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Based on interview, record review, digital video recording review and policy review, the hospital failed to maintain an accurate central log for patients presenting to the Emergency Department (ED) for care when they failed to enter one patient (#23) on the ED log, and provide within its capability and capacity stabilization for one patient (#3) of 23 ED records reviewed from 02/15/24 through 07/15/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC).

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition)," revised 12/13/23, showed the following:
- Any individual presenting to an SSM Hospital or dedicated ED requesting emergency care receives a medical screening examination (MSE) conducted by Qualified Medical Personnel to determine the presence of an EMC.
- In the event an individual presents with an EMC, ED staff will provide stabilizing treatment to the extent of the hospital's capability and capacity and, if indicated, provide an appropriate transfer to another hospital.
- An EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity including psychiatric (relating to mental illness) disturbances and substance abuse such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy.
- A MSE is an examination which is sufficiently detailed to reveal whether the patient suffers from an EMC, which includes an individual under the influence of drugs or alcohol, or an individual expressing suicidal (to cause one's own death) or homicidal thoughts (HI, thoughts or attempts to cause another's death) or gestures, and must include medically indicated screens, tests, mental status evaluations, history and physical examination, etc.
- Stabilized means that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility.
- The MSE must be provided within the capability of the hospital's ED, including ancillary services routinely available to the ED, to determine whether or not an EMC exists.
- If an EMC is determined to exist, all ministries shall provide any necessary stabilizing treatment or provide an appropriate transfer.
- Psychiatric patients are considered stable when they are protected and prevented from injuring or harming him/herself or others.
- A central log would be maintained containing information on each individual who came on the hospital campus requesting assistance. This documentation would occur whether the patient left before an MSE could be performed or if they refused treatment.

Based on interviews, record review, digital video recording review and policy review, the hospital failed to maintain an accurate central log for patients who presented to the Emergency Department (ED) for care. The hospital failed to enter one patient (#23) on the log of 23 records reviewed from 02/15/24 through 07/15/24. This failure had the potential to affect all patients that presented to the ED. The hospital's average monthly census was 3,235.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition)" dated 12/13/23, showed any individual who presented to the ED would receive a medical screening exam (MSE) to determine the presence of an emergency medical condition (EMC). The medical personnel would provide stabilizing treatment to the extent of their capability. Individuals had the right to refuse a MSE if they chose to leave before evaluation and treatment. The medical record would contain a description of the exam and treatment that was refused by the individual. Psychiatric patients were considered stable when they were protected and prevented from injuring or harming themselves or others. A central log would be maintained containing information on each individual who came on the hospital campus requesting assistance. This documentation would occur whether the patient left before an MSE could be performed or if they refused treatment.

Review of Patient #23's medical record showed he was a 64-year-old man brought to the ED by Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) on 06/13/24 at 7:10 PM, for possible heat exposure. He had a normal physical assessment, normal mood and behavior, and denied suicidal ideation (SI, thoughts of causing one's own death). An electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) and chest X-ray (test that creates pictures of the structures inside the body-particularly bones) were unremarkable. He was given IV (in the vein) fluids and was able to eat and drink in the ED. Repeat blood work showed improvement after the IV fluids. He was diagnosed with non-traumatic rhabdomyolosis (serious syndrome due to muscle injury where the muscles bread down), weakness, and heat exhaustion and discharged on 06/14/24 at 1:45 AM.

Review of the EMS D record titled, "Prehospital Care Report," dated 06/14/24, showed at 3:20 AM Patient #23 wanted to go to the hospital. He became aggressive and combative with EMS and then the ED staff. The ED staff told the patient to leave, and security escorted the patient off the hospital's property.

Review of the video footage from the DePaul Hospital ED on 06/14/24 showed:
- At 3:38 AM EMS entered the ED with Patient #23 on a stretcher.
- At 3:39 AM two ED staff members approached the patient and EMS crew and appeared to interact calmly. A security guard stood nearby watching the patient.
- At 3:40 AM the patient stood up off the stretcher and started walking followed by the security guard. EMS staff stayed in the ED and conferred with the ED staff.
- At 3:41 AM Patient #23 walked out of the ED into the ambulance bay. Two security officers walked several paces behind him. The patient raised two middle fingers as he walked away. The officers followed him at a distance.
- At 3:42 AM the EMS crew left the hospital in the ambulance.

Review of the hospital's undated spreadsheet titled, "EMTALA ED and OB," showed a central log of ED and OB patients who presented for care. Patient #23 was found on the log for his visit on 06/13/24. His encounter when he presented with EMS on 06/14/24 was not logged in this spreadsheet.

During an interview on 07/16/24 at 2:54 PM, Staff T, ED Charge Nurse, stated that she received the EMS report about patient #23. She could not register the patient because he was uncooperative and didn't want to give his information. When asked about EMS having the patient's information, she stated that in hindsight they could have made a chart.

During an interview on 07/17/24 at 9:00 AM, Staff AA, ED Medical Director, stated that all patients who presented to the ED should be logged, even if they declined care.

Based on interview, record review, and policy review, the hospital failed to ensure that emergency medical conditions (EMC) were stabilized for one patient (#3) of 23 Emergency Department (ED) sample cases reviewed from 02/15/24 through 07/15/24, when they were discharged with an unstable medical condition.
Findings included:
Review of the hospital's policy titled, "Emergency Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition)," revised 12/13/23, showed the following:
- The hospital is committed to compliance with the requirements of EMTALA and will ensure any individual presenting to a dedicated ED requesting emergency care receives a medical screening examination (MSE) conducted by Qualified Medical Personnel to determine the presence of an EMC.
- In the event an individual presents with an EMC dedicated ED staff will provide stabilizing treatment to the extent of the hospital's/dedicated ED capability and capacity and, if indicated, provide an appropriate transfer to another hospital with the capability and capacity to treat the individual.
- An EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity including psychiatric (relating to mental illness) disturbances and substance abuse such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy.
- A MSE is an examination which is sufficiently detailed to reveal whether the patient suffers from an EMC, which includes an individual under the influence of drugs or alcohol, or an individual expressing suicidal (to cause one's own death) or homicidal (HI, thoughts or attempts to cause another's death) thoughts or gestures, and must include medically indicated screens, tests, mental status evaluations, history and physical examination, etc.
- Stabilized means that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility.
- If an EMC is determined to exist, all ministries shall provide any necessary stabilizing treatment or provide an appropriate transfer.
- Psychiatric patients are considered stable when they are protected and prevented from injuring or harming him/herself or others.

Review of the Emergency Medical Service (EMS, emergency response personnel, such as paramedics, first responders, etc.) document titled, "EMS Incident 011467," dated 03/09/24, from EMS G, showed that Patient #3's chief complaint was paranoia and he had been off his medications. He had a medical history of anxiety (a feeling of fear or worry experienced intermittently), bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows) and schizophrenia (serious mental disorder that affects a person's ability to think, feel and behave clearly) and his mental status was documented as anxious, paranoid (excessive suspiciousness without adequate cause) and manic (elevated or excited mood or behavior). Upon arrival to the scene the patient was awake and alert, standing in the driveway with police. Patient #3 reported to EMS that he wanted to go to a mental health facility because he did not feel safe and he thought there were a lot of people coming after him and his family. He had not slept in two days and had been off his medications for at least six months. A verbal report was given to staff at SSM DePaul ED.

Review of Patient #3's medical record dated 03/09/24, from Hospital A, showed the following:
- He arrived at the hospital via EMS at 3:50 PM, for paranoid behavior and not making sense.
- Vital signs (VS, measurements of the body's most basic functions) were within normal limits and a physical examination showed he was awake, alert and paranoid.
- A behavioral health assessment showed Patient #3 reported a mental health history but was unable to state his diagnosis. The patient reported a history of suicidal ideation (SI, thoughts of causing one's own death), paranoia and auditory hallucinations (AH, hearing things that are not heard by others, imaginary) but denied suicidal behavior, HI, suicidal actions and visual hallucinations (VH, seeing things that are not seen by others, imaginary). He reported a history of using ecstasy but had not used it in about three years. He drank alcohol once per week and had his last drink a few days prior. The patient was able to contract for safety outside of the hospital but was not able to show forward thinking. Aggressive behaviors included getting into a fight earlier in the day at a fast food restaurant.
- A calculated Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) showed there was no risk indicated.
- Mental status symptoms included paranoid delusions (false ideas about what is taking place or who one is) and AH with increased severity and frequency. A mental status examination showed he had poor insight, with a calm, flat, distracted and suspicious mood/affect (the expression of emotion or feelings displayed to others). His behavior was cooperative with good eye contact, but he was distracted.
- A Patient Health Questionnaire 2 (PHQ-2, a brief screening tool for major depression [a long period of feeling worried or empty with a loss of interest in activities once enjoyed], a score of three or greater indicated major depressive disorder is likely) showed a score of three. The patient reported feeling down, depressed or hopeless nearly every day. The score prompted a Patient Health Questionnaire 9 (PHQ-9, a brief screening tool that can assist clinicians with diagnosing depression and monitoring treatment response, a score of 20-27 indicated severe depression, and treatment should include antidepressants with or without psychotherapy) to be completed and the patient scored a 21.
- Nursing documentation showed that Patient #3's family called and expressed many concerns for Patient #3, but the family was unable to get to the hospital to complete an affidavit (a written statement confirmed by oath, for use as evidence in court).
- No ancillary testing was completed, and no medications were administered during the ED visit. Central intake determined that Patient #3 did not meet inpatient criteria and the patient would follow up with out-patient resources that were provided to him. He was discharged to his home at 10:02 PM, with a diagnosis of unspecified psychosis (a serious mental illness characterized by defective or lost contact with reality).

Review of Patient #3's medical record dated 03/10/24, from Hospital A, showed the following:
- Patient #3 presented to the ED by private vehicle at 3:18 PM, with a chief complaint of behavioral health concerns. Patient #3's mother reported he was very paranoid and aggressive and she was worried about him. She felt he was a danger to himself and others and he had not slept in three days.
- Physician documentation showed Patient #3 had paranoid behavior, was aggressive, actively hallucinating, lunging at shadows, speaking nonsensically and not able to be easily redirected. A psychiatric assessment showed he was paranoid, labile (abnormal variability in mood with repeated, rapid and abrupt shifts in emotional expression) and tangential (a type of thought disorder in which each of a series of thoughts seems less closely related to the original thought than the one before it). A behavioral health evaluation was ordered.
- Patient #3's mother and Staff Z, Registered Nurse (RN), completed affidavits related to Patient #3's behavior. Staff Z wrote in her affidavit that Patient #3 arrived at the ED agitated, highly delusional, paranoid and not directable as he was responding to what appeared to be AH and VH. He attempted to elope (when a patient makes in intentional, unauthorized departure from a medical facility), lunged aggressively at two other patients on the unit and was not able to contract for safety. Patient #3's mother wrote in her affidavit that he had been moving non-stop, working, hanging out, not sleeping, stressing about work, felt threatened, was paranoid and depressed. He used illegal drugs to self-medicate. He did not make sense when he was talking, and he could not be trusted. He had been very unpredictable and aggressive towards others. She woke up the morning of 03/10/24 and Patient #3 had let strangers in while they were asleep. He attacked someone on 03/09/24.
- An electrocardiogram (ECG, test that records the electrical signal from the heart to check for different heart conditions) was performed and was negative.
- At 3:38 PM, Zyprexa (medication used to treat mental disorders) and Ativan (a medication used to treat anxiety or sleep difficulty) were administered as an injection intramuscularly (IM, within the muscle).
- At 5:02 PM, his blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) was elevated at 140/98. His VS were not rechecked during the ED visit.
- At 5:47 PM, Physician documentation showed Patient #3 had a history of schizophrenia, medication non-compliance, was combative upon his arrival, actively hallucinating, speaking to people who were not there, attacking shadows and also other patients. He was unable to be de-escalated or re-oriented. He had been sedated with IM medication and was medically cleared for psychiatric evaluation and inpatient admission. The clinical impression was schizophrenia, agitation requiring sedation, bizarre and aggressive behavior. The diagnosis and treatment were significantly limited due to alcohol and substance use. His final disposition was pending the central intake evaluation.
- At 8:20 PM, central intake reviewed the patient's chart and discussed the case with Staff R, Behavioral Health Nurse Practitioner (NP). Based on the information discussed it was determined that the patient did meet criteria for an inpatient behavioral health admission for psychosis.
- At 8:30 PM, documentation showed attempts were made to complete a behavioral health assessment, but Patient #3 was too sedated to participate.
- At 9:06 PM, a licensed clinical social worker (LCSW), attempted to perform a behavioral health intake evaluation but each section showed "patient was just awake prior to the evaluation, then refused to wake for the evaluation."
- At 9:21 PM, Physician documentation showed he spoke with central intake and the plan was made for an involuntary admission (a legal process through which a person is hospitalized and treated for mental health disorders without their consent).
- Included within the medical record were the affidavits, notice of admission of involuntary patients and application for a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) completed on 03/10/24.
- On 03/11/24 at 7:35 AM, Staff R documented Patient #3 was resting in his bed and answered questions appropriately. Patient #3 reported he used ecstasy and at times he would become paranoid when he used it. He denied SI, HI, AH and VH. He denied any compliance with medications or outpatient follow up. His mood continued to be anxious with poor insight, judgement, and decision-making skills. Per Patient #3's mother the patient had been randomly attacking people in public and had punched someone who had been driving with their window down. He agreed to contract for safety outside of the hospital and was no longer responding to internal stimuli. The plan was made for the patient to discharge to his home and follow up with outpatient behavioral health and a substance abuse program.
- Patient safety rounding (15-minute visualization and documentation of the safety of each patient) documentation showed Patient #3 slept from 4:00 PM on 03/10/24 until 7:30 AM on 03/11/24. Documentation on 03/11/24 from 7:45 AM until 8:15 AM, showed he was on a phone call and agitated/upset.
- At 8:30 AM, he was agitated/upset and discharged.

Review of Patient #3's medical record dated 03/11/24, at Hospital A, showed:
- At 9:58 AM, Patient #3 presented to the ED via private vehicle for behavioral health concerns.
- Physician documentations indicated Patient #3 and his aunt presented requesting a psychiatric evaluation. He reported that he was worried about his family. He denied SI and HI, but indicated he was paranoid and had a substance abuse issue.
- His VS were obtained; his BP was 133/84.
- His physician psychiatric evaluation described his mood, affect and behavior as normal, and his thought content as paranoid. A behavioral health assessment was ordered.
- An affidavit completed by Patient #3's Aunt showed she did not want him to be released from the hospital due to his schizophrenia. She was worried about him harming himself and others. He was paranoid and claimed others knew where he stayed from several years ago and could not sleep because of this. He walked around their home with a knife to protect his family. He invited a stranger up to his mother's home so he could hurt them. He could not sit still, and from previous experience with him, exhibiting these behaviors, she felt he was not well and could really harm someone if left unsupervised. He threatened slit the throat of a staff member at the hospital. He was paranoid about hospital staff, thinking they were going to do something to him. When she asked who they were, he responded his ex-girlfriend from years ago.
- Staff Y, Behavioral Health Tele-Assessor, documented that Patient #3 reported a history of bipolar disorder, SI and hospitalizations. He denied a history of delusions and any type of hallucinations. He reported substance abuse and occasionally drinking alcohol at social events. The patient indicated he did not want to be admitted to inpatient psychiatry, just wanted his medications re-started. He had been off of his psychiatric medications for six months. Patient #3 reported HI toward anyone who touched his family. Two days prior he hit someone in the mouth because they talked about his brother. He denied SI, self-harm or hallucinations. He was not able to contract for safety outside of the hospital and was a danger to others.
- His provisional diagnosis was substance induced mood disorder, and Staff Y, Staff R, Behavioral Health NP, and Staff X, Physician, discussed the behavioral health evaluation and CSSR-S moderate risk score. Staff R determined Patient #3 did not meet inpatient criteria for behavioral health services due to him not being a danger to himself or others.
- His VS were not rechecked and no ancillary testing was completed.
- On 03/11/24 at 11:46 AM, he was discharged to his home.

Review of Patient #3's medical record dated 03/11/24 through 03/13/24, at Hospital F, showed:
- At 3:15 PM, Patient #3 presented to the ED via private vehicle for HI.
- A behavioral health assessment, urine drug screen and blood work were ordered.
- Results indicated an elevated blood alcohol level, high cholesterol and low vitamin D level.
- His urine drug screen was positive for marijuana.
- Nursing documented Patient #3 denied SI, reported generalized HI, and paranoia. AH were telling him to hurt people. He indicated that he had hurt his brother's friend earlier in the week.
- At 4:26 PM, a behavioral health assessment was completed which determined he would be admitted to inpatient behavioral health.
- He was given Zyprexa IM. He remained calm, cooperative and was receptive to the admission.
- On 03/13/24, he was transferred to Hospital B for admission to a behavioral health unit.

Review of Patient #3's medical record dated 03/13/24 through 03/15/24, at Hospital B, showed:
- He was admitted for a psychiatric evaluation and HI.
- The patient was started on cholesterol medication, fluoxetine (an antidepressant drug), Zyprexa and vitamin D.
- He was evaluated by a social worker and set up with an outpatient psychiatric provider.
- On 03/15/24, he was discharged home with a final diagnosis of schizophrenia and depressive disorder.

During an interview on 07/17/24 at 9:00 AM, Staff AA, ED Medical Director, stated that behavioral health tele-assessors evaluated behavioral health patients, but the decision to discharge or admit them fell on the ED Physician. The tele-assessors just collected the information and presented it to the providers. Blood work orders were based on clinical evaluation and physical examination. A positive urine drug screen would not change the decision to admit or discharge a patient. Prescribing medications to behavioral health patients was case specific. ED physicians wouldn't generally prescribe long term medications. Any medication that required monitoring would be left to the established mental health provider. Affidavits were informative but would not determine a patient's admission or discharge.

During a telephone interview on 07/24/24 at 12:27 PM, Staff HH, ED Service Technician, stated that Patient #3 threatened to slit her throat on 03/10/24. She called security, reported the incident to Staff Z, RN, and the ED Provider. She was surprised that Patient #3 had been discharged on 03/11/24 because of the way he had been acting.

During an interview on 07/17/24 at 9:50 AM, Staff R, Behavioral Health NP, stated that he evaluated Patient #3 on 03/10/24 and on 03/11/24 after he woke up. Patient #3 admitted to using ecstasy and had sobered up by the time he saw him. He felt the patient's psychosis was drug induced. When he evaluated Patient #3, he was alert and safe to go. A 96 hour hold only meant that the patient would be evaluated within 96 hours. He did not know why Staff Y, Behavioral Health Tele-Assessor, would document that the patient was a danger to himself and others. When Staff Y, Staff R and Staff X, ED Physician, spoke about Patient #3 they were all in agreement that his behavior was substance induced and he was safe to go home. If the tele-assessor and ED physician were not in agreement, they would admit the patient. They were usually able to come to a mutual agreement. He did not like to prescribe medications in the ED because there was usually no follow up. If a patient had a reaction to medications he prescribed and there was a bad outcome, he would be responsible. He did not have anything to do with ordering urine drug screens or blood work. It would be nice to know if a patient's psychosis was drug related or organic, since some patients lied about drug use.

During a telephone interview on 07/17/24 at 10:30 AM, Staff Z, RN, stated that Patient #3 acted very bizarre and psychotic. His family was very concerned about his behavior. The patient would give the right answer to questions one minute, then go off on a tangent. He was very disorganized, had flight of ideas and was paranoid. He had attacked people. He lunged at a patient who was sitting on a stretcher in the hallway and ran out of his room and planning to attack another patient he felt had threatened him. He was able to be re-directed and had not threatened her or any other staff member that she knew of. By the time Patient #3 was re-evaluated on his second visit he had sobered up and was no longer exhibiting bizarre behavior.

During a telephone interview on 07/17/24 at 11:00 AM, Staff X, ED Physician, stated that he did not remember Patient #3. He would do the medical evaluation for behavioral health patients, then get social work involved. If there were any medical issues he would order laboratory testing, otherwise, nothing would be ordered for behavioral health concerns. Tele-assessors made recommendations to the Behavioral Health NP, who would directly evaluate the patient. If their assessment correlated to the patient, they determined whether to admit or discharge them. Urine drug screens were not very accurate, and he would only order one if he was concerned about a metabolic issue or if the patient's VS were not stable. He and Staff R decided together whether or not to prescribe medications to behavioral patients. If the patient had a known psychiatric history, then he absolutely would start the patient on psychiatric medications in the ED and have the patient follow up with an outpatient provider to monitor the drug.

During a telephone interview on 07/24/24 at 11:45 AM, Staff II, Medical Director of Psychiatry, stated that medications were not always prescribed to behavioral health patients from the ED, it was up to the individual ED Provider. Starting psychiatric medications for patients who had been off of their medications for six months or more, with an unclear diagnosis, could be harmful, especially if they were on illegal substances. He stated that he would prefer a psychiatric patient be stable before prescribing medications. Urine drug screens could be useful and quite beneficial for determining which medications to put a patient on. Those decisions would be up to the ED provider.

During a telephone interview on 07/18/24 at 7:30 AM, Staff Y, Behavioral Health Tele-Assessor, stated that she did not remember Patient #3 or his case. She did review the chart and stated that she did not know why Patient #3 was not admitted. She had conversations with ED Providers after she completed behavioral health assessments. She advocated for all her patients, but the ED Provider had the ultimate decision.