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Based on interviews, record review, observations and a review of the Hospital Internal Investigation, it was determined that Hospital Emergency Department (ED) #1 failed to provide a medical screening examination for Patient (Pt.) #1 after a request for care was made on behalf of Pt. #1 by the Police Department (PD) Officer. Nurse #1 did not direct the PD Officer to bring Pt. #1 into the ED for triage and a medical screening exam. Nurse #1 directed PD Officer to do what was best for Pt. #1 without a direct assessment being done.

Findings include:

1) The Emergency Medical Services (EMS) ambulance trip record, dated 10/22/12 at 6:13 P.M, indicated that EMS personnel arrived at Pt. #1's home. The EMS trip record indicated that Pt. #1 required psychiatric care.

The Triage Assessment, (sorting patients and setting priorities for their treatment in urgent care settings), dated 10/22/12 at 6:30 P.M., indicated that Patient (Pt.) #1 presented to Emergency Department (ED) #1 at 5:23 P.M. for a psychiatric evaluation. The Triage Assessment indicated that earlier that day, Pt. #1 was discharged from a psychiatric hospital and went to his/her mother's house. Pt. #1 began throwing around medications and the Police were called. At ED #1, Pt. #1 was immediately triaged as a Emergency Severity Index [ESI] Level 3. (Emergency Severity Index, ranging from one to five, is a severity rating system utilized during triage to determine the level of emergency care the patient needed. Severity Level 3 indicates that 2 or more resources are required and the patient needs treatment within 1 to 3 hours. The Triage Assessment indicated that Pt. #1 denied having suicidal intentions.

2) ED Nurse #1 was interviewed on 10/31/12. ED Nurse #1 said that when Pt. #1 arrived, Pt. #1 was asked to sit in a chair near the nursing station because no bed was available. ED Nurse #1 said that about five to ten minutes later, Pt. #1 became aggressive and tried to start a fight with another patient near him/her. ED Nurse #1 said he tried to calm Pt. #1. ED Nurse #1 said Pt. #1 requested a bed and was informed he/she would have to wait until a bed became available. Nurse #1 said Pt. #1 was upset with the wait and walked out of the ED.

3) The Director of Quality Improvement was interviewed on 10/31/12 at 8:15 A.M. The Director of Quality Improvement said that after Pt. #1 left the ED, he/she went to the Hospital's lobby area where the switchboard was located. The Director of Quality Improvement said that Pt. #1 demonstrated aggressive behavior with the Switchboard Operator and was demanding a bed and ripping up papers on her desk. The Switchboard Operator called the Security Guard .

4) Security Guard #1 was interviewed on 10/31/12 at 11:40 A.M. Security Guard #1 said that he was called to the main desk in the lobby at 6:52 P.M.. Security Guard #1 said that Pt. #1 reported the he/she wanted a bed NOW!. Security Guard #1 said Pt. #1 reported that he/she didn't want to wait for an evaluation in the ED, he/she just wanted a bed. Security Guard #1 said that he explained to Pt. #1 that he/she needed to be seen in the ED to be assigned a bed. The Security Guard #1 said that Pt. #1 ran out of the Hospital, threw a rock at the glass entrance and then ran to the street, into oncoming traffic. Police Officers responded and apprehended Pt. #1 and placed him/her in handcuffs and transported Pt. #1 back to ED #1 in the Police Cruiser.

5) ED Nurse #1 said the Police Officer came into the ED and reported that Pt. #1 was outside in the Police Cruiser. The PD Officer entered the ED and informed Nurse #1 that Pt. #1 was in the Cruiser and asked what he should do. Nurse #1 told the PD Officer that he should do what was best for Pt. #1. Nurse #1 did not ensure that Pt. #1 was brought back into the ED to be triaged or provided with a medical screening examination.

The PD Officer left the ED and spoke with Pt. #1 who said that he/she wanted to go to another ED for a psychiatric evaluation. An ambulance was summoned to the parking lot of ED #1 and Pt. #1 was transported to Hospital ED #2.

6) The Hospital's Internal Investigation indicated Pt. #1 did not receive a medical screening examination and the PD Officer arranged for ambulance transfer from Hospital #1's property to Hospital #2's ED.