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Based on interview, medical record review, video review, and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#10) of twenty Emergency Department (ED) records reviewed from 12/08/24 to 06/08/25. This failed practice had the potential to cause harm to all patients who presented to the hospital with an EMC.

Findings included:

Review of the hospital's document, "EMTALA Policy," dated 03/04/25, showed individuals who came to the ED with behavioral symptoms received an appropriate MSE and a behavioral health screening to determine if an EMC existed. EMC's manifested acute symptoms of sufficient severity, including psychiatric disturbances that placed themselves or others in danger, such as suicidal ideation (SI, thoughts of causing one's own death) and homicidal ideation (HI, thoughts or attempts to cause another's death) or gestures. If an EMC existed, the hospital provided further medical examination and any stabilizing treatment necessary within the capability of the hospital and staff. Stabilizing treatment assured no further likely deterioration of the individual's condition.

Review of the hospital's policy titled, "Patient Refusing Treatment/Leaving Without Being Seen/Leaving Against Medical Advice (AMA)," updated 04/15/25, showed a patient had the right to refuse medical care and treatment when deemed capable and competent to make choices concerning health care. If the patient was judged to be acutely incapacitated standard medical intervention was indicated. The provider had the duty to treat suicidal or homicidal patients. It was the responsibility of hospital personnel to initiate appropriate intervention to secure the safety of patients, visitors, or employees, from individuals who demonstrated suicidal or homicidal gestures or were non-compliant with recommended treatment. Patients presenting to the ED with psychiatric symptoms or verbalization of psychiatric symptoms, and the provider screening determines a psychiatric consult is appropriate, the patient may not sign out AMA or discharge until the psychiatric consultation is complete and disposition is determined by the providers. The ONLY patients who can leave AMA while on a hold/uncleared from psychiatric professionals or have psychiatric professional recommendations for any disposition other than discharging home, are the patients who are under, or taken into, the custody and control of law enforcement. Law enforcement is advised against removing the patient from emergency care services until clearance is complete, other safety concerns for the patient's wellbeing have resolved, or Law enforcement receives verbal and written risks and benefits of the patient receiving psychiatric assessment and care from the care team. If law enforcement still wants to remove the patient from the ER, immediately alert the director or manager of the department, house supervisor and senior leadership on call. An AMA form will be signed by law enforcement. If law enforcement refuses to sign the AMA form, staff are to document the refusal with two signatures.

Review of the hospital's policy titled, "Use of Force Policy," dated 08/02/10, showed the use of force necessary to control a situation or individual would be justified when the clear and present danger of bodily injury to the security officer or another person was immediately present; when making an arrest; and when attempting to control a violent patient. Security officers were authorized to carry firearms and tasers with a valid weapons permit. The hospital ensured that security officers would only use the degree of force that was reasonably necessary to bring an incident under control. A security officer was authorized to use non-deadly force to protect himself or another person from physical harm; to restrain a person resisting a lawful arrest; or to bring an unlawful or unsafe situation under control. Whenever a security officer used force in any form they would complete a detailed written report prior to the end of their watch.

Please refer to 2406 for further details.


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Based on interview, medical record review, video review, and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#10) of twenty Emergency Department (ED) records reviewed from 12/08/24 to 06/08/25. This failed practice had the potential to cause harm to all patients who presented to the hospital with an EMC.

Findings included:

Review of the hospital's document, "EMTALA Policy," dated 03/04/25, showed individuals who came to the ED with behavioral symptoms received an appropriate MSE and a behavioral health screening to determine if an EMC existed. EMC's manifested acute symptoms of sufficient severity, including psychiatric disturbances that placed themselves or others in danger, such as suicidal ideation (SI, thoughts of causing one's own death) and homicidal ideation (HI, thoughts or attempts to cause another's death) or gestures. If an EMC existed, the hospital provided further medical examination and any stabilizing treatment necessary within the capability of the hospital and staff. Stabilizing treatment assured no further likely deterioration of the individual's condition.

Review of the hospital's policy titled, "Patient Refusing Treatment/Leaving Without Being Seen/Leaving Against Medical Advice (AMA)," updated 04/15/25, showed a patient had the right to refuse medical care and treatment when deemed capable and competent to make choices concerning health care. If the patient was judged to be acutely incapacitated standard medical intervention was indicated. The provider had the duty to treat suicidal or homicidal patients. It was the responsibility of hospital personnel to initiate appropriate intervention to secure the safety of patients, visitors, or employees, from individuals who demonstrated suicidal or homicidal gestures or were non-compliant with recommended treatment. Patients presenting to the ED with psychiatric symptoms or verbalization of psychiatric symptoms, and the provider screening determines a psychiatric consult is appropriate, the patient may not sign out AMA or discharge until the psychiatric consultation is complete and disposition is determined by the providers. The only patients who can leave AMA while on a hold/uncleared from psychiatric professionals or have psychiatric professional recommendations for any disposition other than discharging home, are the patients who are under, or taken into, the custody and control of law enforcement. Law enforcement is advised against removing the patient from emergency care services until clearance is complete, other safety concerns for the patient's wellbeing have resolved, or law enforcement receives verbal and written risks and benefits of the patient receiving psychiatric assessment and care from the care team. If law enforcement still wants to remove the patient from the ED, immediately alert the director or manager of the department, house supervisor and senior leadership on call. An AMA form will be signed by law enforcement. If law enforcement refuses to sign the AMA form, staff are to document the refusal with two signatures.

Review of the document titled, "Investigation-Event Description," dated 05/09/25, showed that on 05/08/25 at 7:02 PM, law enforcement escorted Patient #10 to the ED with two affidavits (a written statement confirmed by oath, for use as evidence in court) stating he was homicidal and needed evaluation. Medical treatments were ordered, including psychiatric medications. The patient was medically cleared and was awaiting a telehealth (remote delivery of healthcare services while the health care provider is at a separate location, including exams and consultations, through video and telephone communication) psychiatric assessment. The medications administered made the patient tired, and he was unable to participate in his evaluation. He was returned to the queue since he could not participate in the assessment. While he awaited to be assessed, he became aggressive. He shouted, paced and made sexually inappropriate comments. He verbally threatened staff despite their attempts to de-escalate. He lunged towards a staff member and grabbed him by the throat. Two Registered Nurses (RNs) and a security officer used nonviolent crisis intervention training (NVCI) techniques to escort the patient into his room and onto the floor. He attempted to grab the security officer's weapon and screamed that he was going to shoot everyone. The security officer then placed him in handcuffs and sat him up. Law enforcement was contacted, and he was charged with assault. Staff informed law enforcement that the patient was "medically cleared" and he was escorted from the ED.

Review of the hospital's undated video titled, "C182 Emergency Room 1 Hall (V1) 20250509_031757.mp4," showed:
- At minute 00:02, Staff G, RN, and another male staff member walked from the nurse's station to the patient's room directly across the hall. Staff G pointed to the patient's room from the hallway as he walked, while the other staff member stood at the door.
- At minute 00:22, Staff G appeared to give direction and attend the patient from the hallway.
- At minute 00:39, both men walked back to the nurse's station outside Patient #10's room.
- At minute 00:49, Patient #10 stood in his doorway dressed in a brief. Staff appeared to direct him to his room.
- At minute 1:28, the patient opened his door wearing a brief and began to leave his room. Staff appeared to direct him back into his room. Staff G approached. They turned lights on and remained near the closed glass door.
- At minute 1:47, Staff G opened the door and appeared to converse with the patient. Another male staff remained close by but out of the patient's view.
- At minute 2:21, both men walked to the nurse's station outside the door.
- At minute 2:35, both men were at the patient's room, and again the Patient came to them in his brief. Staff G continued to point to the inside of his room. Patient #10 remained at the doorway and conversed with staff.
- At minute 3:09, the patient appeared increasingly agitated by pointing his finger as another male approached.
- At minute 3:14, security approached the hallway outside his door.
- At minute 3:22, staff grabbed gloves from the hallway. Staff G pointed to his room and the patient walked inside.
- At minute 3:30, the patient, male staff and Staff G were in the doorway when Patient #10 lunged at Staff G and placed his hand on the nurse's throat. Staff G, the assisting staff member, and a security guard grabbed the patient's shoulder and arm and pushed him into his room. Another staff member assisted. Four staff and the patient were inside his room out of view of the camera.
- At minute 3:37, multiple staff members approached the hallway outside the room.
- At minute 3:41, a cart was pushed against the inside of the glass door.
- At minute 4:00, glass doors were released to swing open for more room in the doorway.
- At minute 4:12, a cart was pushed out into the hallway. Additional staff remained gloved in the hallway ready to assist.
- At minute 5:02, a mattress was taken from the cart in the hallway and placed inside the room.
- At minute 6:08, a nurse gave something to staff inside room.
- At minute 6:59, all staff walked out of the room.
- At minute 7:25, all staff went to the nurse's station just outside the room.
- At minute 8:15, the security guard walked away.
- At minute 8:30, staff spoke with the patient. Other staff continued to walk past the patient's room.
- At minute 9:59, the video concluded.

Review of the document titled, "Interviews," dated 05/09/25, showed the event investigation by leadership included interviews with witnesses to the event. Staff members stated that the patient was escorted to the ED by law enforcement. They were familiar with his condition. Staff attempted to keep him calm by administering Tylenol and a nicotine patch, along with his routine medications, while he waited for a psychiatric assessment. He continued to escalate and threaten. Staff were preparing to administer additional medications to calm him down when he grabbed a nurse by the throat. During the incident, the patient reached for the security officer's weapon and said he was going to shoot the staff. Patient #10 was then placed in handcuffs for approximately seven to 15 minutes. He was monitored by staff until law enforcement arrived. Law enforcement was told that he was medically cleared but hadn't received his psychiatric assessment yet.

Review of the hospital's policy titled, "Use of Force Policy," dated 08/02/10, showed the use of force necessary to control a situation or individual would be justified when the clear and present danger of bodily injury to the security officer or another person was immediately present; when making an arrest; and when attempting to control a violent patient. Security officers were authorized to carry firearms and tasers with a valid weapons permit. The hospital ensured that security officers would only use the degree of force that was reasonably necessary to bring an incident under control. A security officer was authorized to use non-deadly force to protect himself or another person from physical harm; to restrain a person resisting a lawful arrest; or to bring an unlawful or unsafe situation under control. Whenever a security officer used force in any form they would complete a detailed written report prior to the end of their watch.

Review of the document titled, "First Responder Meeting Minutes," dated 05/22/25, showed Staff F, ED Director, and Staff J, Risk Management Director, presented an update on the EMTALA policy. They discussed AMA paperwork to be signed by law enforcement if a patient was arrested and still awaiting the completion of their psychiatric assessment. Staff in attendance agreed with the process change.

Review of the undated document titled, "ER Medical/Mental Health Clearance AMA Disposition with Law Enforcement," showed a flowchart indicating that patients with psychiatric symptoms would receive a MSE and psychiatric screening prior to disposition. The only patients allowed to leave AMA prior to medical or psychiatric clearance would be patients taken into custody by law enforcement with a signed AMA form.

Review of the ambulance report titled, "Incident #: 25-0961," dated 05/08/25, showed:
- At 9:15 AM, EMS arrived at Patient #10's home where he sat on sidewalk steps speaking with police. He was excited with rapid breaths. His chief complaint was recorded as a behavior episode that included anxiety, delusional disorders, and worries. He was uncooperative.
- The patient asked if EMS was going to hurt him and if he was going to die. When paramedics assured him and asked questions, he answered with more questions that were not logical to the conversation. His pulse (normal pulse/heartbeats for adults range from 60 to 100 beats per minute [bpm]) was strong and fast. They asked permission to gather his vital signs (VS, measurements of the body's most basic functions).
- At 9:25 AM, his VS showed he was alert, his blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80), was unobtainable because he moved his arms in conversation, his pulse was 135 bpm, his breaths were 24 per minute, his oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) was 98% without assistance.
- His breathing was shallow and rapid, so they placed a nasal cannula (NC, a lightweight tube with two prongs for insertion into the nostrils and delivery of oxygen) on 2 liters of oxygen into his nose and coached him to breath slower.
- At 9:33 AM, he was alert, his BP was unobtainable, his pulse was 120 bpm, breaths were 18, and oxygen saturation was 99% with assistance of oxygen.
- EMS spoke with the patient's grandmother who owned the home. She stated that he acted strangely that morning. He had a history of mental disorder. Another family member called the police on her behalf.
- When EMS discussed going to the hospital, the patient cried stating that he didn't know what was wrong. Paramedics told the patient he needed to go to the hospital for a medical diagnosis and he expressed a fear of dying and spoke of his religious beliefs. He agreed to go to the hospital with EMS.
- At 9:43 AM, he was alert, his BP was 124/91, pulse was 121, breathing was 18, oxygen saturation was 98%.
- In the ambulance, he was alert and oriented to who he was, where he was, and the event taking place. He was not oriented to time. He had trouble obeying commands and questioned the motives of EMS's assessments. Assured by the paramedics, he allowed assessment of his head, neck, face, shoulders, chest, abdomen and all extremities. No abnormalities were found. His right ankle was wrapped in an ACE bandage. He refused to share information about his injury.
- The patient denied any medical history and refused to sign ambulance documentation.
- At 9:45 AM, EMS transferred care to Cass Regional Medical Center.

Review of Patient #10's medical record dated 05/08/25, at 9:46 AM, showed:
- Prior to arrival, Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) reported the patient was anxious, uncooperative but non-combative.
- Upon arrival Patient #10 told ED staff he did not know why EMS brought him in. His chief complaint was anxiety. Limitations included altered mental status (any change in a person's mood, behavior, psychomotor skills, and/or cognition). During triage he asked the nurse, "You're not going to kill me, are you?" He denied SI, HI, or the need for medical attention. He requested to leave AMA.
- He was alert and oriented, his pulse was elevated at 119 bpm and all other vital signs (VS, measurements of the body's most basic functions) were within normal limits (WNL).
- At 10:01 AM, he was assessed by a provider. Physician notes stated the patient's grandmother informed law enforcement that he was acting strangely. The patient stated he wanted to have sex with girls and play video games. He was slightly confrontational and sexually inappropriate with staff, experienced occasional anxiety, but otherwise denied any complaints. A review of systems was normal. A psychiatric examination showed the patient was anxious and manic (elevated or exited mood or behavior). Physician documentation showed that he interpreted the electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions), but none were found in the record. No other testing was completed.
- At 10:35 AM, discharge notes indicated he had "normal cognitive status," and his chief complaint was stabilized. The patient was able to answer questions with no altered mental status. A signed note stated he was treated for panic attack and leaving AMA, but final records indicated he was discharged home. There was no signed AMA paperwork included in the medical record.

Review of Patient #10's medical record dated 05/08/25, at 7:02 PM, showed:
- He returned to the ED in the custody of law enforcement for SI and HI. He threatened to kill his sister and her boyfriend. He wanted law enforcement to shoot the boyfriend and himself.
- At 7:05 PM, an order was placed for a behavioral health evaluation via telehealth. He was determined to be acutely psychotic (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature). He was pacing and was undressed. His heart rate was elevated at 125 bpm and his BP was elevated at 172/96.
- Physician documentation showed he had leukocytosis (an increased number of white blood cells in the blood, especially during an infection), slight metabolic acidosis (condition where too much acid accumulates in the body and can be related to a buildup of body toxins or kidney failure) and a potassium (mineral in the blood or body fluid) level of 3.3. Laboratory values showed an elevated blood glucose (sugar) of 152. A urine drug screen was presumptive positive for marijuana.
- Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) and Geodon (an antipsychotic medication used to treat schizophrenia and the manic symptoms of bipolar disorder [manic depression]) were administered, in addition to some of his home medications and oral potassium (mineral in the blood or body fluid) replacement. The patient slept when his telehealth mental evaluation prompted. He was placed back into the queue.
- At 9:19 PM, nursing documentation showed Patient #10 asked the sitter (a person assigned to continuously observe a patient within close proximity, to ensure their safety) for a "blowjob," the patient was told by security to go back to his room.
- At 10:13 PM, Patient #10 received Geodon after threatening to shoot a security officer in the head.
- At 10:27 PM, nursing documentation showed Patient #10 was told again to not make inappropriate comments toward staff after asking the sitter if he could give her an orgasm.
- On 05/09/25 at 3:03 AM, he woke up from the initial medications and requested Tylenol for a headache and a nicotine patch. Both were administered.
- At 3:17 AM, the patient continued to yell obscene things about orgasms and made lewd comments toward the sitter.
- At 3:21 AM, nursing documentation showed the patient became agitated, grabbed a nurse by the throat requiring additional staff members to intervene. He was placed in handcuffs by security and the local law enforcement was contacted. While he sat on the floor handcuffed, he yelled, "I am smarter than you, I'm the smartest man on the planet, I have never had an orgasm."
- At 4:07 AM, he was transferred into the custody of law enforcement with diagnoses of acute psychosis (a serious mental illness characterized by defective or lost contact with reality), bipolar one (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), fatigue (weakness or tiredness), and HI.
- His psychiatric evaluation was not completed prior to his discharge into law enforcement custody.

During a telephone interview on 06/10/25 at 1:26 PM, Staff H, ED Medical Director, stated that a psychiatric evaluation was part of a mental health patient's screening. The hospital utilized telehealth mental health providers. Patient #10 was known to refuse telehealth on previous ED visits. He was placed in the queue to await a psychiatric assessment. If patients were not able to participate in the telehealth psychiatric assessment, they were moved to the bottom of the queue to wait for another attempt. Patient #10 presented angry, refused to speak with staff and then escalated. Medications were administered, but he remained a threat to the ED staff. Law enforcement responded to assist, and he told them he wanted to go to jail. The responding officers indicated that they could take him into custody since he choked a staff member. Patient #10 was medically stable and was awaiting his psychiatric assessment. He expected staff to de-escalate mental health patients earlier in the process by responding to the needs they voiced.

During an interview on 06/10/25 at 9:45 AM, Staff F, ED Director, stated that complete MSEs for mental health patients required both physical and psychiatric evaluations.

During a telephone interview on 06/10/25 at 12:23 PM, Staff G, RN, stated that Patient #10 frequented the ED related to his medication non-compliance. He removed his clothes and was wearing only an adult diaper. He threatened to harm staff with a gun and was constantly yelling sexual obscenities at the sitter. His physical assessment and medical clearance were completed, and he was awaiting the psychiatric evaluation. His HI continued after he received his home medications, and the comfort measures staff provided for his complaints. He became agitated with Staff G and choked him. Staff G was unaware of who called law enforcement. He would call law enforcement if staff members were in danger.

During an interview on 06/10/25 at 10:49 AM, Staff E, Security Supervisor, stated that security encouraged the ED staff to call law enforcement when necessary to keep patients, staff and visitors safe. Law enforcement officers typically did not intervene, they would stand by to ensure safety. Patient #10 committed assault when he attempted to choke a staff member, which was a potential felony. Staff E stated that when the "elements of a crime were there," it was up to law enforcement to decide whether to detain the individual. Hospital staff members informed the police officers of the hospital's obligation to psychiatric patients at a recent quarterly meeting that was held with local first responders.

During an interview on 06/10/25 at 2:33 PM, Staff I, Quality and Patient Safety Director, stated the investigation of Patient #10's event prompted a change in the hospital's AMA policy which included law enforcement's role when patients were taken into custody prior to the completion of their MSE. Local first responders were educated in a quarterly meeting regarding the hospital's obligation under EMTALA. Event algorithms were posted in the ED and given to staff to provide guidance in certain situations. Correction plans included chart audits that involved various diagnoses, including psychiatric complaints. She expected clear communication between law enforcement and the hospital staff. Law enforcement was expected to remain with the patient until all assessments were completed and medical staff permitted them to escort the patient out.


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