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Based on record review, interview, and observation it was determined that the hospital failed to comply with CFR)(s) 489.24(a) & 489.24(c) and provide an appropriate screening for one of 26 patients (Patient #26).

On the late evening of 05/23/21, Patient #26 presented to the hospital campus under a peace officer emergency detention for a psychiatric crisis. The officer contacted the hospital's Intake Department for Patient #26's assessment by ringing the doorbell on the first floor locked hospital door. Per phone, Intake staff informed the officer that the hospital was on divert. The peace officer left the campus and transported Patient#26 to another hospital where the patient was emergently admitted that night to stabilize the patient's suicidal ideation.

Cross Refer to A2406

Based on record review, interview, and observation it was determined that the hospital failed to provide an appropriate screening of one of 26 patients (Patient #26).

After evidencing a substantial risk of serious harm to himself, Patient #26 presented to the hospital campus under a peace officer emergency detention the night of 05/23/21. The officer rang the bell to contact the Hospital Intake Department for a patient screening. Per phone, the hospital's Intake staff failed to inquire about Patient #26 and advised the officer that the hospital was on divert. The peace officer left the campus and transported Patient #26 to Hospital B where the patient was admitted that night with suicidal ideation and self-mutilating behavior.

Findings included:

Observations on 06/01/21 at 1100 and approximately 1500 evidenced that visitor entry into the hospital required contacting hospital staff through a doorbell located at the first and fifth floor locked entry doors. Staff answered the bell and granted access.

Record review of an email dated 06/07/21 at 1932, Peace Officer #9 confirmed that Peace Officer #10 was on the Hospital A campus with Patient #26 the night of 05/23/21.

Record review of Hospital A's Intake log did not reflect an intake assessment dated 05/23/21 between 2200 and 2300.

During a telephone interview on 06/01/21 at 1509 Hospital A Personnel #5 stated he received a call from a police officer on 05/23/21. The officer informed Hospital A Personnel #5 that "he wanted to bring somebody in." Hospital A Personnel #5 informed the officer that the hospital was "on divert." Hospital A Personnel #5 was surveyor asked whether it was possible that the officer and the patient were on campus at that time and answered "yes." Hospital A Personnel #5 denied asking for the officer's location or a patient name at that time.

Notification of Emergency Detention dated 05/23/21 at 2338 reflected the Peace Officer #10 had "reason to believe that ...(Patient #26) evidences a substantial risk of serious harm to himself or others...he was sending text messages of him hurting/cutting himself... stating he was suicidal ..."

Record review of Patient #26's Hospital B's Rapid Initial Assessment dated 05/23/21 at 2307 reflected Patient#26 had wished to be dead for over a month and wanted to "just stop breathing." Patient #26 had scars from self-mutilation. The patient was noted with auditory hallucinations and paranoia. Prior to his admission, the patient had consumed two bottles of whiskey.

Patient #26's Hospital B's Inpatient Physician Admission Orders dated 05/23/21 at 2335 reflected preliminary diagnoses that included Major Depressive Disorder. The patient was placed on special close observational status for suicide precautions. The admitting physician certified that the patient needed inpatient hospitalization due to his suicide risk, incapacitating Anxiety and/or Depression and intrapersonal crisis. Outpatient treatment was not indicated. Discharge goals for Patient #26 included a decrease in depression and hopelessness.

During an interview on 06/01/21 at approximately 1730, Hospital A Personnel #3 stated an inquiry regarding the officer's location at a time of divert "would have been a good question to ask."

Review of the hospital policy Number GBH.Intake.016 titled "Log of Individuals Presenting for Emergency Services" dated 01/2021 reflected the policy that the hospital "will ensure that all individuals who present themselves for emergency services are documented on the Emergency Medical Treatment and Active Labor Act (EMTALA) log."