HospitalInspections.org

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Based on record review and interview the facility failed to abide by the provider's agreement that required a hospital to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases.
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Based on record review and interview, the facility failed to provide a complete emergency medical screening examination (MSE) for one of 20 (Patient #1) patients whose records were reviewed when:
1. Patient #1's physical exam did not include a sufficient neurologic examination to determine if an emergency medical condition (EMC) was present following a physical altercation and possible traumatic event at home and chief complaints of choking without loss of consciousness.
2. No psychiatric evaluation for Patient #1 was found in the chart despite Staff #13 noting that Patient #1 would need a mental health evaluation and likely a psychiatric consult.
3. There was insufficient information obtained to rule out the emergency medical condition (EMC) of suicide or self-harm and an EMC was not clearly noted by any of the 3 physicians who examined Patient #1.
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Based on record review and interviews, the facility failed to provide an appropriate transfer for one of 20 (Patient #1) patients whose records were reviewed. Patient #1 did not receive an appropriate transfer to an acute psychiatric care facility when they failed to:
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1. Notify the receiving hospital, and verify the receiving facility had available space and qualified personnel for Patient #1's transfer or secure an accepting physician.
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2. Indicate the risks and benefits of transfer in writing.
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3. Complete the physician certification with a summary of risks and benefits.
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4. Send the receiving facility all medical records related to the emergency medical condition for Patient #1 who was being transferred for inpatient care at the psychiatric facility.
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Cross refer A2406 and A2409.
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Based on record review and interview, the facility failed to provide a complete emergency medical screening examination (MSE) for one of 20 (Patient #1) patients whose records were reviewed when:
1. Patient #1's physical exam did not include a sufficient neurologic examination to determine if an emergency medical condition (EMC) was present following a physical altercation and possible traumatic event at home and chief complaints of choking without loss of consciousness.
2. No psychiatric evaluation for Patient #1 was found in the chart despite Staff #13 noting that Patient #1 would need a mental health evaluation and likely a psychiatric consult.
3. There was insufficient information obtained to rule out the emergency medical condition (EMC) of suicide or self-harm and an EMC was not clearly noted by any of the 3 physicians who examined Patient #1.
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Findings include:
Review of Police Case DE2407320 on July 20, 2024, due to a report of a Major Disturbance:
Police were dispatched to the residence of Patient #1 on (July 20, 2024) at approximately 3:52 PM due to a report of a major disturbance. Patient #1 had left his home and was located at an intersection nearby. Patient #1 stated that his mother was mad at him for throwing a water bottle at his stepfather after being pushed by him "hard". Per the report, Patient #1 alleged that he was told to get off the couch, a verbal altercation ensued, Patient #1 reports he was pushed to the floor, Patient #1 threw the water bottle at his stepdad, his stepfather began choking Patient #1 by placing both hands around his neck. Patient #1 alleges that it happened quickly and did not cause him to blackout or stop breathing. Then, Patient #1 and his stepfather were choking each other. Patient #1 stated that his mother confronted him while holding an extension cord in her hand and waved it around in a whipping motion. Patient #1 grabbed the cord from his mother and stated, "I'm not afraid to die; you're not fixing to hit me with no extension cord." Patient #1 then hit himself on the right side of his neck and stated, "You're not fixing to hit me with that, I will hit myself with it." Additionally, it was noted in the officer's report that patient's mother "told the offender that she would be calling his probation officer and offender said 'F all of this, I don't care if I live or die, I'll kill my motherf'n self'. After he grabbed the charger off her bed he placed it around his neck and 'the boys' took the cord from around his neck." Patient #1's mother then told Patient #1 she was going to take him to (a psych facility) because he was trying to kill himself. Patient #1 denied trying to hurt or kill himself. Officer #2 observed a scratch on the right side of Patient #1's neck with broken skin.
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Patient #1's brothers witnessed the incident and mostly corroborated the report received.
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Patient #1's mother denied attempting to spank him and denied witnessing the stepfather choking him. Patient #1's mother denied waving a charging cord at Patient #1 and stated that Patient #1 brought the cord into play.
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Officer #2 stated the following:
Due to his statements/actions about self-harm and his diagnosis of the offender, it was deemed the offender was a danger to himself and others. The offender was transported to Children's Medical Center for APOWW and medical clearance by Ofc (Officer #1)." Refer to assisting officer badge #401 for details on this process.
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The report by the assisting officer, Officer #1, alleges the following:
On 7/20/24 at approximately 1552 hours, she (Officer #1) #401 was dispatched to a major disturbance at the home of Patient #1. Officer #1 stated that he was not there upon arrival at Patient #1's house. Officer #1 stated that she was in a marked squad car and returned to it to search for Patient #1. Patient #1 relayed the above to Officer #1. Patient #1 was detained by Officer #1 and placed in the squad car. Once detained, Officer #1 "made contact with the siblings, who witnessed the confrontation for their side of the story, corroborating with Patient #1's story". The story told to Officer #1 by Patient #1's mother differed from the above report. Based on her findings, Officer #1 " ...determined that (Patient #1) would be transported to (Facility A) for further evaluation due to his statements/actions about self-harm and his diagnosis. Upon arrival, Officer (Staff #1) informed that (Facility A) no longer accepted APOWWs but could treat (Patient #1) medically. Once (Patient #1) was medically cleared by the doctors (at Facility A), he (Patient #1) was transported to (Facility B) for emergency detention ..."
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Patient #1 was listed as the Offender, his stepfather as the Victim, and Patient #1's mother and two brothers were listed as Witnesses. The offense was listed as "Emergency detention/mental illness/risk of harm. Patient #1 was "cleared by arrest" on 07/24/2024, at 9:59 AM.
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Medical Record Review at Facility A:
Patient #1 was a 16-year-old male who arrived at Hospital A in the custody of a police officer on 07/20/2024 at 5:21 PM with a chief complaint of "choking" per Staff #19 (Triage RN) on 07/20/2021 at 5:32 PM. Staff's Initial Triage Notes included: "ED fellow notified of abrasions noted to pts neck. (Patient #1) stable to go to regular room at this time, per ED fellow. (Patient #1) stated he was choked by dad using his hands lasting about 10 secs" Staff #19 escalated the status of (Patient #1) as a "possible traumatic event". A suicide screening exam was done at 5:33 PM and the patient answered no to all questions regarding suicidal ideation, present and past. Triage Notes also included at 5:41 PM "(markings on right side of neck ... No loss of consciousness ... Vital signs stable)."
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At 5:47 PM, a Medical Screening Exam was initiated by Staff #13 (Treating ED Physician). The chief complaint at that time was choking. Notes included:
" ...(Patient #1) is a 16 y.o. male with a PMHx (past medical history) of psychiatric disorders including anxiety, bipolar disorder, depression, and ADHD (attention deficit and hyperactivity disorder), multiple psych admits most recently last month, on multiple medications and receives psych care at (named clinic). Pt with numerous domestic violence charges for violence against family members.
Patient #1 presents today with police for medical clearance after an altercation at home. After the altercation, pt took a phone charger and pulled it around his neck, pt then stated he 'didn't care if (he) died". Mom called 911 and pt brought to the ED by police for medical clearance.
Noted to have ligature marks around his neck. Denies LOC, difficulty speaking, respiratory distress, abnormal voice change. No HA, visual changes, CP or SOB. Pt denies any SI, HI, denies intention of self-harm ..."
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The physical examination was pertinent for a patient who was awake and answering questions during the examination. The neck exam revealed "superficial abrasions and ligature marks to the right neck, tenderness to palpation to the right neck, and no crepitus." There was no C-spine tenderness. No evaluation of tenderness of the anterior neck or hyoid bone was done for possible choking events. Only an exam of the posterior neck was noted. There was no evaluation of the patient's capacity to swallow or speak.
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The Review of Systems revealed that a limited neurological exam was done for Patient #1stating, "he is alert." No further neurologic exam was done.
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The Psychiatric exam states only that Patient #1 was "calm, cooperative. No suicidal ideation, no homicidal ideation." Following commands during the examination." Patient #1 was also noted to have had a "flat affect."
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Per the ED physician's medical decision-making: " ...(Patient #1) Pt here with police for medical clearance. Patient meets trauma activation criteria based on mechanism. Plan for CTA, urine drug screen. Per police, when medically clear, will discharge to police custody.
No concern for SI or HI, mom states police were called due to dangerous behavior/ activity at home. No indication for MHAT (mental health assessment team) evaluation ..."
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A second physician (Staff # 17) assessed Patient #1 at 6:34 PM and notes include:
" ...16-year-old male with a past medical history of bipolar, ADHD presents after strangulation. Per patient, he got into an argument with his mom. Afterwards, they were sitting on the cough and his stepdad told him to get off the couch, they got into an altercation, and he threw a water bottle at stepdad. Stepdad then went and put his hands around his neck, strangled him for about 5-10 seconds. Patient denies SOB or LOC. Complains of some discomfort in throat but denies any sore throat, pain in neck, vocal changes. No other injuries or traumas. Patient says after he was strangled, his mom and him got into another argument. She tried to hit him with a phone charger and so he took the phone charger and put it around his neck posteriorly. He said he did not do this with an intention to strangle himself or end his life. He denies any current or previous SI. Denies any HI. No other complaints at this time. ..."
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Review of Systems:
HENT: Positive for sore throat. Negative for congestion, trouble swallowing and voice change.
Neurological: Negative for speech difficulty and headaches.
Psychiatric/Behavioral: Negative for behavioral problems.
There was no assessment of potential hallucinations, delusions, depression, or anxiety.
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Physical Assessment:
Neck:
Thyroid: No thyromegaly.
Vascular: No JVD.
Trachea: No tracheal deviation.
Comments: Ligature marks to right side of neck
Psychiatric:
Comments: Flat affect
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Medical Decision Making:
(Patient #1) "16-year-old male with a history of bipolar presents after strangulation. Reportedly strangled by stepdad, no LOC. No other injuries. Then got into argument with mom and placed cord around his neck, concern for possible SI though patient denies this. Well appearing on exam though visible ligature marks. Will obtain CTA, medically clear, and consult social work/behavioral health."
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SW Reassessment Note by Staff #16 at 6:48 PM:
" ...HPI: Pt (Patient #1) shared that he was sitting on a couch and pt mother wanted him to sit right (something amongst the lines), (Patient #1) was shoved by stepfather, who retaliated by throwing water with ice on him, pt stepfather in returned choked (Patient #1). Visible marks are on his neck. SW spoke to officer (Officer #1) from DeSoto PD #401 #214-663-5236 aware of CPS report being made. (Officer #1) able to confirm exact story (Patient #1) shared, pt mom story deviated, favoring stepfather. (Patient #1) mom not supportive, challenging staff.
Living Status: Patient lives at home with mother, stepfather and 3 siblings. (10,13 and 14)
Clinical Impressions: (Patient #1) has a history of mental health support, currently has a case open already with probation, takes medication for various psych diagnosis. Officer at bedside is familiar with family, shares that mother has high involvement and history of being unsupportive towards patient. SW also spoke and updated medical team.
Plan: Social Worker will follow up as needed to assess for coping and any other resources. Please contact social worker with any immediate needs or concerns while patient is admitted ..."
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The ED Care Timeline notes that at 7:17 PM Staff #14 (ED RN) discussed Patient #1 with Staff #16 (Licensed Medical Social Worker), Officer 1 (DPD), and Staff #13. An order was received for continuous visual observation (CVO). Staff #14 then "Called (an unidentifiable Staff RN) at flow (patient flow) to request CVO at bedside. Pt calm and cooperative with this RN."
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An Emergency Note by Staff #14 at 10:10 PM noted that Patient #1 was wearing a purple gown. (Many facilities use "purple gowns" to denote behavioral health patients who are a flight risk or risk for self-harm.)
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At 7:30 PM, a CVO note by Staff #21 (Patient Care Technician) noted that "(Patient #1) Pt becoming increasingly anxious about transferring to another facility."
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At 7:45 PM a "Trauma Activation Alert" (Due to concern for strangling) was initiated by Staff #22 (RN)
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At 7:45 PM Trauma Services Provider Assessment by Staff #18 (Trauma Physician). The notes included:
"(Patient #1) a 16 y.o. male with significant history of bipolar disorder, ADHD, anxiety, depression, multiple psych admits, and multiple prior domestic violence charges who presents with police after self-inflicted strangulation with phone charger during altercation with mother and stepfather. No loss of consciousness. No current suicidal ideation."
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The physical examination noted that Patient #1's eyes opened spontaneously, and he had normal verbal responses. The examination also noted that Patient #1 was moving spontaneously, his head was normocephalic and atraumatic. The examination noted that a C-collar was in place, mild tenderness of the neck was noted, and marks to the neck were present. Staff #18 noted that Patient #1 was alert with normal mood and behavior.
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Plan:
"C-collar ...CT angio (angiogram) neck ...Pain control ...
...Medically clear for discharge from the ER ... without acute injury. Okay to clear collar clinically ..."
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A Nursing note at 19:50 noted, " Aspen collar (C-collar) was placed for spine precautions.
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At 8:18 PM the CT Arteriogram of the neck returned with normal results.
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At 8:57 PM a SW Progress Note by Staff #15 noted the following:
" ...Assessment Completed: in the Emergency Room ...
(Patient #1) is a 16 y.o. male presented to ED for concerns of strangulation. Social worker received handoff from day shift social worker, informed CPS reported needed regarding patient reporting of altercation with stepfather.
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An Addendum note at this time by Staff #15 noted the following:
"1030pm: Patient medically cleared for discharge. Social worker received update from RN that patient will be discharging with Desoto PD to Hospital for APOWW (Apprehension by Police Without a Warrant)."
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"1130: Called received from current CPS worker (name and number), update provided (name) states patient can discharge from (Facility A) to Desoto PD and will follow-up with Desoto PD after (Patient #1) arrives."
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At 11:30 PM, Patient #1 was discharged home by Facility A.
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Discharge Notes by Staff #14:
"(Patient #1) Pt alert/awake. Respirations unlabored. Discussed patient with (Staff #15), social worker. States that per CPS, patient can be discharged to Desoto Police. Desoto Police officer, (DPD Staff #4) (badge #371) at bedside. States they want patient placed under APOWW and therefore they will take him to a PSYCH facility after medical discharge. (Staff #10), ED
Charge aware. Pt ready for discharge. Discharge instructions reviewed with mom. Signed by Desoto Police officer. Pt in his custody. Pt ambulatory around room with steady gait. Appears in no acute distress. Getting dressed. Pt out of ED in no acute distress. With Desoto Police."
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Diagnoses made for this visit:
1. Asphyxiation due to mechanical threat to breathing due to other causes, assault, initial encounter.
2. Parent-step child conflict.
3. Assault by strike against or bumped into another person, initial encounter.
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No involuntary hold for Patient #1 was implemented to assure safety until such time as appropriate psychiatric evaluation was performed. No involuntary hold paperwork was found in the chart for Patient #1 despite a justifiable concern and an appropriate notification of CPS. No psychiatric evaluation for Patient #1 was found in the chart despite Staff #13 noting that Patient #1 would need a mental health evaluation and likely a psychiatric consult. There was insufficient information obtained to rule out the emergency medical condition (EMC) of suicide or self-harm and an EMC was not clearly noted by any of the 3 physicians who examined Patient #1.
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Facility B Medical Record Review:
On July 21, 2024, at 12:03 AM, Patient #1 arrived at Facility B in police custody.
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On July 21, 2024, at 12:04 AM, Staff #22, the triage nurse, noted that Patient #1 arrived in police custody for being suicidal and had "reportedly got into an altercation with his stepfather in which (Patient #1) states his stepfather choked him. (Patient #1) states about 5 minutes after that he wrapped a cord around his neck. (Patient #1) states his mother thought he was trying to harm himself. (Patient #1) denies attempting to harm himself. (Patient #1) states he did not wrap the cord completely around his neck. No bruising or ligature marks noted. (Patient #1) states he is not suicidal ..."
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On July 21, 2024, at 12:42 AM, Staff #24, the ED Physician, noted: "presents under emergency detention for concern for SI (suicidal ideation). He currently denies SI. He reports he wrapped a cord around his neck tonight and told his mom that he wasn't afraid to die. He has never tried to hurt himself before. He was unsure what medications he was supposed to be on. He denies any auditory hallucinations. He has no medical complaints." He was medically cleared for psychiatric evaluation ..."
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On July 21, 2024, at 3:12 AM, Staff #25 (Psychiatry) cleared the involuntary psychiatric hold and suicide risk.
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On July 21, 2024, at 3:20 AM, an addendum per Staff #24 (ED physician) noted the following:
I discussed patient with psych faculty Staff #25 (Psychiatry). Patient will be cleared. Discharge.
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On July 21, 2024, at 5:00 AM, Patient #1 was discharged home after the APOWW was discontinued.
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Policy Review:
Facility A's "Emergency Medical Treatment (EMTALA) and Patient Transfer -
Dallas Policy, last reviewed and effective on 05/03/2024, stated on page 1 of 16:
" ...Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance, and symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
a. Placing the health of the individual (or with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy;
b. Serious impairment to any bodily functions;
c. Serious dysfunction of any bodily organ or part, or
d. With respect to a pregnant woman who is having contractions:
i. That there is inadequate time to affect a safe transfer to another hospital before delivery, or
ii. That the transfer may pose a threat to the health or safety of the woman or the unborn child ..."
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And on page 2 of 16:
Medical Screening Examination (MSE) means the process to reach, with reasonable clinical confidence, the point at which it may be determined whether or not an individual has an emergency medical condition. An MSE is not an isolated event. It is an ongoing process that begins, but typically does not end, with triage. An MSE has the following elements:
a. Log Entry and Disposition
b. Triage Record
c. Ongoing recording of vital signs and ongoing monitoring of Patient's medical condition
d. History
e. Physical Examination
f. Use of available ancillary services, diagnostic testing and procedures, and physician consultative services as relevant to check for an emergency medical condition.
g. Adequate documentation of all the above elements and the determination regarding the emergency medical condition ..."
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And page 3 of 16:
" ...To stabilize means, with respect to an emergency medical condition, to provide such medical
treatment of the condition necessary to assure, within reasonable medical probability, that no
material deterioration of the condition is likely to result from or occur during the transfer of the
individual from a facility, or, with respect to a pregnant woman in labor, that the woman has
delivered the child and the placenta. To be considered stable, the emergency medical condition
that caused the Patient to seek care in the Emergency Department must be resolved, although the
underlying medical condition may persist ..."
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And page 4 of 16:
" ...A. Medical Screening. The Hospital recognizes the right of an individual to receive, within the capabilities and capacity of the Hospital:
a. An appropriate MSE, including ancillary services routinely available to the Emergency Department, diagnostic testing and procedures and physician consultative services to determine whether or not an emergency medical condition exists;
b. If an emergency medical condition exists, necessary stabilizing treatment (including treatment for an unborn child); and
c. If necessary, an appropriate transfer of an individual with an emergency medical condition to another facility even if the individual cannot pay, does not have medical insurance, or is not entitled to Medicare or Medicaid.
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The Hospital should not move individuals off-campus for the MSE ..."
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And on page 5 of 16:
" ...C. Depending on the individual's presenting signs and symptoms to the Emergency Department, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures, such as (but not limited to) lumbar punctures, x-rays, CT scans, clinical laboratory tests, and/or other diagnostic tests and procedures. The MSE may require use of physician consultative services ..."
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And on pages 5 - 6 of 16:
" ...D. Documentation of the MSE should reflect the clinical components of the MSE and the physician's or QMP's assessment and plan of care for the Patient, including presenting signs and symptoms for the visit, ongoing monitoring of the Patient's vital signs and needs of the patients throughout the Emergency Department visit until the point of admission, discharge, or transfer. The physician or QMP's documentation of the MSE should address the elements of the examination that support the evaluation of whether or not the emergency medical condition exists and addressing the Patient's presenting signs and symptoms, including, but not limited to, past medical history, physical exam of the patient, ordered and completed laboratory and/or diagnostic testing and/or procedures, inquiries or consults with on-call physician specialists, the medical decision making regarding the differential diagnosis and reasoning and final assessment results of the MSE and whether or not an emergency medical condition exists, address any unresolved items that were determined to be non-emergent medical conditions, the discharge plan (including outpatient referrals for follow up and/or continuum of care services to address the Patient's signs and symptoms and any non-emergent medical condition for further evaluation and treatment, or transfer of the Patient to another medical facility to care and treatment of the Patient's emergency medical condition), and disposition ..."
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Interviews:
On September 24, 2024, at 10:45 AM, the treating ED Physician (Staff #13) was interviewed. The Surveyor and Staff #13 reviewed the case for Patient #verbally, and Staff #13 was asked if she remembered the case. Staff #13 stated that she remembered Patient #1. Staff #13 was asked what she remembered about his presentation. Staff #13 indicated that the story relayed by police and Patient #1's mother and the story of Patient #1 was not in sync. Staff #13 further indicated that Patient #1 had marks on his neck consistent with ligature marks.
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Staff #13 was asked to explain an Emergency Medical Condition (EMC). Staff #13 stated, "Anyone who needs immediate or emergent medical or psych care and if not stable for transfer, we stabilize."
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Staff #13 was asked to explain what stabilizing an EMC meant. Staff #13 stated, "We would provide any medical or psych transfer within capability. Anything with ABC's is stabilized, eminent delivery if needed."
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Staff #13 stated that Patient #1 " ...was psych and medically stable, he was calm and cooperative, answered questions, followed commands.
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On 09/24/2024 at 11:00 AM, Staff #12 (Emergency Department Manager) was interviewed. Staff #12 was asked to explain what an EMC was. Staff #12 stated, "Providing enough care and intervention to transfer them to another facility if we don't provide that service or admit them if we do."
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Based on medical record reviews, document reviews, and interviews, Facility A failed to complete an appropriate transfer for one of 20 patients whose records were reviewed (Patient #1) when they failed to:
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1. Notify the receiving hospital, and verify the receiving facility had available space and qualified personnel for Patient #1's transfer or secure an accepting physician.
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2. Indicate the risks and benefits of transfer in writing.
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3. Complete the physician certification with a summary of risks and benefits.
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4. Send the receiving facility all medical records related to the emergency medical condition for Patient #1 who was being transferred for inpatient care at the psychiatric facility.
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Findings included:
Review of Police Case DE2407320 on July 20, 2024, due to a report of a Major Disturbance:
Police were dispatched to the residence of Patient #1 on (July 20, 2024) at approximately 3:52 PM due to a report of a major disturbance. Patient #1 had left his home and was located at an intersection nearby. Patient #1 stated that his mother was mad at him for throwing a water bottle at his stepfather after being pushed by him "hard". Per the report, Patient #1 alleged that he was told to get off the couch, a verbal altercation ensued, Patient #1 was pushed to the floor, Patient #1 threw the water bottle at his stepdad, his stepfather began choking Patient #1 by placing both hands around his neck. Patient #1 alleges that it happened quickly and did not cause him to blackout or stop breathing. Then, Patient #1 and his stepfather were choking each other. Patient #1 stated that his mother confronted him while holding an extension cord in her hand and waved it around in a whipping motion. Patient #1 grabbed the cord from his mother and stated, "I'm not afraid to die; you're not fixing to hit me with no extension cord." Patient #1 then hit himself on the right side of his neck and stated, "You're not fixing to hit me with that, I will hit myself with it." Patient #1's mother then told Patient #1 she was going to take him to (a psych facility) because he was trying to kill himself. Patient #1 denied trying to hurt or kill himself. Officer #2 observed a scratch on the right side of Patient #1's neck with broken skin.
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Patient #1's brothers witnessed the incident and mostly corroborated the report received.
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Patient #1's mother denied attempting to spank him and denied witnessing the stepfather choking him. Patient #1's mother denied waving a charging cord at Patient #1 and stated that Patient #1 brought the cord into play.
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Officer #2 stated the following:
Due to his statements/actions about self-harm and his diagnosis of the offender, it was deemed the offender was a danger to himself and others. The offender was transported to Children's Medical Center for APOWW and medical clearance by Ofc (Officer #1)." Refer to assisting officer badge #401 for details on this process.
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The report by the assisting officer, Officer #1, alleges the following:
On 7/20/24 at approximately 1552 hours, she (Officer #1) #401 was dispatched to a major disturbance at the home of Patient #1. Officer #1 stated that he was not there upon arrival at Patient #1's house. Officer #1 stated that she was in a marked squad car and returned to it to search for Patient #1. Patient #1 relayed the above to Officer #1. Patient #1 was detained by Officer #1 and placed in the squad car. Once detained, Officer #1 "made contact with the siblings, who witnessed the confrontation for their side of the story, corroborating with Patient #1's story". The story told to Officer #1 by Patient #1's mother differed from the above report. Based on her findings, Officer #1 " ...determined that (Patient #1) would be transported to (Facility A) for further evaluation due to his statements/actions about self-harm and his diagnosis. Upon arrival, Officer (Staff #1) informed that (Facility A) no longer accepted APOWWs but could treat (Patient #1) medically. Once (Patient #1) was medically cleared by the doctors (at Facility A), he (Patient #1) was transported to (Facility B) for emergency detention ..."
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Patient #1 was listed as the Offender, his stepfather as the Victim, and Patient #1's mother and two brothers were listed as Witnesses. The offense was listed as "Emergency detention/mental illness/risk of harm. Patient #1 was "cleared by arrest" on 07/24/2024, at 9:59 AM.
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Medical Record Review at Facility A:
Patient #1 was a 16-year-old male who arrived at Hospital A in the custody of a police officer on 07/20/2024 at 5:21 PM with a chief complaint of "choking" per Staff #19 (Triage RN) on 07/20/2021 at 5:32 PM. Staff's Initial Triage Notes included: "ED fellow notified of abrasions noted to pts neck. (Patient #1) stable to go to regular room at this time, per ED fellow. (Patient #1) stated he was choked by dad using his hands lasting about 10 secs" Staff #19 escalated the status of (Patient #1) as a "possible traumatic event". A suicide screening exam was done at 5:33 PM and the patient answered no to all questions regarding suicidal ideation, present and past. Triage Notes also included at 5:41 PM "(markings on right side of neck ... No loss of consciousness ... Vital signs stable)."
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At 5:47 PM, a Medical Screening Exam was initiated by Staff #13 (Treating ED Physician). The chief complaint at that time was choking. Notes included:
" ...(Patient #1) is a 16 y.o. male with a PMHx (past medical history) of psychiatric disorders including anxiety, bipolar disorder, depression, and ADHD (attention deficit and hyperactivity disorder), multiple psych admits most recently last month, on multiple medications and receives psych care at (named clinic). Pt with numerous domestic violence charges for violence against family members.
Patient #1 presents today with police for medical clearance after an altercation at home. After the altercation, pt took a phone charger and pulled it around his neck, pt then stated he 'didn't care if (he) died". Mom called 911 and pt brought to the ED by police for medical clearance.
Noted to have ligature marks around his neck. Denies LOC, difficulty speaking, respiratory distress, abnormal voice change. No HA, visual changes, CP or SOB. Pt denies any SI, HI, denies intention of self-harm ..."
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The physical examination was pertinent for a patient who was awake and answering questions during the examination. The neck exam revealed "superficial abrasions and ligature marks to the right neck, tenderness to palpation to the right neck, and no crepitus." There was no C-spine tenderness. No evaluation of tenderness of the anterior neck or hyoid bone was done for possible choking events. Only an exam of the posterior neck was noted. There was no evaluation of the patient's capacity to swallow or speak.
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The Review of Systems revealed that a limited neurological exam was done for Patient #1stating, "he is alert." No further neurologic exam was done.
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The Psychiatric exam states only that Patient #1 was "calm, cooperative. No suicidal ideation, no homicidal ideation." Following commands during the examination." Patient #1 was also noted to have had a "flat affect."
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Per the ED physician's medical decision-making: " ...(Patient #1) Pt here with police for medical clearance. Patient meets trauma activation criteria based on mechanism. Plan for CTA, urine drug screen. Per police, when medically clear, will discharge to police custody.
No concern for SI or HI, mom states police were called due to dangerous behavior/ activity at home. No indication for MHAT (mental health assessment team) evaluation ..."
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A second physician (Staff # 17) assessed Patient #1 at 6:34 PM and notes include:
" ...16-year-old male with a past medical history of bipolar, ADHD presents after strangulation. Per patient, he got into an argument with his mom. Afterwards, they were sitting on the cough and his stepdad told him to get off the couch, they got into an altercation, and he threw a water bottle at stepdad. Stepdad then went and put his hands around his neck, strangled him for about 5-10 seconds. Patient denies SOB or LOC. Complains of some discomfort in throat but denies any sore throat, pain in neck, vocal changes. No other injuries or traumas. Patient says after he was strangled, his mom and him got into another argument. She tried to hit him with a phone charger and so he took the phone charger and put it around his neck posteriorly. He said he did not do this with an intention to strangle himself or end his life. He denies any current or previous SI. Denies any HI. No other complaints at this time. ..."
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Review of Systems:
HENT: Positive for sore throat. Negative for congestion, trouble swallowing and voice change.
Neurological: Negative for speech difficulty and headaches.
Psychiatric/Behavioral: Negative for behavioral problems.
There was no assessment of potential hallucinations, delusions, depression, or anxiety.
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Physical Assessment:
Neck:
Thyroid: No thyromegaly.
Vascular: No JVD.
Trachea: No tracheal deviation.
Comments: Ligature marks to right side of neck
Psychiatric:
Comments: Flat affect
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Medical Decision Making:
(Patient #1) "16-year-old male with a history of bipolar presents after strangulation. Reportedly strangled by stepdad, no LOC. No other injuries. Then got into argument with mom and placed cord around his neck, concern for possible SI though patient denies this. Well appearing on exam though visible ligature marks. Will obtain CTA, medically clear, and consult social work/behavioral health."
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SW Reassessment Note by Staff #16 at 6:48 PM:
" ...HPI: Pt (Patient #1) shared that he was sitting on a couch and pt mother wanted him to sit right (something amongst the lines), (Patient #1) was shoved by stepfather, who retaliated by throwing water with ice on him, pt stepfather in returned choked (Patient #1). Visible marks are on his neck. SW spoke to officer (Officer #1) from DeSoto PD #401 #214-663-5236 aware of CPS report being made. (Officer #1) able to confirm exact story (Patient #1) shared, pt mom story deviated, favoring stepfather. (Patient #1) mom not supportive, challenging staff.
Living Status: Patient lives at home with mother, stepfather and 3 siblings. (10,13 and 14)
Clinical Impressions: (Patient #1) has a history of mental health support, currently has a case open already with probation, takes medication for various psych diagnosis. Officer at bedside is familiar with family, shares that mother has high involvement and history of being unsupportive towards patient. SW also spoke and updated medical team.
Plan: Social Worker will follow up as needed to assess for coping and any other resources. Please contact social worker with any immediate needs or concerns while patient is admitted ..."
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The ED Care Timeline notes that at 7:17 PM Staff #14 (ED RN) discussed Patient #1 with Staff #16 (Licensed Medical Social Worker), Officer 1 (DPD), and Staff #13. An order was received for continuous visual observation (CVO). Staff #14 then "Called (an unidentifiable Staff RN) at flow (patient flow) to request CVO at bedside. Pt calm and cooperative with this RN."
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An Emergency Note by Staff #14 at 10:10 PM noted that Patient #1 was wearing a purple gown. (Many facilities use "purple gowns" to denote behavioral health patients who are a flight risk or risk for self-harm.)
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At 7:30 PM, a CVO note by Staff #21 (Patient Care Technician) noted that "(Patient #1) Pt becoming increasingly anxious about transferring to another facility."
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At 7:45 PM a "Trauma Activation Alert" (Due to concern for strangling) was initiated by Staff #22 (RN)
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At 7:45 PM Trauma Services Provider Assessment by Staff #18 (Trauma Physician). The notes included:
"(Patient #1) a 16 y.o. male with significant history of bipolar disorder, ADHD, anxiety, depression, multiple psych admits, and multiple prior domestic violence charges who presents with police after self-inflicted strangulation with phone charger during altercation with mother and stepfather. No loss of consciousness. No current suicidal ideation."
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The physical examination noted that Patient #1's eyes opened spontaneously, and he had normal verbal responses. The examination also noted that Patient #1 was moving spontaneously, his head was normocephalic and atraumatic. The examination noted that a C-collar was in place, mild tenderness of the neck was noted, and marks to the neck were present. Staff #18 noted that Patient #1 was alert with normal mood and behavior.
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Plan:
"C-collar ...CT angio (angiogram) neck ...Pain control ...
...Medically clear for discharge from the ER ... without acute injury. Okay to clear collar clinically ..."
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A Nursing note at 19:50 noted, " Aspen collar (C-collar) was placed for spine precautions.
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At 8:18 PM the CT Arteriogram of the neck returned with normal results.
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At 8:57 PM a SW Progress Note by Staff #15 noted the following:
" ...Assessment Completed: in the Emergency Room ...
(Patient #1) is a 16 y.o. male presented to ED for concerns of strangulation. Social worker received handoff from day shift social worker, informed CPS reported needed regarding patient reporting of altercation with stepfather.
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An Addendum note at this time by Staff #15 noted the following:
"1030pm: Patient medically cleared for discharge. Social worker received update from RN that patient will be discharging with Desoto PD to Hospital for APOWW (Apprehension by Police Without a Warrant)."
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"1130: Called received from current CPS worker (name and number), update provided (name) states patient can discharge from (Facility A) to Desoto PD and will follow-up with Desoto PD after (Patient #1) arrives."
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At 11:30 PM, Patient #1 was discharged home by Facility A.
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Discharge Notes by Staff #14:
"(Patient #1) Pt alert/awake. Respirations unlabored. Discussed patient with (Staff #15), social worker. States that per CPS, patient can be discharged to Desoto Police. Desoto Police officer, (DPD Staff #4) (badge #371) at bedside. States they want patient placed under APOWW and therefore they will take him to a PSYCH facility after medical discharge. (Staff #10), ED
Charge aware. Pt ready for discharge. Discharge instructions reviewed with mom. Signed by Desoto Police officer. Pt in his custody. Pt ambulatory around room with steady gait. Appears in no acute distress. Getting dressed. Pt out of ED in no acute distress. With Desoto Police."
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Diagnoses made for this visit:
1. Asphyxiation due to mechanical threat to breathing due to other causes, assault, initial encounter.
2. Parent-step child conflict.
3. Assault by strike against or bumped into another person, initial encounter.
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There were no documented attempts for an appropriate transfer, no documentation of an accepting physician, and no evidence that medical records were provided to the receiving facility. There was no memorandum of transfer (MOT) with a physician's certification, notification of the risks and benefits of a transfer, and no signed patient refusal of a transfer found in the medical record review.
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Facility B Medical Record Review:
On July 21, 2024, at 12:03 AM, Patient #1 arrived at Facility B in police custody.
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On July 21, 2024, at 12:04 AM, Staff #22, the triage nurse, noted that Patient #1 arrived in police custody for being suicidal and had "reportedly got into an altercation with his stepfather in which (Patient #1) states his stepfather choked him. (Patient #1) states about 5 minutes after that he wrapped a cord around his neck. (Patient #1) states his mother thought he was trying to harm himself. (Patient #1) denies attempting to harm himself. (Patient #1) states he did not wrap the cord completely around his neck. No bruising or ligature marks noted. (Patient #1) states he is not suicidal ..."
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On July 21, 2024, at 12:42 AM, Staff #24, the ED Physician, noted: "presents under emergency detention for concern for SI (suicidal ideation). He currently denies SI. He reports he wrapped a cord around his neck tonight and told his mom that he wasn't afraid to die. He has never tried to hurt himself before. He was unsure what medications he was supposed to be on. He denies any auditory hallucinations. He has no medical complaints." He was medically cleared for psychiatric evaluation ..."
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On July 21, 2024, at 3:12 AM, Staff #25 (Psychiatry) cleared the involuntary psychiatric hold and suicide risk.
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On July 21, 2024, at 3:20 AM, an addendum per Staff #24 (ED physician) noted the following:
I discussed patient with psych faculty Staff #25 (Psychiatry). Patient will be cleared. Discharge.
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On July 21, 2024, at 5:00 AM, Patient #1 was discharged home after the APOWW was discontinued.
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Facility A Policy Reviews:
Facility A's "Emergency Medical Treatment (EMTALA) and Patient Transfer -
Dallas Policy, last reviewed and effective on 05/03/2024, stated on page 3 of 16:
"...Transfer means the movement (including the discharge) of an individual outside a hospital's facilities at the direction of any person employed by (or affiliated or associated with) the hospital but does not include such a movement of an individual who has been declared dead or leaves the
facility without the permission of any such person. (Pursuant to state hospital licensing
regulations, the movement of a stable patient from the hospital to another medical facility is not considered to be a transfer if it is the understanding and intent of both hospitals that the patient is going to the second hospital only for tests, the patient will not remain overnight at the second hospital, and the patient will return to the first hospital, provided that the patient remains stable during the transfer.) An appropriate transfer occurs when:
a. The transferring hospital provides treatment within its capabilities to minimize risks to
the Patient (and to the unborn child if the Patient is pregnant)
b. The receiving facility agrees to the transfer and has the capability and capacity (bed and
staff) to treat the Patient.
c. The transferring hospital sends pertinent medical records and a completed Memorandum of Transfer (MOT).
d. The transfer occurs with qualified personnel and equipment..."
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And on page 8 of 16:
" ...D. When a Patient has an emergency medical condition that has not been stabilized, the Patient may be transferred if:
a. The Patient requests transfer against medical advice and the physician or Hospital informs the Patient of the Hospital's responsibility to provide stabilizing treatment to the Patient and the risks and benefits of transfer and obtain the patient's or legally responsible person's request for transfer in writing; or
b. The transferring physician completes a certification statement (as set out in c. below), which includes a summary of risks and benefits, that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of medical treatment at another facility outweigh the increased risks to the patient, and in the case of labor, to the unborn child from effecting the transfer. Other qualified medical personnel may complete the certification statement on behalf of the physician after consultation with the physician if the physician is not present in the emergency room at the time of the transfer. The physician shall countersign the certification as soon as possible if it is completed initially by Hospital personnel.
i. Certification of Risks and Benefits should be documented on the Memorandum of Transfer ..."
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And on page 9 - 10 of 16:
" ...F. Memorandum of Transfer (MOT) is necessary to transfer a patient:
a. Children's Medical Center of Dallas will provide a MOT, as prescribed by state law.
b. The MOT will be signed by the transferring physician, approved, and signed by the Children's Medical Center of Dallas administration, and a copy must accompany the Patient being transferred, along with the appropriate medical record information.
c. Transfers into Children's Medical Center of Dallas will require an MOT from the transferring hospital and will accompany the Patient along with pertinent medical record information. It is the Children's Medical Center of Dallas accepting unit's responsibility to record the date and time of Patient arrival and to obtain the receiving physician's signature on the MOT.
d. MOTs will be maintained in both the Patient's medical record and separately from the medical record. Health Information Management (HIM) shall retain the separate copies of the MOT with the transfer record for a minimum of five years. These records shall be available for review and inspection as necessary by the Texas Health and Human Services Commission.
e. The MOT document will follow the standard form established by the Texas Health and
Human Services Commission, but shall include the following information (if known)
but not limited to:
i. Full Name;
ii. Race, religion, national origin, age, sex, physical handicap;
iii. Address and next of kin, address, and phone number;
iv. Names, telephone numbers and addresses of the transferring and receiving physicians;
v. Names, telephone numbers and addresses of the transferring and receiving hospitals;
vi. Time and date on which the Patient first presented or was presented to the transferring physician and transferring hospital;
vii. Time and date on which the transferring physician secured a receiving physician;
viii. Name, date and time hospital administration was contacted in the receiving hospital;
ix. Signature, time and title of the transferring hospital administration official who
contacted the receiving hospital;
x. Certification by the transferring physician (if applicable);
xi. Time and date on which the receiving physician assumed responsibility for the patient;
xii. Time and date on which the Patient arrived at the receiving hospital;
xiii. Signature and date of receiving hospital administration official;
xiv. Type of vehicle and company used;
xv. Type of equipment and personnel needed in transfers;
xvi. Name and city of hospital to which the Patient was transported;
xvii. Diagnosis by the transferring physician; and
xviii. Attachments by transferring hospital ..."
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And on page 13 of 16:
"...K. Medical Records
A. A copy of the Patient's medical records related to the emergency medical condition and relevant to the transfer and continuing care that are available at the time of transfer (including medical records, test results, informed written consent or physician certification, and name and address of any on-call physician who refused or failed to
appear within a reasonable time to provide necessary stabilizing treatment) will be sent to the receiving physician and hospital. ..."
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Interviews:
On September 24, 2024, at 10:45 AM, the treating ED Physician (Staff #13) was interviewed. The case for Patient #1 was reviewed verbally and Staff #13 was asked if she remembered the case. Staff #13 stated that she remembered Patient #1. Staff #13 was asked what she remembered about his presentation. Staff #13 stated that the story relayed from police and Patient #1's mother and the story of Patient #1 were not in sync. Staff #13 further stated that Patient #1 had marks on his neck consistent with ligature marks.
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Staff #13 was asked if transfer was arranged through the transfer coordinators (in keeping with Facility A's policy) or a doctor-to-doctor report had been called. Staff #13 stated, "This patient was medically cleared and discharged from our Emergency Department; he was not transferred." Staff #13 further stated that a doctor-to-doctor report "would apply to patients being transferred. As this patient was discharged, we did not go through the transfer process, arrange transfer, obtain an accepting physician, or give doc-to-doc hand off ..."
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On 10/01/2024 at 4:20 PM, Staff #6 (Vice President of Accreditation) was interviewed. Staff #6 was asked about patient transfers. Staff #6 indicated that transfers should include: " ...The MOT and a copy of the medical records will be transported with the patient. Regardless of the mode of transportation for the transfer, the MOT and a copy of the medical records will be transported with the patient. If by chance, some information is not available at time of transport such as an x-ray report that information would be faxed/sent to the facility." Staff #6 was asked if a doctor-to-doctor report and securing a bed with the receiving facility should be completed upon transfer. Staff #6 confirmed that it should.
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