I. Based on document review and staff interviews, the Acute Care Hospital's administrative staff failed to ensure Emergency Department (ED) staff followed the hospital's EMTALA policy to provide an aedquate medical screening examination for 2 of 11 patients who presented to the ED between 10/9/2017 and 3/25/2018 in need of a psychiatric evaluation. Patient #2 (scored 5/6 points on the suicide screen) (MDS) dated [DATE] at 1:07 AM for a chief complaint of depression and requested a psychiatric evaluation. Patient #2 was escorted out of the ambulance bay by security at 1:30 AM before a medical screening examination (MSE) was performed. Patient #4 (brought in by a Police Department with a history of 2 strokes, a heart defect and past attempts at suicide)presented to the hospital for a psychiatric evaluation and due to an uncompleted suicide screen by the triage nurse, was asked to wait in the waiting room without supervision and left without being seen. Failure to ensure an appropriate Medical Screening Examination was done on Patient #2 and Patient #4 resulted in Patient #2 returning to the hospital within 2 days and being admitted by a provider and Patient #4 leaving the hospital without supervision, potentially leaving this patient at high risk of suicide. The hospital had the capacity with available psychiatric beds available during the dates Patient #2 and Patient #4 entered the ED. The hospital also had the capabilities in on call psychiatrist services to meet the needs of the patients but failed to do so. Please refer to A-2406 for more details. II. Based on document review and staff interviews, the Acute Care Hospital's administrative staff failed to ensure Emergency Department (ED) staff followed the hospital's EMTALA policy to provide stabilizing treatment of an emergency medical condition to 2 of 11 patients who presented to the ED between 10/9/2017 and 3/25/2018 in need of a psychiatric evaluation . Patient #13 presented to the ED in need of a psychiatric evaluation, left without being seen and returned within 4 hours and was admitted with committal papers. Patient #3 presented to the ED due to suicidal ideations and left without being seen by a provider. The Acute Care Hospital's administrative staff identified an average of 4305 patients per month who presented and requested emergency medical care at the dedicated ED. Failure to provide all available stabilizing treatment resulted in 1 patient leaving the hospital after a psychiatric bed was obtained to admit the patient, and 1 patient being deemed as needing a psychiatric evaluation leaving the hospital without a responsible adult and being picked up by police department on a court committal within four hours after leaving the hospital, and then admitted . The hospital had the capacity with available psychiatric beds available during the dates Patient #13 and Patient #3 entered the ED. The hospital also had the capabilities in on call psychiatrist services to meet the needs of the patients but failed to do so. Please refer to A-2407 for more details.

Based on document review and staff interviews, the Acute Care Hospital's administrative staff failed to ensure 2 of 11 patients (Patient #2 and Patient #4) who presented to the Emergency Department (ED) between 10/9/2017 and 3/25/2018 in need of a psychiatric evaluation received a proper Medical Screening Examination (MSE). A. According to documentation recorded by Emergency Medical Technician-Paramedic (EMT-P) Staff P, Patient #2 (scored 5/6 points on the suicide screen) and (MDS) dated [DATE] at 1:07AM for a chief complaint of depression, requesting a psychiatric evaluation at an acuity level of 2 (Emergent). Patient #2 was escorted out of the ambulance bay by security at 1:30 AM on 3/20/18 before a MSE was performed by the provider. B. Patient #4 (brought in by Police Department with a history of 2 strokes, a heart defect and past attempts at suicide)presented to the hospital for a psychiatric evaluation and due to an uncompleted suicide screen by the triage nurse, was asked to wait in the waiting room without supervision and left without being seen Failure to ensure an appropriate Medical Screening Examination (MSE) was completed on Patient #2 and Patient #4 resulted in Patient #2 returning to the hospital within 2 days related to the same concerns and was admitted by a provider and Patient #4 exited the hospital without supervision, potentially leaving this patient at high risk of suicide. Findings include: Review of the hospital policy "EMERGENCY EXAMINATION AND TRANSFER POLICY - EMTALA", revised 9/2017, revealed in part, "Conditions to be referred for Prompt Screening... Intoxicated or under the influence of mood altering substances evidenced by behavior ...psychiatric disturbances and/or symptoms of substance abuse ..." A. According to review of Patient #2's chart revealed the following. Patient #2 presented to the hospital ED at 1:07 AM on 3/20/2018. The electronic record entry by EMT-P Staff P revealed Patient #2's suicide screen identified a score of 5 out of 6 possible points related to suicidal ideations and was documented at an acuity level of 2 that according to hospital documentation classified Patient #2 as Emergent during the triage evaluation completed at 1:15 AM on 3/20/18.. At 1:30 AM documentation revealed Patient #2 acknowledged smoking methamphetamine's earlier that day. Patient #2 requested help for detoxification (detox). Upon requesting detox, the Behavioral Health Social Worker (BHSW) E informed Patient #2 it would be a 3-4 week wait for a detox program to accept the patient and Patient #2 can't stay at the hospital to wait for a bed to open at a detox program. Documentation by ED Registered Nurse (RN) G on 3/20/18 revealed patient remarks related to increased depression and delusions are still present. ED RN G documented Patient #2 reported about being really sick but no one wants to help them. Patient #2 commented to staff they did not know what was going to happen and could not control if they died . Patient #2 stated to the ED RN G there are lots of ways to kill myself. According to ED RN G Documentation by ED Physician Assistant Certified (PA-C) F on 3/20 revealed Patient #2 left the hospital prior to the medical evaluation. ED PA-C F reported the nursing documentation for Patient #2 revealed a comment about cutting, but the nursing staff did not believe these were suicidal statements and did not beleive the police department needed to be notified. The hospital documentation revealed Patient #2 became upset about the report of no rooms being available and began to leave the ED between 1:30 AM and 1:45 AM on 3/20/18. Security staff then followed Patient #2 out of the ambulance bay. 1. Review of the census for the East Behavioral Health Unit on 3/20/2018 revealed the hospital had 2 beds available according to the report. The hospital had the capability with an on call psychiatrist that night and capacity with 2 open beds to accept Patient #2. Information reviewed from the hospital failed to differentiate psychiatric beds and detox beds. 2. An interview with ED Nursing Manager L on 3/29/2018 at 10:10 AM revealed: The Triage Nurse asks the question if the patient is suicidal or homicidal but the actual suicide screen is completed back in the exam area not at triage. ED Nurse Manager L reported what she expects of staff if a patient has a 5/6 on a suicide screen is to try to calm the patient down and find a way to get them to stay and be evaluated by the provider not to have security essentially escort the patient out of the ambulance bay. She expects triage nurses to constantly assess the patient making sure patients are safe and to take them back immediately if a room is available. ED Nursed Manager L acknowledged in her interview that Patient #2 failed to receive a MSE. 3. During an interview with BHSW E on 3/28/2018 at 10:37AM revealed: BHSW E acknowledged not reviewing the triage assessment of Patient #2's suicide screen of 5/6. When BHSW E views the suicide screen answers of 5/6 she usually sees the patient as more lost and hopeless but the patient may still be suicidal.. According to BHSW E when she sees a patient she is evaluating for safety issues as to whether the patient reported suicidal or homicidal ideations, delusions and paranoia. BHSW E acknowledged she failed to ask if Patient #2 had a plan for suicide, reporting they just wanted to get away from it all. BHSW E reported a MSE by a provider failed to be completed on Patient #2. 4. Interview with Psychiatric Advanced Registered Nurse Practitioner (ARNP) C on 3/29/2018 at 10:38 AM revealed: Psychiatric ARNP C stated she would expect a psychiatric social worker to do a thorough assessment and that staff is trained to do these assessments. When asked if the assessment completed on Patient #2 reflected the training taught, Psychiatric ARNP C reported it was not. Psychiatric ARNP C reported that this patient would have needed to be looked into more and the how assessmentat into Patient #2 occurred failed to reflect what the hospital stands for related to mental health care. 5. During an interview on 3/28/2018 at 5:58 PM ED RN G reported performing an assessment on Patient #2. Patient #2 told ED RN G they did not have a set plan, but there are lots of ways to kill yourself. ED RN G said security stayed in the area and when Patient #2 left security assisted Patient #2 obtain personal belongings out of a locker and directed them through the ambulance bay instead of having them go through the ED main waiting room area. According to ED RN G, Patient #2 left the ED prior to an MSE by the provider. 6. During an interview on 3/28/2018 at 8:30 AM revealed on, 3/20/2018 ED Physician Assistant (PA)-C F went to assess Patient #2 the nurse reported to him Patient #2 just left out the ambulance bay and security followed. ED PA-C F reportedly asked BHSW E if Patient #2 mentioned suicidal or homicidal thoughts and was told no. ED PA-C F reported Patient #2 (MDS) dated [DATE] with chief complaint of suicidal ideation, hallucinations and paranoia. According to ED PA-C F, Patient #2 reported being at another Hospital #2 earlier in the day and being untruthful with them and left Hospital #2 to present here again. ED PA-C F reported Patient #2 relayed concerns of hurting themselves. ED PA-C F recommended psychiatry evaluation and safety admission for statements related to suicidal ideations. 7. Review of the second medical chart revealed Patient #2 returned to the hospital ED at 12:06 PM on 3/22/2018 with chief complaint of suicidal ideation. The documented suicide screen revealed 2 out of 6 possible points and a recommendation from ED PA-C F based on patient statements and concerns for safety admission to the Behavioral Health Unit is warranted. Patient #2 was admitted to the Psychiatry service at 12:34 PM on 3/22/2018. B. Review of the medical chart revealed Patient #4 (MDS) dated [DATE] at 6:01 PM for a psychiatric evaluation. ED RN H performed the triage assessment and listed the acuity level at a 3 (Urgent) but failed to complete a Columbia suicide screen, a part of a psychiatric assessment. Documentation revealed Patient #4 failed to be placed into a ED room for evaluation. The medical record lacked documentation that Patient #4 was supervised after being brought in by Law Enforcement for a psychiatric evaluation. Patient #4's medical record revealed a history of depression with anxiety, psychosis, schizoaffective disorder, accidental drug overdose, IV drug use, a heart defect and stroke. The medical record failed to contain a Medical Screening Exam (MSE) on Patient #4 by a provider. 1. During a telephone interview with ED RN H on 3/28/2018 at 2:19 PM revealed: ED RN H reported usually police department brings patients in due to suicidal or homicidal thoughts or a substance abuse committal. ED RN H acknowledged her lack of completing a suicide screen for Patient #4 and offered no explanation why this failed to be completed. 2. During an interview on 3/29/2018 at 9:40 AM revealed: ED Nurse Manager L reported she expects the triage nurse to do a quick assessment and if someone is brought in for a psychiatric evaluation to ask if they are suicidal or homicidal. ED Nurse Manager L confirmed the Triage nurse failed to inquire and ask Patient #4 if they were suicidal or homicidal before being asked to return to the waiting room. ED Nurse Manager L also acknowledged there is a lack of documentation of Patient #4 's activities in the waiting room, until it was documented that Patient #4 exited the ED. ED Nurse Manager L acknowledged Patient #4 failed to receive a MSE for the chief complaint of psychiatric evaluation.

Based on document review and staff interviews, the Acute Care Hospital's administrative staff failed to ensure 2 of 11 patients who presented to the Emergency Department (ED) between 10/9/2017 and 3/25/2018 in need of a psychiatric evaluation received stabilizing treatment of an emergency medical condition (EMC). Patient #13 presented to the ED escorted by the Law Enforcement in need of a psychiatric evaluation for Post Traumatic Stress Disorder (PTSD), potential over dose, hallucinations and suicidal ideations. The record reflected that Patient #13 eloped from the ED the following morning prior to receiving stabilizing treatment and was returned within 4 hours and was admitted with court committal paperwork. Patient #3 presented to the ED for suicidal ideations and left without being seen by a provider. The Acute Care Hospital's administrative staff identified an average of 4305 patients per month who presented and requested emergency medical care. Failure to provide stabilizing treatment resulted in 1 patient being deemed as needing a psychiatric evaluation leaving the hospital without a responsible adult and being picked up by police department on a court committal within four hours after leaving the hospital, and then admitted and 1 patient leaving the hospital after a psychiatric bed was obtained to admit the patient. Findings included: 1. Review of the hospital policy "EMERGENCY EXAMINATION AND TRANSFER POLICY - EMTALA", revised 9/2017, revealed in part, "FURTHER STEPS WHEN EMERGENCY MEDICAL CONDITION IS FOUND. If the person has an emergency medical condition, further medical examination and treatment within the capabilities of the staff and facilities must be provided as required to stabilize the Emergency Medical Condition ..." 2. Review of the medical record revealed Patient #13 (MDS) dated [DATE] at 7:28 PM seeking a psychiatric evaluation and left the ED against medical advice (AMA) on 11/29/2017 at 12:20 AM. Patient #13 was brought to the hospital's ED by police after the patient's family reported patient had potentially overdosed on his medications. Patient#13's family also reported the patient was running around chasing people with a crowbar today. Patient #13 denied the family's reports of his activities. Review of ED Physician I's documentation of Patient #13's examination on 11/28/2017 at 9:31 PM revealed the patient was agitated, had slurred speech, and appeared to be clinically intoxicated. Urine drug screen registered positive for amphetamines and cannabinoids. Ethanol (alcohol) level was negative. During the evaluation, the patient remained slightly altered secondary to intoxication and wanted to keep the patient in the ED overnight unless someone could pick him up from the ED. The patient was unable to obtain a ride from the ED and the patient agreed on a plan to stay in the ED and reevaluate him in the morning. The provider was notified about midnight that the patient had eloped from the ED. The staff notified the police department. A 72 hour hold was obtained from the magistrate on call. The police were called again to bring the patient back to the ED. Review of Social Worker's (SW) evaluation of Patient #13 dated and timed on 11/28/2017 at 7:34 PM revealed Patient #13 presented to the ED via police for a psychiatric evaluation due to family's concerns of patient possibly overdosing, suicidal ideations, hallucinations and being a danger to others. Patient denies suicidal/homicidal ideations. Spoke with the provider and due to the patient's altered status, plan of care was decided that patient could discharge if a sober party was able to pick patient up or patient would need to remain in the department until the patient could be reassessed when clinically sober. The patient initially agreed to this plan of care and made multiple phone calls to attempt to find a ride but was unsuccessful. Notified by staff that patient had eloped from the department, provider notified who stated he wanted patient to be returned to the department. Security notified and 911 contacted. Review of nursing documentation revealed Patient #13 was on a 1:1 monitoring with visual checks every 30 minutes. Suicide checks documented on 11/28/2017 at 7:45 PM, 8:00 PM, 8:52 PM, 9:30 PM, and 9:45 PM. Patient #13's medical record lacked documentation of suicide checks after 9:45 PM until the patient left the ED at 12:18 AM. Nursing documentation at 8:09 PM showed Patient #13 stated to ED RN K that he would like to sign out AMA after the police leaves or after the doctor sees him. The physician was informed of the patient's statements. Patient #13 walked out of his ED room on 11/29/2017 at 12:18 AM and said "I'm outta here". Patient proceeded toward exit. Security notified. Per security, patient seen running out of ED entrance. Police department notified and given patient's description. Provider updated. 3. On 11/29/2017 the hospital had 3 adult psychiatric rooms available at the time Patient #13 left the hospital's emergency department. 4. Review of a second medical record showed Patient #13 returned to the hospital accompanied by law enforcement on 11/29/17 at 3:43 AM for a behavioral health evaluation. Patient #13 was then admitted to the hospital's psychiatric unit on an involuntarily basis with high risk of bodily harm. Patient #13 was discharged [DATE] 17 from the hospital's psychiatric unit. 5. During an interview on 3/28/18 at 10:00 AM, ED Physician I stated Patient #13 had slurred speech and was agitated. Physician I stated in his clinical impression, Patient #13 appeared to be under the influence. Physician I stated any patient leaving intoxicated would be a threat to themselves. Patient #13 was clinically intoxicated but did not have a court committal hold until he was medically unsafe. When the patient left without being reevaluated, we contacted the police department to track the patient down. 6. During an interview on 3/29/18 at 9:17 AM, ED Physician I stated Patient #13 was not able to make his own decisions based on the patient's intoxication and because of that the patient was in a medically unsafe condition. Physician I stated there was a risk for the patient to make bad judgements based on his sobriety status. Physician I stated the patient had a mental illness diagnoses history of PTSD [Post Traumatic Stress Disorder] and Depression. 7. During an interview on 3/28/18 at 2:40 PM, Social Worker (SW) J stated the night Patient #13 came into the ED, the patient's mother had called the ED and reported she was concerned for the patient's safety. The patient denied overdosing or suicidal ideations but he was slurring his words and had altered mental status. The patient was agreeable to stay in the ED per the provider's request but then the patient walked out. SW J stated the physician was called and he obtained a court order hold. The police were then notified and the police brought the patient back and he was admitted at that time. 8. During an interview on 3/29/18 at 9:40 AM, ED Nurse Manager L stated the following regarding Patient #13's chart review. ED Nurse Manager L stated it was difficult to speak to what stabilizing treatment that was provided to the patient from 9:45 PM to 12:18 AM when the patient walked out of the ED other than the lab values came back. ED Nurse Manager L agreed to the lack of documentation of what happened with the patient from 9:45 PM to 12:18 AM. 9. Review of Patient #3's medical record revealed Patient #3 presented to the hospital's ED on 3/20/2018 at 1:32 PM with chief complaint of suicidal and possible homicidal thoughts.Emergency Department staff instituted 1:1 sitter with continuous close watch for Patient #3. According to the record at 2:48 PM ED Physician A requested a room for Patient #3 in the Behavioral Health Unit. Psychiatric ARNP C agreed to admit Patient #3 to the Behavioral Health Unit. ED RN N documented that ED Physician A gave verbal order that Patient #3 may leave AMA if he became uncooperative related to the patient not being suicidal or homicidal. At 5:02 PM ED RN N charted that Patient #3 left without being seen. 5:07 PM Patient #3 requested to leave related to it taking too long to get admitted . 5:07 PM ED RN N documented Patient #3 left by himself. 10. During an interview with ED RN O on 3/28/2018 at 12:00PM revealed: Triaged Patient #3, appeared nervous and jumping from subject to subject and did not want to sit down. The friend with Patient #3 reported to ED RN O they believed Patient #3 could be homicidal. 11. During an interview with ED Physician A on 3/28/2018 at 3:19 PM revealed: ED Physician A consulted with Psychiatric ARNP C and was able to obtain a room for Patient #3. ED Physician A told Patient #3 they would be admitted if Patient #3 was cooperative and completed the laboratory tests requested by the doctor. 12. During an interview with Psychiatric ARNP C on 3/29/2018 at 10:38 AM revealed: Psychiatric ARNP reported that even though Patient #3 met criteria for admission due to being manic, they were going to be allowed to leave AMA if they were uncooperative per ED Physician A's wishes. When asked if uncooperative patients are admitted to the Behavioral Health Unit, Psychiatric ARNP C acknowledged they are. Psychiatric ARNP C confirmed the Behavioral Health Unit accepts uncooperative patients. 13. During an interview with ED RN D on 3/28/2018 at 7:15 PM revealed: ED RN D remembered asking Patient #3 to urinate for testing and get into scrubs so they could be admitted to the Behavioral Health Unit. Patient #3 refused to urinate; therefore they were not able to be admitted to the floor until they would agree to do so. ED RN D also revealed there have been patients that have been admitted to the Behavioral Health Unit without doing lab work that was requested. 14. During an interview with ED Physician B on 3/28/2018 at 2:00 PM revealed: he didn't see Patient #3 and that ED Physician A said Patient #3 was free to leave AMA if they wanted to. ED Physician B stated that Patient #3 was going to be admitted because they would not go home, it is called a social admission. ED Physician B reported social admissions are done by staff to please the patients even though they do not meet criteria.