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Based on interview and record review of Emergency Department (ED) logs, 72 Hour Return logs, medical records, and Staffing and Physician On-Call Schedules, the facility failed to appropriately complete a medical screening examination within its capacity and capability for one patient (#1) of 20 patient's records reviewed, when the facility failed to notify the patient's guardian of her imminent discharge and they allowed her to leave unattended. The average ED monthly census was 5,727. The facility census was 300.

The hospital had the capacity and capability including an on-call psychiatrist to complete an appropriate medical screening examination to determine whether the patient had a psychiatric emergency prior to an unsupervised discharge of a patient with a significant history of mental illness residing in a locked unit at a nursing facility and under guardianship.

Refer to A2406 for details.

Based on interview, record review and policy review the facility failed to provide an appropriate Medical Screening Exam (MSE) sufficient to determine whether an emergency medical condition existed for one patient (#1) of 20 patient's reviewed. Patient #1's guardian was not notifed prior to or at the time of discharge from the ED. Approximately seventeen hours after discharge, local police found Patient #1 wandering the streets and took her to Hospital B for treatment to stabilize her psychiatric emergency. The hospital's failure to provide an appropriate examination within its capabilities and capacity had the potential to increase the risk for a negative outcome for all individuals seeking treatment within the Emergency Department (ED). The ED average monthly census was 5,727. The facility census was 300.

Findings included:

1. Review of the facility's policy titled, "EMTALA Policy," (Emergency Medical Treatment and Labor Act) dated 12/2008, showed:
- Each individual who requests medical treatment will receive a MSE, regardless of their ability to pay.
- An MSE is an examination which is sufficiently detailed to reveal whether the patient suffers from an emergency medical condition (EMC). The MSE must include medically indicated screens, tests, mental status evaluations, history and physical examination, etc.
- Every individual, regardless of ability to pay for services, transferred from the facility to either another health care facility or testing center, will be transferred via an appropriate mode of transportation and accompanied by qualified medical personnel as deemed appropriate by patient's physician.

2. Review of Patient #1's ED record showed:
- The patient arrived at the facility per Emergency Medical Service (EMS) on 05/08/16 at 11:41 AM.
- The physician's notes showed the patient's chief complaint was suicidal; she wanted to cut her throat with a knife.
- Patient #1 reported that she did not like how she was treated at her current residence (long-term care facility).
- The physician had contact with the patient at 12:10 PM. He noted she was cooperative, pleasant, lying in bed eating peanut butter, and denied any suicidal ideation (SI, thoughts to harm self) or homicidal ideation (HI, thoughts to harm others).
- Past medical history included:
- Schizophrenia (a long-term mental disorder that is a break down in the relation between thought, emotion, and behavior which leads to faulty perception, inappropriate actions and feelings, and withdrawal from reality);
- Drug abuse;
- Mild Mental Retardation (intellectual function below average and will have significant limitations with daily living);
- Delirium (acutely disturbed state of mind characterized by restlessness, illusions, and incoherence of thought and speech);
- Bipolar 1 Disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks);
- Generalized anxiety disorder; and
- Obsessive-Compulsive Disorder (anxiety disorder in which people have unwanted and repeated thoughts, feelings, ideas, sensations, obsessions, or behaviors that make them feel driven to do something, compulsions).

- The Central Intake (CI) Assessment (psychiatric assessment) showed that Patient #1 was evaluated between 4:00 - 4:30 PM on 5/8/16 and that she was brought to the ED due to "endorsing thoughts of suicide with a plan to cut her throat." Further documentation showed that the patient was under the care of a psychiatrist, had lost custody of her children, is disabled due to her mental health, was supported by a "guardian and staff at nursing home", reported feeling depressed about not having her children and "people chastising me." "Patient is well known to SSM healthcare with multiple admissions for aggressive behaviors, depression, suicidal thoughts, and auditory hallucinations." Further documentation showed that the patient had been verbally and physically aggressive with staff in the past and the last episode was 4/19/16 and that she had a history of using crack cocaine, borderline intellectual functioning, and poor insight and judgement. The CI staff documented he discussed the case with the on call psychiatrist and the ED physician who agreed that the patient did not meet criteria for inpatient admission because the "patient was able to contract for safety while in the ED."

- The CI discharge note showed the hospital notified the facility where Patient #1 lived of her discharge to return to the facility.
- Patient #1 was discharged at 8:37 PM with a plan for transport back to the locked unit of the nursing facility in an unsecured vehicle.

- Review of Hospital B's medical record indicated Patient #1 presented to their ED on 5/9/16 approximately 17 hours after discharge from SSM Health DePaul Hospital and was admitted for stabilizing treatment of a psychiatric emergency. Further documentation in Hospital B's medical record showed that the patient arrived by ambulance in the custody of law enforcement; that EMS reported patient # 1's mother was her guardian, and threatened to harm self by cutting her throat, and was verbally abusive. Further documentation showed that Patient #1 actively responded to internal stimuli (thoughts or sensations that trigger a person to do something), had visual hallucinations (apparent perception of something not present) and was combative.

During telephone interviews on 05/17/16 at 4:36 PM and 05/24/16 at 4:40 PM, Staff N, CI Assessor, stated that Patient #1 told him during his assessment that she had a guardian; he told nursing; and called the long-term care facility and confirmed this. He stated that Patient #1 was not compliant with taking routine medication when on her own. Patient #1 could be impulsive and display physical and verbal aggression.

3. Record review of an e-mail on 05/24/16 at 9:54 AM sent by Staff E, Regulatory and Risk, showed that the facility had no policy and procedure for ED staff to notify a
guardian before discharge.

4. Record review of a facility provided document titled "Twenty-Second Judicial Circuit," dated 02/29/16, showed on 02/26/16 that Patient #1's mother was appointed as her guardian.

During an interview on 05/17/16 at 3:07 PM, and on 05/19/16 at 9:00 AM and 1:45 PM, SSM Health DePaul Hospital Physician L stated that his impression was that Patient #1 was aggressive and made threats to hurt herself so she would be sent out of the long-term care facility where she lived. He was unaware Patient #1 lived in a secured long-term care facility. He did not always talk with patient families if the patient could talk to him.

During an interview on 05/17/16 at 9:45 AM and telephone interview on 05/31/16 at 11:36 AM, Staff H, Registered Nurse (RN), stated that if a patient comes to the ED from a facility there was a reason for them living there and they needed supervision. She did not remember asking Patient #1 if she had a guardian, but it was a nursing responsibility. She stated that typically, the CI Assessors do not review their findings with the nurses. She did not remember if she read Patient #1's CI notes, but probably did not.

There was no documentation that the physician or nursing staff asked the patient if she had a guardian or that they notified her mother, who was her guardian, before discharge.

During a telephone interview on 05/24/16 at 9:05 AM, SSM Health DePaul Hospital RN G stated that:
- She was the nurse that discharged Patient #1 from the main ED after she was
notified that a cab was there for Patient #1.
- Staff G watched her walk into the ED waiting room, but did not see Patient #1 get into the cab.
- Patient's that lived in nursing facilities needed supervision to ensure their safety.
- Patient #1 had a history of being aggressive and violent.
- When Patient #1's aggression escalated she could be a danger to herself and others and would need supervision.

During a telephone interview on 05/17/16 at 3:37 PM, Staff M, Clinical Support Nurse
stated that she received a call at midnight or after on 05/09/16 from the cab company that the patient did not use her ride. She knew that the patient was waiting for discharge earlier in the shift. She failed to escalate this information because it was not uncommon for patients to leave due to the long wait (up to three hours) before the cab arrived at the facility.

During an interview on 05/16/16 at approximately 3:30 PM and 05/17/16 at 10:45 AM, Staff F, Clinical Director of the ED, stated that:
- The patient came from a group home, was seen in the ED, was cleared and discharged.
- The mother was not notified as the staff thought the patient was her own guardian.
- The patient was discharged and waited for her ride in the main ED.
- When the ride was at the hospital the triage nurse notified the ED nurse.
- The patient did not get into the cab and left SSM Health DePaul Hospital.
- The next day at approximately 10:00 AM the facility where the patient lived notified staff that the patient failed to arrive.
- Staff F began an investigation and looked for the patient.
- She called nurses, had security make a search, and called law enforcement, but they were unable to file a missing person report at that time.
- A staff person from the long-term care facility where the patient lived notified Staff F to talk with a business that assists people to find long-term places to live.
- Staff F spoke with the patient's Case Manager from this business. Later the Case Manager notified Staff D, Regulatory and Risk Coordinator, and explained a co-worker had sighted the patient in a store and encouraged the patient to go with her, but the patient ran away. Staff F knew the area where the patient was sighted and it was close to Hospital B. Staff F notified Hospital B and found that the patient was currently in Hospital B's ED. Staff F notified the patient's mother and Case Manger (both had already been notified).
- Guardianship papers were later found in the Electronic Health Record.

During an interview on 06/02/16 at 10:26 AM, Patient #1's mother and guardian stated that SSM Health DePaul failed to notify her while Patient #1 was an ED patient and before Patient #1 was discharged.

During a telephone interview on 05/31/16 at 2:17 PM, Staff U, ED Medical Director, stated that it was not the ED responsibility to notify the guardian when the patient was discharged for return to the long-term care facility.