HospitalInspections.org

Based on review of medical records, EMS (emergency medical services) report, facility's video surveillance, policy and procedures and staff interviews, it was determined that the facility failed to ensure that an appropriate medical screening examination was provided within the capability emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for one (P#1) out of 20 patients who presented to the Emergency Department (ED) with psychiatric complaints
Specifically, the facility failed to discharge and readmit P#1 after he (P#1) left the ED and was returned by law enforcement which resulted in P#1 not receiving an appropriate medical screening examination after returning to the hospital's ED.

Cross refer to A-2406 as it relates to the facility's failure to provide an appropriate Medical Screening Examination for P#1, when he presented to the ED with psychiatric complaints.

Based on review of medical records, EMS (emergency medical services) report, facility's video surveillance, policy and procedures and staff interviews, it was determined that the facility failed to ensure that an appropriate medical screening examination was provided within the capability emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for one (P#1) out of 20 patients who presented to the Emergency Department (ED) with psychiatric complaints. Specifically, the facility failed to discharge and readmit P#1 after he (P#1) left the ED and was returned by law enforcement which resulted in P#1 not receiving an appropriate medical screening examination after returning to the hospital's ED.

Cross refer to A-2406 as it relates to the facility's failure to provide an appropriate Medical Screening Examination for P#1, when he presented to the ED with psychiatric complaints.
Findings include:


The Emergency Medical Services (EMS) trip report dated 12/18/24 at 1833 was reviewed. The section of the narrative revealed in part, "Dispatched ...behavioral Disturbance ... Pt (Patient) was located upstairs taking with PD (Police Department). Pt. wife stated that the patient has a history of Dementia and that she had MPOA (medical power of attorney). Pt wife reports that they had an argument and it turned violent as the patient started to hit and break things. Pt wife wants the Pt. transported. FD (Fire Department) and PD on scene report that the Pt. did state that the Pt had stated stuff about SI (Suicidal Ideation) and HI (Homicidal Ideation), But Pt denies it in the presence of EMS. Pt Stated that the argument started because he is unable to drive and he was wanting to go to the store for smokeless tobacco. Pt is alert and oriented x 4. Pt denies any SI or HI thoughts. Pt denies any pain. Pt. Skin is warm and dry ... Pt agreed to with EMS to the hospital ...Pt was transported to Memorial. .. P#1 was nonviolent with EMS and still denied any suicidal or homicidal thoughts. Further review of the EMS report revealed that EMS staff called the hospital prior to arriving to the hospital's ED. A report was given to the staff that Patient #1 was experiencing "Psychiatric Problem/Abnormal behavior/Suicide attempt" and emergent. P#1 was wheeled to the Emergency Department (ED) room A41 ... Verbal report was given to the ED nurse". Documentation on the EMS report revealed the Primary Impression: Behavioral/Psychiatric disorder. The Medical History was listed as Behavior: Dementia (with Behavioral disturbance; CV (cardiovascular) -Primary Hypertensin; Endocrine -Diabetes Non-Insulin Dependent.


A review of the video surveillance while P#1 was in the ED reveals the following:
AMB HALL 4 TIMELINE
12/18/2024
7:13:05 PM P#1 brought in through EMS Bay
7:18:40 PM Vitals are taken from P#1.
7:28:27- 7:28:51 PM Nurse talks to P#1
7:29:40 PM P#1 moved to hall between D and A pods by medics.
7:37:37 - 7:39:04 PM Woman in tan Sweatshirt speaks with P#1
7:41:48- 7:41:59 PM Same woman speaks to P#1 confirms bracelet number.
8:04:09- 8:05:03 PM Doctor speaks with P#1
8:10:10-8:12:00 PM Nurse speaks to woman in lobby.
9:20:06-9:21:52 PM Woman (Wife) speaks with Triage desk nurse a few times
9:22:25 PM Woman and other male walk out of waiting room to silver SUV (Sports Utility Vehicle) in ED lot
9:52:20 PM Nurse gets P#1 up from stretcher and walks him out.
9:54:04 PM Nurse brings P#1 to waiting room and sits him down.
9:56:24 PM Nurse comes out and brings P#1 out lobby doors, speaks with man in who walks out into parking lot and appears to speak with people in silver SUV and returns shortly and has another conversation with Nurse and the Nurse brings P#1 back in.
9:59:24 PM Nurse brings P#1 back to waiting area and sits him down.
10:39:38 PM P#1 gets up and walks to main hallway
10:40:28 PM P#1 tries to enter hospital through main doors from ED
10:41:46 PM P#1 finds bathroom after asking security
10:43:45 PM P#1 returns to waiting area
10:52:22 PM Nurse retrieves P#1 from waiting area and brings him to back
10:54:45 PM P#1 placed in bed in AMB Hall 4
10:55:06 PM Woman comes back into ED lobby speaks to triage desk for a minute and then goes back to sit in waiting room.
10:56:42 PM Nurse brings P#1 food
10:56:56- 11:00:40 PM Woman goes to bathroom
11:05:50-11:06:57 PM Nurse brings woman into back and speaks with her in front of triage then woman leaves and walks to silver SUV.
11:09:48 PM Silver SUV leaves parking lot
11:37:10 PM P#1 is given blanket
12/19/2024
12:40:55 AM P#1 appears to be registering again with staff member
1:09:23 AM P#1 gets up from bed
1:10:23 AM P#1 speaks to nurse and walks toward triage
1:14:03 AM P#1 returns to B-pod and walks down hall towards back hallway
1:16:22 AM P#1 is exiting through Rx hallway
1:17:53 AM P#1 walking out ACI (A.C. Institute) walkway and crossing lot
1:23:10 AM P#1 walking on roadway SE (Southeast) side of another hospital located in the area
1:23:57 AM P#1 walks on another hospital located on access road
2:46:30 AM P#1 brought back to ED by the City Police Department
2:47:11 AM P#1 put in bed in A pod
8:03:35 PM P#1 bed moved nearer to D-pod
12/20/2024
2:22:14 AM P#1 transported by EMS from ED



A review of P#1's medical record revealed he was admitted to the Emergency Department (ED) on 12/18/24 at 7:14 p.m. P#1 chief complaint was for psychiatric evaluation after physical altercation with his wife at home. His admitting diagnosis was restlessness and agitation. P#1 medical history included vascular dementia (dementia caused by vascular problems), type two (2) diabetes mellitus (inability to regulate glucose), atrial fibrillation (irregular heartbeat), hypercholesterolemia (high cholesterol), hypertension (high blood pressure) and nicotine dependence (a chronic condition where there is a strong need for nicotine). Further review revealed that on arrival to the ED P#1 was pleasant, answering all questions appropriately. P#1 was evaluated by MD (Medical Doctor) FF on arrival and who documented that P#1 was calm, very relaxed and was laughing and very jovial. MD FF further documented that P#1 was not suicidal or homicidal and that he felt comfortable with P#1 being discharged but the family felt that he (P#1) was unsafe. MD FF further documented that P#1's wife was the only person at the home and family felt that P#1 would potentially harm her. A further review of P#1's chart revealed the family did not feel comfortable taking him home. MD FF documented that this seems to be a reoccurring problem and at this time P#1 did not meet criteria for a 1013 (involuntary admission) nor did he meet criteria for admission with no active complaints. The decision was made by MD FF that P#1 would be observed in the ED and have case management get involved on the morning of 12/19/24. The facility failed to ensure that an appropriate medical screening examination was provided that was in capability and of the hospital's ED. This was evidenced by failing to ensure that a psychiatric evaluation was provided related to the patient's history of Dementia, Police Department stated patient expressing suicidal and homicidal ideations, and chief complaint of psychiatric evaluation.

Further review of P#1's medical record revealed P#1's nurse was attending to a critical patient on 12/19/24 around 2:00 a.m. When she returned around 3:00 a.m. P#1 was not in his bed. She notified the charge nurse who then notified security and the house supervisor. P#1 was found approximately one hour later by the city police and returned to the ED safely with no harm.

At 10:36 a.m. on 12/19/24 MD JJ was called to the bedside by the nurses. MD JJ spoke with P#1's wife as well as his son on the phone. The son informed MD JJ that he was a neurologist (medical doctor who specializes in the diagnosis and treatment of disorders and diseases of the brain, spinal cord and nervous system) out of state. P#1 son did provide additional information stating that P#1 has had vascular dementia with increasing agitation and inability to care for himself over the past few weeks or longer. P#1's chart further revealed that his son informed MD JJ that on multiple occasions the police and first responders have been called to the home due to agitation/behavior disturbances. The son also revealed this behavior had been escalating at home although P#1 had been calm and cooperative in the ED and he had no complaints at that time. MD JJ documented that P#1's son stated he spoke with a Geri-psych facility in another county that had agreed to accept P#1 if he was placed on 1013 for inability to care for himself. MD JJ documented that at the request of wife/son in conjunction with additional information, he did believe this was reasonable. MD JJ documented he planned on placing patient on 1013 and transferring him to the psychiatric facility. MD JJ further documented that the family did describe episodes of agitation with psychotic features, threatening behavior towards his wife and MD JJ felt there was a component of psychiatric illness/decompensation in addition to dementia contributing to his presentation today and P#1 would benefit from stabilization from a geriatric psychiatric facility. A 1013 form was signed by MD JJ on 12/19/24 at 10:36 a.m. P#1 was transferred to the psychiatric facility on 12/20/24 at 2:32 a.m. The facility failed to ensure that their policy was followed as evidenced by the facility failed to ensure that upon the patient's initial return after elopement a re-assessment was initially done upon the patient's return to the ED; and vital signs were not obtained until 5 hours after the patient returned to the ED. Additionally, the facility failed to ensure the patient was placed in Pod D after the after the patient was placed on a involuntary hold.



A review of the facility policy titled "Leaving Hospital Before Discharge "ID 11175366, last Revised 02/2022, revealed in part, the policy provided guidelines to clinical personnel for patients that leave the hospital before discharge orders have been written by a provider. Further review of the "Policy Statement" revealed in part, "Patient have the right to leave unless the patient lacks decision making capacity." The section of the policy titled "C. Procedure for Elopement of Patient without Decision Making Capacity; Minor; or patient with Involuntary Hold" revealed the policy. The nurse shall assess the potential for elopement at admission. a. Patients at risk for elopement include but are not limited to those who have documented history of ...those who are cognitively impaired ...2. The nurse would communicate that the patient has been assesses to be at risk for elopement to Security Department ...If elopement occurs: ... The nurse would notify the patient's family 9. The nurse would hold the room while attempts were made to locate the patient leaving the hospital. 10. Upon return to the hospital, the nurse would notify parties of the patient's return, including the Leaving Hospital Before Discharge. Notify attending physician of the patient's return to hospital. ..or have Emergency Department physician perform exam."


The facility's policy titled, "EMTALA - Medical Screening Examination and Stabilization ", policy #11175306, last revised 05/2022 was reviewed. The policy revealed that the purpose of the policy was to establish guidelines for providing appropriate medical screening examinations (MSE) and any necessary stabilizing treatment or an appropriate transfer of the individual.
Continued review revealed, Procedure:
1. When an MSE is required, a hospital must provide an appropriate MSE within the capability of the hospital ' s emergency department, including ancillary services routinely available to the ED, to determine whether or not an EMC exists. An MSE is required when:
a. The individual comes to an ED of a hospital and a request is made by the individual or on the individual ' s behalf for examination or treatment for a medical condition, including where:
i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition ...
3. Extent of MSE
e. Extent of MSE varies by presenting symptoms. The MSE may vary depending on the individual's signs and symptoms:
i. Depending on the individual's presenting symptoms, 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, clinical laboratory tests, CT scans and other diagnostic tests and procedures.
iii. Individuals with psychiatric or behavioral symptoms: The medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicates danger to self or others ...
ii. Psychiatric QMP. The ED physician shall consult the QMP providing the behavioral assessment for psychiatric purposes but shall remain the primary decision-maker with regard to transfer and discharge of the individual presenting to the DED with psychiatric or behavioral emergencies. Should an individual with a psychiatric or behavioral emergency present to a behavioral department of a hospital that meets the requirements of a DED, that department is responsible for ensuring that the individual has the appropriate MSE, including any behavioral examination, and providing necessary stabilizing treatment.

A review of the facility ' s policy titled, "Involuntary Hold ", policy #13838401, last revised 08/2020, revealed that the purpose of the policy was to define the process for caring for involuntary patients while in the ED or medical unit.
Continued review revealed, Procedure:
A. For all involuntary patients, whether medically cleared or not:
1. Place the original 1013/2013 form on the patient chart
2. Physician shall place an involuntary order in the electronic medical record
3. Physician shall place an order for psychiatry consult
4. The charge nurse will complete a form as stated for a one-on-one sitter.
a. One-to-one sitter is not required if the patient is in ED (Pod D).
C. Involuntary patients who have been medically cleared in the ED:
1. These patients should be placed in Pod D.
2. An assessment or reassessment is to be documented.
a. Initially on arrival to ED
b. With change in patient condition
c. Behavioral Health Reassessment to be completed every shift minimally.


An interview was conducted in the conference room with Director of Patient Safety (DPS) AA on 12/30/24 at 9:43 a.m. He has been employed in this position for one (1) year. When discussing video surveillance DPS AA stated he was familiar with this patient. He revealed P#1 had a stroke and ended up with dementia. DPS further revealed he spoke with P#1's son stating the Crisis Intervention Team was called to P#1 home and decided he needed to be transferred to a named hospital. DPS AA stated the Emergency Department was very busy that night and P#1 had to be placed in a hallway bed. He further stated the physician talked to P#1 and said he was alert and oriented. DPS AA stated P#1's son said physician did not speak to wife. DPS AA stated another patient in the hallway had a seizure and P#1's nurse had to take care of the emergency. P#1's nurse said she went to discharge the patient to the wife, and she refused to take him home because she was scared. The physician agreed to keep P#1 in the ED and have case management consulted for placement for him. DPS AA stated it was during the seizure event when P#1 left the ED without anyone knowing.

An interview was conducted in the conference room with ED Nurse Manager (NM) CC 12/30/24 at 11:10 a.m. NM CC remembers P#1 revealing he was brought into the ED via Emergency Medical Services (EMS) after having alteration with wife at home. NM CC further recalled that the ED physician evaluated P#1, determined that P#1 did not need to be admitted to hospital and did not meet criteria for 1013 and marked him to be discharged home. NM CC further revealed P#1's nurse spoke with wife regarding P#1 being discharged home. The wife did not want to take him back home fearing for her safety. P#1's nurse notified the charge nurse and P#1 was brought back to ED for case management consult. NM CC stated P#1 was not a 1013 at this time. P#1 was placed in a care space (hallway bed) in the ED and proceeded to leave the facility while awaiting case management to evaluate him in the morning. His nurse did not see him leave. After his nurse finished taking care of a critical patient, she realized P#1 was not in his care space. She notified the charge nurse, security and nursing supervisor. The city Police Department (PD) was notified by security. The city PD found P#1 on (name of ) Ave and brought P#1 back to the facility. NM CC did not recall if nurses informed wife that P#1 left.

An interview was conducted on 12/30/24 at 1:00 p.m. via telephone with the Nursing Supervisor (NS) DD. NS DD recalls getting a call around midnight on 12/18/24 from P#1's son asking that P#1 being placed on a 1013 so he could be placed in a behavior health facility. NS DD revealed he spoke with MD FF. MD FF revealed P#1 had already been discharged and was sitting in the waiting room waiting for his wife to return to pick him up. MD FF revealed to NS DD that P#1 was alert and oriented and did not meet criteria for a 1013. MD FF stated P#1 could not be admitted against his will since he was alert and oriented and did not appear to be a threat to himself or others at that time. NS DD also spoke with RN II, who was the charge nurse on night shift for 12/18/24 and he agreed with MD FF that P#1 did not meet 1013 criteria. MD FF agreed to bring P#1 back into the ED and have case management get involve with evaluating him for facility placement in the morning. P#1 was brought back into the ED and place in a bed in the hallway to wait for case management the next morning. NS DD received a call from RN II around 1:00 a.m. regarding P#1 leaving the facility without notification to staff. RN II had already notified security, and security notified the city Police Department. NS DD stated he went to the ED and within 10 minutes of receiving the call P#1's son called him regarding P#1 not being in the ED. NS DD further revealed the protocol for a patient receiving a psychiatric evaluation in the ED is to evaluate whether or not the patient was a danger to himself or others, can he care for himself, if not, does he have someone to care for him. NS DD further revealed he believes P#1 became tired of being in the ED waiting for case management and decided to leave. NS DD also stated that MD FF could not justify signing a 1013 and taking away P#1's rights.

An interview was conducted on 12/30/24 at 2:50 p.m. via telephone with the Emergency Department (ED) Medical Director (MD) EE. MD EE was made aware of the situation with P#1 from MD FF and MD JJ. MD EE stated she was not in the ED when the incident occurred but was able to speak with Patient #1 during the remainder of his visit in the ED the next day. MD EE revealed P#1 had a history of dementia and that he had gotten upset with his wife at home for not taking him to buy some tobacco products. MD EE further revealed that MD FF evaluated P#1 on arrival to the ED and documented that he did not meet 1013 criteria. P#1 was not suicidal or homicidal and that he was stable to be discharged from the ED. MD EE was informed the family did not want P#1 to be discharged because his wife was fearful of her safety. MD FF agreed to hold P#1 until case management could evaluate him the next morning. MD EE further revealed that MD JJ spoke with son on the morning of 12/19/24. The son revealed to MD JJ that he had arranged for P#1 to be accepted at a behavior health facility in another county, but he would have to have a signed 1013 to be able to be transferred. MD EE stated MD JJ agreed to sign the 1013 and P#1 was transferred out. MD EE further revealed the protocol for meeting criteria for a 1013 is the ED physician gets a history by talking to the patient and family and seeing if the patient has a history of mental illness. MD EE stated the 1013 signed for P#1 was done as a favor to the family so they could get placement for his dementia.

During a telephone interview on 12/30/24 at 5:00 p.m. with Licensed Practical Nurse (LPN) GG remembered P#1.. He arrived by stretcher via EMS and LPN GG remembers EMS telling her P#1 had an altercation with his wife and that he needed to be evaluated for aggression. LPN GG remembers keeping P#1 in the waiting room so P#1 would not become agitated, and updated P#1's wife on numerous occasions. P#1's wife informed LPN GG that she was concerned that his dementia was getting worse. She also informed LPN GG that P#1 had not seen a neurologist since being in Savannah. LPN GG informed MD FF. LPN GG stated P#1's wife left the waiting area at one time to go to her car and charge her phone. When P#1 was discharged LPN GG attempted to call P#1's wife with the number on his medical record. She was not able to contact her. P#1 called his wife on his cell phone at that time, and she answered. LPN GG stated the conversation was on speaker. P#1 informed his wife that he was being discharged and that she needed to come in and get the discharge instructions and pick him up. LPN GG stated P#1's wife informed him she was not taking him home and hung up on him. LPN GG also revealed that P#1 had no recall of having an altercation with his wife. LPN GG stated she called P#1's wife, and she informed her that she needed to talk to her son. LPN GG informed P#1's wife to call and speak with the charge nurse. LPN GG stated the son called her and stated that it was not okay to discharge his father (P#1) and that it was an unsafe discharge. The son stated his mother was not safe if P#1 was discharged. LPN GG further stated that she put the son and hold and informed RN II of the call. RN II spoke with the son and transferred him to NS DD. LPN GG then saw that P#1 was readmitted for case management to get involved. LPN GG stated P#1 was then moved to a different area so he would not be stimulated then she did not take care of him any longer.

During an interview via telephone on 12/31/24 at 7:20 a.m. with Registered Nurse (RN) II, he explained that he was the charge nurse on the night shift. RN II recalled P#1 and that he was pleasant and recalled that P#1 spoke of his love for his family. He was not assigned to P#1 but did speak with him. RN II stated he was notified that P#1 had left the ED, and he followed protocol. RN II stated he called security, and security notified the city police department.

During an interview via telephone on 12/31/24 at 7:30 a.m. RN HH recalled that P#1 was her patient after being brought back into the ED to wait for case management the next morning. RN HH recalled that P#1 was pleasant, he was in a hall bed, and she gave him food to eat. RN HH stated she did not speak with his wife. RN HH stated the protocol for a patient leaving the ED without notification is to notify the charge nurse and the charge nurse would notify security and the city police department. RN HH also stated that while she took care of P#1 he was not a 1013.

During a telephone interview on 12/31/24 at 3:20 p.m., MD JJ stated that he became aware of P#1 when he was asked by a nurse on 12/19/24 to speak to the patient due to family members wanting P#1 to be admitted to a behavioral health facility. MD JJ recalled that P#1 had vascular dementia, and he (MD JJ) was informed by the son and P#1's wife that law enforcement had been called to their home a number of times due to behavior disturbances. MD JJ stated that P#1's son presented himself as a neurologist and stated he had found a behavioral health facility that was willing to accept P#1; but P#1 needed to have a signed 1013 form stating he could not care for himself. MD JJ thought since the son had gone through all the steps to find placement for P#1 then he would help him by signing the 1013 form. MD JJ ordered basic blood work required for a transfer to a behavior health facility and P#1 was transferred without incident.