stated only the conversation with the nurse. When asked what documentation he read prior to the patient's discharge, MD 6 stated "just [MD 4]'s note"; MD 6 stated he did not read any SW notes. When asked if he physically assessed the patient after being paged, MD 6 stated "no." When asked if he discussed this discharge with his attending physician [a fully licensed physician that oversees a care team and the work of residents] he stated, "no."