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Based on observation, record review, and interview, the facility (Hospital A) failed to comply with 42CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases.

Based on record review, and interviews, the facility (Hospital A) failed to perform and document an appropriate medical screening examination (MSE) in the emergency department (ED) to determine if the patient was stable or had an emergency medical condition for one of twenty patients (Patient #7) whose records were reviewed, in that:

Patient #7 was experiencing a potential psychiatric emergency which resulted in the patient's family calling the local police department and EMS (emergency medical services) to have Patient #7 transported to the facility A's emergency department (ED). The police observed Patient #7 with a handgun pointing at his head.

Facility A did not provide Patient #7 with a comprehensive assessment that included a psychiatric evaluation by a qualified medical professional (QMP) to determine if Patient #7 had an emergency medical condition that could have included a psychiatric emergency


See Tag 2406

Based on record review, and interviews, the facility (Hospital A) failed to perform and document an appropriate medical screening examination (MSE) in the emergency department (ED) to determine if the patient was stable or had an emergency medical condition for one of twenty patients (Patient #7) whose records were reviewed, in that:

Patient #7 was experiencing a potential psychiatric emergency which resulted in the patient's family calling the local police department and EMS (emergency medical services) to have Patient #7 transported to the facility A's emergency department (ED). The police observed Patient #7 with a handgun pointing at his head.

Facility A did not provide Patient #7 with a comprehensive assessment that included a psychiatric evaluation by a qualified medical professional (QMP) to determine if Patient #7 had an emergency medical condition that could have included a psychiatric emergency.

The findings included:

Record Reviews of Facility A:

A review of Facility A's policy titled, "Emergency Medical Treatment and Labor Act" (EMTALA) (revised, 12/17) read in part, "The [Facility's name] will provide an individual that is not a patient who comes into the emergency department, an appropriate MSE within the capability of [Facility's name] including ancillary services routinely available to the ED to determine whether or not a EMC exits, regardless of the individual's ability to pay. The EMTALA obligations are triggered when there has been a request for medical care by a individual within the dedicated emergency department (DED) or when an individual requests emergency medical care on hospital property, other than in the DED. If an EMC is determined to exist, [Facility A's name] must provide any necessary stabilizing treatment within its capabilities of the staff and facilities available at [Facility A's name] or an appropriate transfer.

A review of the Patient #7's medical record included an emergency medical service (EMS) report.

A review of the EMS report dated, 03/30/2025 revealed in part, "33-year-old male [Patient #7] under ED (emergency detention) warrant, A&OX's 4 (person is fully alert and oriented to person, place, time, and situation), GCS -15 (Glasgow Coma Scale-used to assess level of consciousness. 15-normal), right knee pain secondary to psychiatric emergency with SI (suicidal ideation). History of right knee surgery." Further review revealed the following vital signs for Patient #7: B/P- 140/100, HR-120, RR-24, and SPO2-99%.

A review of Patient #7's medical record revealed that the patient was a 33-year-old male who presented to Facility A's emergency department via EMS accompanied by the local police under emergency detention warrant on 03/30/2025 with a chief complaint of suicidal ideation (SI). Patient #7 had attempted suicide by firearm.

Further review of Patient #7's medical record included a 2-page document titled, "Physician Documentation - HPI." dated 03/30/25 at 12:30 AM.

A review of page one of the "Physician Documentation-HPI" revealed in part, "33-year-old male [Patient #7] here per police for suicidal ideation. Sister called, patient [#7] found with handgun in hand due to knee pain. under EDW (emergency detention warrant) for SI. Past medical history, PTSD (post traumatic stress disorder)."

Further review of the "Physician Documentation-HPI" revealed the following documentation:
Physical Exam: Vital signs reviewed, no acute distress, no respiratory distress.
Psychiatric: suicidal ideation (SI) with plan, to shoot self.
Differential diagnosis: Suicidal ideation, depression.

A review of the "Triage Assessment" completed on 03/30/2025 at 12:45 AM by ED RN Staff G which indicated, "Pt brought in by EMS and law enforcement after having a suicide attempt with a fire arm. Per law enforcement officer, Pt had a weapon pointing to his head; Law enforcement officer stated that he was able to convince the Pt not to use the weapon on himself and was able to take the weapon from him. Pt also c/complained of right knee pain and states his knee "popped" earlier today. Pt also states he had been drinking earlier today; Pt states he had 24 beers."

A review of the past medical history for Patient #7 revealed he had a history of neurological problems, head trauma, brain injury and TBI (traumatic brain injury).

Treatments/Interventions: Labs: blood/alcohol/urine toxicology and x-ray of right knee.

The lab results revealed a read back protocol was initiated and ED Physician Staff D was notified at 2:01 AM of a Critical Lab- blood alcohol level was 273 mg/dL. Additionally, an X-ray of the right knee revealed no fracture or dislocation, no trauma and no acute findings.

The ED provider notes completed on 03/30/2025 at 1:55 AM revealed a Suicide risk assessment was completed by ED/RN Staff G- and revealed the following:
"Ideation:
Suicide Ideation: Vague
Suicide Plan: Vague
Major Depressive Episode: Y
Feelings of Hopelessness: Y
History:
Previous Suicide Attempts: Y
Suicide Attempt Method: Shooting
Hx Family Suicide: N
Hx Panic Disorder: N
Hx of Recent Loss: N
History of Substance Abuse: Y
Substance Use: Alcohol
Competency:
Thought Process: Intact
Delusions Not Present
Hallucinations None
Impulse control Description Fair
Daily Functioning:
Patient Appearance: Well Groomed
Loss of Daily functioning: N
Sleep Symptoms: Restlessness, Difficulty Falling Asleep, Insomnia
comprehension Ability: No Impairment
Oral Expression Ability: No Impairment
Written Expression Ability: No Impairment
Risk:
Suicide Risk Degree: High
Precautions Needed, Close Observation, Suicide Risk Precautions
Suicide Risk Assessment Comments:
Suicide Screening:
Thoughts of Suicide? N
Thoughts That Life is Not Worth Living? Y
Feeling Depressed of Hopelessness? Y"

Further review of the ED provider notes did not include documented evidence that Patient #7 was observed under suicide precautions, or documentation of the one-on-one observation of this patient.

A review of page two of the "Physician Documentation-HPI" in the "Medical Decision Making" section revealed the following documentation by ED Physician Staff D 03/30/25 at 2:30 AM.
"Differential Diagnoses: 1-Suicidal Ideation, 2-Depression.
Imaging ordered: X-ray of right knee. Results-negative
Labs: Hematology and Chemistry. Noted blood alcohol level-273
Final Diagnosis: Alcohol Intoxication.
Patient Disposition: AMA (against medical advice).
Notes: "Patient did not want to wait for alcohol level to go down prior to psychiatric evaluation, signed out AMA. Police contacted once patient [#1] left our facility [A]."

2:30 AM - Discharge Summary:
Final diagnosis: Alcohol intoxication.
Patient #7 with alcohol intoxication and suicidal ideation. Unable to get consultation with Facility B. Patient #7 did not want to wait for alcohol level to go down prior to psychiatric evaluation. Patient #7 signed out against medical advice and eloped from the emergency department (ED). Local police department contacted once Patient #7 left the ED at 0230 AM.

2:27 AM - Disposition: patient left AMA.

2:30 AM - Facility A's ED Staff contacted police.

3:43 AM- Facility B (behavioral healthcare) notified Facility A that Patient #7 was in their custody.

Facility A's Document Reviews:

A review of the EMS report dated 03/30/25 stated that the patient (#7) is a 33-year-old male under ED (emergency detention) warrant. A& O 'X's 4 (person is fully alert and oriented to person, place, time, and situation). Patient #7 with right knee pain secondary to psychiatric emergency with SI.

A review of the document titled "Notification or Emergency Detention" dated 3/29/25 time, 11:10 PM, revealed in part, " 1. I have reason to believe that Patient #7, evidences mental illness ...2. I have reason to believe and do believe that Patient #7 evidences a substantial risk of harm to himself or others based upon the following: "wanted to commit suicide by gun. Does not want to live due to emotional and physical pain." 3. I have reason to believe and do believe that Patient #7's risk of harm is imminent unless Patient #7 is immediately restrained. 4. My beliefs are based upon the following recent behavior: overt acts, attempts, statements, or threats, observed by me or reliably reported to me, attempted suicide."

A review of facility A's document titled, "Emergency Department Release Form Responsibility For Refusals" dated 3/30/25. This document was checked and signed by Patient #7 under LAMS (Left after medical screening exam), against the advice of the attending physician or hospital authorities.

A review of Facility A's document titled "Psychiatric Emergency Flow Chart" (revised 09/01/21) revealed in part: "The Peace Officer may use the following indicators to determine if a medical emergency exists: · Overdose · Acute intoxication with alcohol or drugs · Chest pain · Fluctuating consciousness · Stab wound, bleeding, or serious injury · Seizure activity · Complications from Diabetes · Injured in assault or flight · Victim of a sexual assault · Person is a resident of a nursing home or assisted living facility. Note: With the elderly, sometimes medical problems can cause symptoms that look like mental illness but are not. It is important to rule out medical problems as the cause. Further review of the Psychiatric Emergency Flow Chart included a diagram of what to do once the peace officer determines that the individual is in a crisis, they are to take the individual either to a in-patient psychiatric facility or if there is a medical emergency they are to bring the individual to a medical hospital until the individual is stabilized and medically safe for law enforcement to transport to a mental health authority.

Staff Interviews:

During an interview with ED, RN Trauma Coordinator Staff F, on 4/21/25 at 3:00 PM, she stated that when a patient presents to the emergency room under an emergency detention, the police officer must remain with the patient until they are transferred to the accepting unit (facility). Staff F further stated that Facility A does not have a psychiatric unit and does not have police department and no security on site. Staff F stated that in the event of a patient who becomes aggressive, they do have a panic button to alert the local police department who will respond, and send police to the ED.

During an interview with the ED-Medical Director Staff C on 4/23/25 at: 11:28 am, that he was made aware of the incident regarding Patient #7, that the patient presented to the ED via EMS accompanied by police office under emergency detention for SI. He further stated that Patient #7 was a war veteran and had a history of post traumatic stress disorder (PTSD). Staff C stated that the Attending physician Staff D had asked the police officer to remain with Patient #7, because he was aggressive and intoxicated, but the police office refused and left. Staff C stated that Patient #7 became aggressive with the nurses and ran out through the trauma doors.

Staff C further stated, when a patient presents to the ED with suicidal ideation (SI) and is under emergency detention, the facility is to provide an MSE, any labs/imaging to ensure there is no emergency medical condition (EMC), stabilize and medically clear the patient for mental health evaluation and then transfer patient to inpatient mental health facility or safety plan as determined by the mental health evaluation.

Staff C stated that three nurses had been assaulted by aggressive patients and their facility does not have ability to hold patients down. Staff C stated asked the local police department, that patients brought under emergency detention must stay with patients until transferred to inpatient unit after evaluation with MHMR. Staff C stated that when patients become aggressive, the ED nurses are instructed to move away, back off, and contact police department immediately after they walk out the door.

During an interview with ED/Physician Staff D on 4/23/25 at: 12:38 PM, Staff D stated that during MSE, Patient #7 stated that he had been drinking heavily, had an extensive gun collection. It was reported by police that the family called, was concerned that the Patient #7 would hurt himself. Per police officer, Patient #7 had gun to his head. Per police Patient #7 was taken to MHMR facility for Psychiatric evaluation, but refused to take Patient #7 until medically cleared, had to take Patient #7 to the nearest emergency department (Facility A) for medical clearance.

Staff D stated that Facility A's ED does not have security, and it is expected that the police officer remains with the patient until they are medically cleared. Staff D stated if the patient becomes violent the officer is to remain with patient until they are medically cleared. Staff D stated that when Patient #7 presented to ED under emergency detention, the nurses asked police officer to remain with the patient, the police officer refused, stated, no.

Staff D stated that initially, Patient #7 was cooperative, agreed to do urine and blood samples and asked the patient to remain until all care was provided, and behavioral health evaluation done by MHMR. Staff D stated when the police officer left, Patient #7 became agitated and threatening towards ED staff, stated that if he wanted to leave, no one in the ED could stop him. Staff D stated that he explained to the patient that he was not being held against his will, and that he just needed to complete his medical clearance and his evaluation. Staff D stated that Patient #7 said, " I do not care, I am going to leave out the door."

Staff D stated that Patient #7 was told by ED staff that he would have to sign and AMA form and that ED staff would have to call the police because he did not complete the medical clearance. Staff D stated that Patient #7 agreed to sign the AMA form and walked out the trauma doors; and ED staff contacted the police.

Staff D stated that this is what he and the ED staff were instructed to do by the Medical Director. That they are to call the police department when a patient becomes aggressive, they are to allow the patient to leave to protect the staff. That is what we are instructed to do.

During an interview with RN ED/Charge Nurse Staff E on 4/23/25 at 1:59 PM,
Staff E stated that she was made aware of the incident, but was not on duty that day. Staff E stated that based on her review of Patient #7's medical record, he was brought via EMS to the emergency department for attempted suicide, was accompanied by police officer under emergency detention and eloped. Staff E stated, that when a patient presents to the ED with SI, the patient is placed in a safe room. She stated that all belongings, anything that the patient could harm themselves with is removed. Staff E stated a complete work up to do labs, (hematology/chemistry) imaging, x-ray done to stabilize and medically clear patient. Staff E stated that once medically cleared will contact Facility B for psychiatric consultation/evaluation. Staff E stated, "from my understanding, the police officer is supposed to stay with patients under emergency detention until the patient is medically cleared and are to accompany patient to inpatient facility. But they never do." Staff E stated, "when a patient that is under emergency detention and leaves before, they are medically cleared, when that occurs, we are to call the police and inform that patient has left."