Based on hospital policy review, medical record reviews, physician and staff interviews the hospital failed to comply with 42 CFR §489.20 and §489.24. The findings include: 1. The hospital's Dedicated Emergency Department (DED) and/or Labor and Delivery (L&D) physician failed to ensure necessary stabilizing treatment for an emergency medical condition by failing to provide within the capabilities of the staff and facilities available at the hospital, for stabilizing treatment as required to stabilize the medical condition for 1 of 7 sampled patients that were transferred with an EMC to other acute care hospitals (Patient #11). ~ Cross refer to §489.24(d)(1) Necessary Stabilizing Treatment for Emergency Medical Conditions, Tag A2407. 2. The hospital's Dedicated Emergency Department (DED) and/or Labor and Delivery (L&D) physician failed to ensure an appropriate transfer by failing to ensure the receiving hospital had available space and qualified personnel for the treatment of the individual; and by failing to ensure the receiving hospital had agreed to accept transfer of the indvidual and to provide appropriate medical treatment for 1 of 7 sampled patients that were transferred with an EMC to other acute care hospitals (Patient #11). ~ Cross refer to §489.24(e)(1)-(2) Appropriate Transfer, Tag A2409.

Based on hospital policy review, medical record reviews, physician and staff interviews the hospital's Dedicated Emergency Department (DED) physician failed to ensure necessary stabilizing treatment for an emergency medical condition by failing to provide within the capabilities of the staff and facilities available at the hospital,stabilizing treatment as required to stabilize the medical condition for 1 of 7 sampled patients that were transferred with an EMC to other acute care hospitals (Patient #11). The findings include: Review of Hospital Policy and Procedure titled "EMTALA: Treatment Of Patients With Emergency Medical Conditions" last revised 07/05/2016 revealed "A. 5. If the qualified medical person determines that an emergency medical condition exists, appropriate treatment shall be offered to stabilize the patient's condition." "Hospital A (Rex Hospital ) closed DED medical record review on 03/01/2017 for patient (Pt) #11 revealed a [AGE]-year-old female that presented via law enforcement on Involuntary Commitment to the DED on 01/28/2017 at 1455 with a chief complaint of hallucinations. Review revealed the patient was placed in a DED room at 1457. Review revealed first provider contact was at 1529. Review of Nursing Triage Note at 1534 revealed Patient #11 was unsure why she was brought to the hospital. Review revealed the patient's family stated "pt has multiple medical problems including mental health issues, and last night she 'ran away' from home and checked herself into a hotel where she was hallucinating that people were going in and out of her hotel room and her sisters were under her bed. ...Family reports pt was supposed to go to (Hospital B name) per her PCP (primary care physician), but was sent here by the magistrate". Review of nursing notes at 1539 revealed vital signs as follows: Oral temperature 98.1; Heart Rate 95; Respirations 14; Blood Pressure 118/79 in left arm; and oxygen saturation 99% on room air. Review revealed discharge vital signs at 1841 as follows: Oral temperature 98.6; Heart Rate 87; Respirations 16; Blood Pressure 121/72 in left arm; and oxygen saturation 98% on room air. Further review revealed Patient #11 was identified as a falls risk related to confusion and that fall precautions were initiated. Review of triage nursing notes at 1541 revealed the patient's acuity (ESI) level was a 2 (Urgent). Further review revealed no documentation of suicidal or homicidal ideations. Record review revealed a psychiatric consult order was placed by the DED physician at 1542 and consult was called by phone at 1546. Review revealed a psychiatric nursing assessment was completed by the primary DED registered nurse at 1545. Psychiatric nursing assessment revealed Patient #11 was alert and oriented to person, place, time and date; follows commands; general attitude: apathetic, defensive; general appearance: disheveled (malnourished); mental status: unremarkable with no delusions noted and no appearance of responding to internal stimuli, does have impaired judgment and insight. Record review revealed a note documented by a patient relations advocate at 1652 with information related to Patient #11's recent visit to Hospital B where she was treated medically and consulted by psychiatry. Note revealed the family was upset and wanted the patient taken to Hospital B but due to the magistrate's order on involuntary commitment papers, the patient was transported to Hospital A by law enforcement. The patient relations advocate discussed the family's wishes with charge nurse, house supervisor and physician and attempted to arrange a lateral transfer to Hospital B. Note revealed request was met with resistance from Hospital B and care was provided by Hospital A. Note revealed the family was made aware that the patient would be treated at Hospital A. Further review of patient relations advocate note revealed the psychiatrist consulted the patient and spoke with the family. Note revealed the involuntary commitment was lifted and family was encouraged to follow-up with Hospital B if further medical or psychiatric evaluation was necessary. Note revealed psychiatrist was at the bedside talking with the patient while completing the examination. Note revealed the psychiatrist would speak with the family separately. Review of an electronic Psychiatric Consultation Note documented at 1822 revealed the patient has a history of psychosis and multiple medical conditions. Review revealed the patient was involuntary committed by her family after she 'ran away' on 01/27/2017 and was hallucinating in her hotel. Further review of psychiatric consult note revealed "Pt (patient) was seen in ED (Emergency Department). She appears to be drowsy. She understands that she is in the hospital, but not sure how she got here. She saw her mom and sister, and had no difficulty recognizing them, and stated that she wants to go home with them. But she also agreed that she needs to go to (Hospital B name) for a checkup first. Of note, she was just released from (Hospital B name) about 2 weeks ago after a month long stay for failure to thrive. Spoke with mom and sister, who are at the hospital, and filed the IVC. They said that pt got upset yesterday, without a clear trigger. She then insisted that she needs to go to a hotel. After family refused to take her anywhere because they worried about her safety, pt somehow made a neighbor drive her to a hotel last night. This morning, pt caller her mom from the hotel, and was completely incoherent. Mom and sister tracked the number back to Embassy Suite, and called the hotel. The hotel staff reported that pt has been calling the front desk complaining 'people were in and out of her room', or 'hiding under her bed' all night. Family stated that pt often have similar kind of complaint due to visual hallucinations. Family worried that pt has not been taking her meds and is unable to take care of herself. Thus, they called pt's PCP and the PCP office advised to file IVC and get the pt to an ED. However, family said that they strongly prefer to go to (Hospital B name) since they know the pt very well both medically and psychiatrically from her recent lengthy hospitalization . Both mom and sister feel very comfortable to drive pt there themselves, as hospital to hospital transfer is very challenging and can take days even if it is successful. In fact, the pt's mom insisted that is what she would like to do. Thus, we discussed with the pt together afterward again, and pt confirmed that she would like to go home with her mom and sister, and agreed that they are going to check up with (Hospital B name) first. Past Psychiatric History: Previous diagnoses: psychosis, likely from medical conditions. hospitalization s: no psych ... Social History Narrative ...Lives with mom and sister ...Review of Systems (ROS) - Psychological ROS: positive for - tired. ...Mental Status Exam: General/Appearance: Appears stated age and malnourished Behavior: Cooperative but irritable at times. ...Speech/Language: paucity Mood: Anxious Affect: Anxious, Constricted and Depressed ...Perceptual disturbances: family reported AVH (auditory verbal hallucinations) last night Orientation: to person and place Attention: Able to fully attend without fluctuations in consciousness Concentration: Distractible Memory: impaired Insight: Impaired Judgment: Impaired Impulse Control: Fair Test Results: ...No results found for this or any previous visit (from past 24 hours) ..." Further review of psychiatric consultation revealed "Assessment: ...Currently, pt feels tired and not actively hallucinating. Family feels that it would be at the best interest of the pt, if she could go to (Hospital B name) ... Since pt has been calm and cooperative currently, and fully agreed to go with her family (sister and mom), and family feel comfortable to drive her directly to [Hospital B name] (mom will sit in the back with the pt, and sister will drive), and family appears to be very reliable, the risks of self-harm or harming other during transportation is low. Thus, IVC is lifted. Pt will be going to (Hospital B name) directly from (Hospital A name), with her family. Risk Assessment: A thorough evaluation has been completed of risk and protective factors including, but not limited to these risk factors, psychosis, and these protective factors, supportive family. In my judgment the patient is at a chronically elevated risk of dangerousness to self (and/or others), but is not an acutely elevated risk. It is important to note that future behaviors cannot be accurately predicted. Safety Concerns: None at present time ...Plan-Lifted IVC so that family will be able to take her directly to (Hospital B name), as they strongly prefer that hospital given pt has recently been there for over one month. Family feel that the staff and doctors there are already familiar with her case, and would be able to perform better care. After carefully assessing the risks of transfer by family, I feel the benefits overweight the risks for doing so. Thus, IVC is lifted. Family is given the information for refile IVC if needed, and they plan to drive directly to (Hospital B's name) ED". Rex Hospital failed to ensure that stabilizing treatment was provided as required that was within the capability of the hospital on [DATE] for Patient #11. Review of electronic DED Provider Note documented at 1824 revealed patient #11 presented with a chief complaint of Involuntary Commitment and hallucinations. Further review revealed patient had multiple medical problems including Lupus, Sjogren's (systemic [DIAGNOSES REDACTED] disease that affects the entire body with dry eyes & dry mouth), Crohn's disease and required Total Parenteral nutrition (TPN) through an indwelling port. Documentation revealed patient had recent hospitalization at Hospital B for failure to thrive. Review revealed the patient checked into a hotel on 01/27/2017 to get away from her sister and mother. Review revealed the family were concerned about the patient's increasing depression and paranoia so they took out Involuntary Commitment papers. Review revealed the patient had no acute issues other than her port being accessed for one week due to home health nurse unable to disconnect. Review of physician's documented physical examination revealed "General: Chronically ill-appearing thin framed black female. She is awake and conversant. ...Psych: Mental status is fairly normal and affect depressed, normal speech pattern and content. ED COURSE & MEDICAL DECISION MAKING: Labs reviewed (per interview MD #1 reviewed previous record from Hospital B) ... This is a [AGE]-year-old female brought in by police under IVC (Involuntary Commitment) which was taken out by her family. From medical standpoint the patient seems overall fairly stable. I consulted our psychiatrist who evaluated the patient and spoke with the family. After this, the psychiatrist is recommended the patient's IVC be lifted. The psychiatrist has done this and the patient was discharged with the family. Diagnosis: #1 psychosis #2 depression #3 lupus #4 Crohn's disease." Review revealed no available documentation of labs or x-rays ordered during this visit. Record review revealed patient #11 was assigned a disposition of discharge by the DED provider at 1923. Review revealed the patient's "After Visit Summary" (discharge instructions) was printed at 1930. Discharge nursing notes at 1946 revealed patient #11 was discharged via wheelchair with family and documentation of a pain assessment with a score of "5" on a scale of 0-10 (10 being worst, 0 being no pain). Further review of discharge notes at 1947 revealed discharge instructions and follow-up care were discussed with patient and the patient verbalized understanding. Review of discharge nursing notes documented at 1947 revealed "Pt (patient) discharged at this time, respirations even & unlabored, ambulatory to and from the wheelchair with a steady gait, NAD (no acute distress) noted, mother at side. Pt verbalizes understanding of discharge instructions and verbalizes conditions which necessitate return to the ED or calling 911, as well as warning signs for possible condition deterioration. Pt's mother verbalizes intention to take the patient to (Hospital B name) for IVC (involuntary commitment)." Review of After Summary Visit (discharge instructions) dated 01/28/207 revealed documentation of follow-up information for family medicine physician that included physician's name and address, vital signs during the visit, procedures/test performed during visit, diagnosis, provider name that saw patient in the DED, telephone numbers for National Suicide Hotlines and NC Crisis lines and home care patient instructions for psychosis diagnosis. Further review of After Summary Visit dated 01/28/2017 at 1945 revealed a signature page with documentation that patient and mother refused to sign discharge instructions. Review of medical record from Hospital B for Patient #11 revealed a "Call In Referrals" was received on 01/28/2017 at 1316 (38 minutes prior to patient arriving at Hospital A) from MD #5 to RN #6 with reason for referral "acute psychotic break". Review revealed Pt #11 arrived in the ED on 01/28/2017 at 2022 with complaint of IVC (Involuntary Commitment). Further review revealed Pt #11 arrived by private vehicle, escorted by her mother, at Hospital B on 01/28/2017 at 2102 with a chief complaint "Altered Mental Status (Patient's mother reports that her daughter's PCP wants her to have a psych (psychiatric) evaluation due to change in behavior)". Review of Emergency Department Provider Notes dated 01/28/2017 at 2102 revealed " ...Family apparently completed IVC paperwork feeling that she was not safe. Police picked patient up and apparently Crisis was on diversion and (Hospital A name) was up for the next patient evaluation. Patient was taken to (Hospital A name), but repeatedly stated that she wanted to come to (Hospital B name) as she had recently been admitted here and all her records were here. Psychiatrist saw her in the ER (Hospital A) and with repeated requests by patient and mom agreed to lift IVC so she could come here ..." Review revealed nursing documentation at 2145 the patient was unwilling to provide discharge paperwork from (Hospital A name) when asked. Review of record revealed Involuntary Commitment Papers were completed by Emergency Department Physician and sent to the magistrate's office on 01/29/2017 at 0225. Review revealed Pt #11 was admitted to observation on 01/29/2017 at 0358 awaiting Psychiatric Bed Placement. Physician interview on 03/02/2017 at 0850 with MD #1, the MD who completed the MSE on Pt #11 at Hospital A, revealed the patient came to the DED after being Involuntary Committed by her family for auditory hallucinations. Interview revealed the patient was lucid, talking and stated she didn't know why she was at the hospital. Interview revealed the patient has no acute complaints, vital signs were stable and patient was mentally competent to make decisions. Interview revealed the DED provider reviewed the patient's previous hospitalization and lab results in Care Everywhere system. Interview revealed patient was medically cleared and psychiatrist was notified for consult. Interview revealed the family were upset that the patient was not taken to Hospital B as requested. Interview revealed DED physician told family he did not see a need for patient transfer or admission to Hospital B but he would try and see if Hospital B would accept patient as a transfer at family request. "I spoke with hospitalist at (Hospital B name) about family's request for transfer, but (Hospital B name) denied patient transfer." Interview revealed "I felt the patient was stable for discharge home." Interview revealed after psychiatric consult and Involuntary Commitment lifted, "the patient was discharged home and was not directed by me to go to (Hospital B name)." Physician interview on 03/02/2017 at 1330 with MD #2, the MD who completed the psychiatric consultation at Hospital A, revealed the patient was not having active hallucinations during his assessment. Interview revealed the patient had no Psychotic Diagnosis. Interview revealed the patient had symptoms of [DIAGNOSES REDACTED]"I did feel some pressure from the family to lift the Involuntary Commitment, but I would not have released her if she was actively hallucinating. The patient was calm with no hallucinations and wanted to go home with her family. The patient knew what she wanted to do." Interview revealed at the time of the Involuntary Commitment removal the patient was "stable to discharge home with follow-up with primary care provider". Interview revealed no follow-up was arranged as patient had been set up with outpatient follow-up appointment from her previous hospitalization at Hospital B. Staff interview on 03/02/2017 at 0938 with RN #3 (Registered Nurse) revealed she was the nurse that discharged patient #11 from Hospital A. Interview revealed the patient stated "I don't want to be here". Interview revealed the patient was drowsy. Interview revealed the family stated she had been this way for a couple of months. Interview revealed the patient was assisted with getting dressed for discharge. Interview revealed the patient transferred from the stretcher to the wheelchair with minimal assistance and was able to ambulate with assistance to the bathroom. Interview revealed "I felt she was okay to send home with family and home health." Interview revealed the patient's mother said she was going to take the patient to Hospital B and have her Involuntary Committed again. Interview revealed the mother did not express her reasons for having the patient Involuntary Committed. Interview revealed the mother was comfortable with the patient being discharged from Hospital A. Staff interview on 03/02/2017 at 1140 with PRA #4 (Patient Relations Advocate) for Hospital A, revealed "my job is to tie everything together between the magistrate, the DED physician and the psychiatrist". Interview revealed Involuntary Commited patients are set up on a "round robin" schedule from the magistrate's office, meaning they are rotated around the area hospitals. Interview revealed the family was not aware the patient was going to be brought to Hospital A as they had requested the magistrate send patient to Hospital B. Interview revealed the family were very insistent that the patient go to Hospital B where they were familiar with her medical and psychiatric problems. Interview revealed after input from DED physician, psychiatrists, charge nurse and house supervisor, a transfer to Hospital B was attempted, but Hospital B refused to accept the patient. Interview revealed the police department offered to take patient to Hospital B, but patient had already been checked in at Hospital A and "I thought it would be a violation if sent to (Hospital B name)". Interview revealed the patient was medically cleared and psychiatrist released the Involuntary Commitment after assessing patient. Interview revealed the psychiatrist met with the family and the patient to discuss decision and plan. The facility failed to ensure that their policy and procedure related to stabilizing treatment was followed as evidenced by failing to provide appropriate treatment to stabilize patient #11's psychiatric condition on 1/28/2017. As patient #11 arrived to Hospital B on 1/28/2017 at 8:22 PM, and Involuntary Commitment Papers were completed by the ED physician on 1/29/2017 at 2:25 AM. The Patient was admitted to observation at Hospital B on 1/29/2017 awaiting psychiatric placement. NC 830

Based on hospital policy review, medical record reviews, physician and staff interviews the hospital's Dedicated Emergency Department (DED) physician failed to ensure an appropriate transfer by failing to ensure the receiving hospital had available space and qualified personnel for the treatment of the individual; and by failing to ensure the receiving hospital had agreed to accept transfer of the individual and to provide appropriate medical treatment for 1 of 7 sampled patients that were transferred with an EMC to other acute care hospitals (Patient #11). The findings include: Review of Hospital Policy and Procedure titled "EMTALA: Treatment Of Patients With Emergency Medical Conditions" last revised 07/05/2016 revealed "C. Discharge or Transfer When Emergency Condition Exists ...4. ...The receiving medical facility must have available space and qualified personnel for the treatment of the patient, and prior to transfer, must have agreed to accept the transfer of the patient and agreed to provide appropriate medical treatment." Hospital A closed DED medical record review on 03/01/2017 for patient (Pt) #11 revealed a [AGE]-year-old female that presented via law enforcement on Involuntary Commitment to the DED on 01/28/2017 at 1455 with a chief complaint of hallucinations. Review revealed the patient was placed in a DED room at 1457. Review revealed first provider contact was at 1529. Review of Nursing Triage Note at 1534 revealed Patient #11 was unsure why she was brought to the hospital. Review revealed the patient's family stated "pt has multiple medical problems including mental health issues, and last night she 'ran away' from home and checked herself into a hotel where she was hallucinating that people were going in and out of her hotel room and her sisters were under her bed. ...Family reports pt was supposed to go to (Hospital B name) per her PCP (primary care physician), but was sent here by the magistrate". Review of nursing notes at 1539 revealed vital signs as follows: Oral temperature 98.1; Heart Rate 95; Respirations 14; Blood Pressure 118/79 in left arm; and oxygen saturation 99% on room air. Review revealed discharge vital signs at 1841 as follows: Oral temperature 98.6; Heart Rate 87; Respirations 16; Blood Pressure 121/72 in left arm; and oxygen saturation 98% on room air. Further review revealed Patient #11 was identified as a falls risk related to confusion and that fall precautions were initiated. Review of triage nursing notes at 1541 revealed the patient's acuity (ESI) level was a 2 (Urgent). Further review revealed no documentation of suicidal or homicidal ideations. Record review revealed a psychiatric consult order was placed by the DED physician at 1542 and consult was called by phone at 1546. Review revealed a psychiatric nursing assessment was completed by the primary DED registered nurse at 1545. Psychiatric nursing assessment revealed Patient #11 was alert and oriented to person, place, time and date; follows commands; general attitude: apathetic, defensive; general appearance: disheveled (malnourished); mental status: unremarkable with no delusions noted and no appearance of responding to internal stimuli, does have impaired judgment and insight. Record review revealed a note documented by a patient relations advocate at 1652 with information related to Patient #11's recent visit to Hospital B where she was treated medically and consulted by psychiatry. Note revealed the family was upset and wanted the patient taken to Hospital B but due to the magistrate's order on involuntary commitment papers, the patient was transported to Hospital A by law enforcement. The patient relations advocate discussed the family's wishes with charge nurse, house supervisor and physician and attempted to arrange a lateral transfer to Hospital B. Note revealed request was met with resistance from Hospital B and care was provided by Hospital A. Note revealed the family was made aware that the patient would be treated at Hospital A. Further review of patient relations advocate note revealed the psychiatrist consulted the patient and spoke with the family. Note revealed the involuntary commitment was lifted and family was encouraged to follow-up with Hospital B if further medical or psychiatric evaluation was necessary. Note revealed psychiatrist was at the bedside talking with the patient while completing the examination. Note revealed the psychiatrist would speak with the family separately. Review of an electronic Psychiatric Consultation Note documented at 1822 revealed the patient has a history of psychosis and multiple medical conditions. Review revealed the patient was involuntary committed by her family after she 'ran away' on 01/27/2017 and was hallucinating in her hotel. Further review of psychiatric consult note revealed "Pt (patient) was seen in ED (Emergency Department). She appears to be drowsy. She understands that she is in the hospital, but not sure how she got here. She saw her mom and sister, and had no difficulty recognizing them, and stated that she wants to go home with them. But she also agreed that she needs to go to (Hospital B name) for a checkup first. Of note, she was just released from (Hospital B name) about 2 weeks ago after a month long stay for failure to thrive. Spoke with mom and sister, who are at the hospital, and filed the IVC. They said that pt got upset yesterday, without a clear trigger. She then insisted that she needs to go to a hotel. After family refused to take her anywhere because they worried about her safety, pt somehow made a neighbor drive her to a hotel last night. This morning, pt caller her mom from the hotel, and was completely incoherent. Mom and sister tracked the number back to Embassy Suite, and called the hotel. The hotel staff reported that pt has been calling the front desk complaining 'people were in and out of her room', or 'hiding under her bed' all night. Family stated that pt often have similar kind of complaint due to visual hallucinations. Family worried that pt has not been taking her meds and is unable to take care of herself. Thus, they called pt's PCP and the PCP office advised to file IVC and get the pt to an ED. However, family said that they strongly prefer to go to (Hospital B name) since they know the pt very well both medically and psychiatrically from her recent lengthy hospitalization . Both mom and sister feel very comfortable to drive pt there themselves, as hospital to hospital transfer is very challenging and can take days even if it is successful. In fact, the pt's mom insisted that is what she would like to do. Thus, we discussed with the pt together afterward again, and pt confirmed that she would like to go home with her mom and sister, and agreed that they are going to check up with (Hospital B name) first. Past Psychiatric History: Previous diagnoses: psychosis, likely from medical conditions. hospitalization s: no psych ... Social History Narrative ...Lives with mom and sister ...Review of Systems (ROS) - Psychological ROS: positive for - tired. ...Mental Status Exam: General/Appearance: Appears stated age and malnourished Behavior: Cooperative but irritable at times. ...Speech/Language: paucity Mood: Anxious Affect: Anxious, Constricted and Depressed ...Perceptual disturbances: family reported AVH (auditory verbal hallucinations) last night Orientation: to person and place Attention: Able to fully attend without fluctuations in consciousness Concentration: Distractible Memory: impaired Insight: Impaired Judgment: Impaired Impulse Control: Fair Test Results: ...No results found for this or any previous visit (from past 24 hours) ..." Further review of psychiatric consultation revealed "Assessment: ...Currently, pt feels tired and not actively hallucinating. Family feels that it would be at the best interest of the pt, if she could go to (Hospital B name) ... Since pt has been calm and cooperative currently, and fully agreed to go with her family (sister and mom), and family feel comfortable to drive her directly to [Hospital B name] (mom will sit in the back with the pt, and sister will drive), and family appears to be very reliable, the risks of self-harm or harming other during transportation is low. Thus, IVC is lifted. Pt will be going to (Hospital B name) directly from (Hospital A name), with her family. Risk Assessment: A thorough evaluation has been completed of risk and protective factors including, but not limited to these risk factors, psychosis, and these protective factors, supportive family. In my judgment the patient is at a chronically elevated risk of dangerousness to self (and/or others), but is not an acutely elevated risk. It is important to note that future behaviors cannot be accurately predicted. Safety Concerns: None at present time ...Plan-Lifted IVC so that family will be able to take her directly to (Hospital B name), as they strongly prefer that hospital given pt has recently been there for over one month. Family feel that the staff and doctors there are already familiar with her case, and would be able to perform better care. After carefully assessing the risks of transfer by family, I feel the benefits overweight the risks for doing so. Thus, IVC is lifted. Family is given the information for refile IVC if needed, and they plan to drive directly to (Hospital B's name) ED". Review of electronic DED Provider Note documented at 1824 revealed patient #11 presented with a chief complaint of Involuntary Commitment and hallucinations. Further review revealed patient had multiple medical problems including Lupus, Sjogren's (systemic [DIAGNOSES REDACTED] disease that affects the entire body with dry eyes & dry mouth), Crohn's disease and required Total parenteral nutrition (TPN) through an indwelling port. Documentation revealed patient had recent hospitalization at Hospital B for failure to thrive. Review revealed the patient checked into a hotel on 01/27/2017 to get away from her sister and mother. Review revealed the family were concerned about the patient's increasing depression and paranoia so they took out Involuntary Commitment papers. Review revealed the patient had no acute issues other than her port being accessed for one week due to home health nurse unable to disconnect. Review of physician's documented physical examination revealed "General: Chronically ill-appearing thin framed black female. She is awake and conversant. ...Psych: Mental status is fairly normal and affect depressed, normal speech pattern and content. ED COURSE & MEDICAL DECISION MAKING: Labs reviewed (per interview MD #1 reviewed previous record from Hospital B) ... This is a [AGE]-year-old female brought in by police under IVC (Involuntary Commitment) which was taken out by her family. From medical standpoint the patient seems overall fairly stable. I consulted our psychiatrist who evaluated the patient and spoke with the family. After this, the psychiatrist is recommended the patient's IVC be lifted. The psychiatrist has done this and the patient was discharged with the family. Diagnosis: #1 psychosis #2 depression #3 lupus #4 Crohn's disease." Review revealed no available documentation of labs or x-rays ordered during this visit. Record review revealed patient #11 was assigned a disposition of discharge by the DED provider at 1923. Review revealed the patient's "After Visit Summary" (discharge instructions) was printed at 1930. Discharge nursing notes at 1946 revealed patient #11 was discharged via wheelchair with family and documentation of a pain assessment with a score of "5" on a scale of 0-10 (10 being worst, 0 being no pain). Further review of discharge notes at 1947 revealed discharge instructions and follow-up care were discussed with patient and the patient verbalized understanding. Review of discharge nursing notes documented at 1947 revealed "Pt (patient) discharged at this time, respirations even & unlabored, ambulatory to and from the wheelchair with a steady gait, NAD (no acute distress) noted, mother at side. Pt verbalizes understanding of discharge instructions and verbalizes conditions which necessitate return to the ED or calling 911, as well as warning signs for possible condition deterioration. Pt's mother verbalizes intention to take the patient to (Hospital B name) for IVC (involuntary commitment)." Review of After Summary Visit (discharge instructions) dated 01/28/207 revealed documentation of follow-up information for family medicine physician that included physician's name and address, vital signs during the visit, procedures/test performed during visit, diagnosis, provider name that saw patient in the DED, telephone numbers for National Suicide Hotlines and NC Crisis lines and home care patient instructions for psychosis diagnosis. Further review of After Summary Visit dated 01/28/2017 at 1945 revealed a signature page with documentation that patient and mother refused to sign discharge instructions. Review of medical record from Hospital B for Patient #11 revealed a "Call In Referrals" was received on 01/28/2017 at 1316 (38 minutes prior to patient arriving at Hospital A) from MD #5 to RN #6 with reason for referral "acute psychotic break". Review revealed Pt #11 arrived in the ED on 01/28/2017 at 2022 with complaint of IVC (Involuntary Commitment). Further review revealed Pt #11 arrived by private vehicle, escorted by her mother, at Hospital B on 01/28/2017 at 2102 with a chief complaint "Altered Mental Status (Patient's mother reports that her daughter's PCP wants her to have a psych (psychiatric) evaluation due to change in behavior)". Review of Emergency Department Provider Notes dated 01/28/2017 at 2102 revealed " ...Family apparently completed IVC paperwork feeling that she was not safe. Police picked patient up and apparently Crisis was on diversion and (Hospital A name) was up for the next patient evaluation. Patient was taken to (Hospital A name), but repeatedly stated that she wanted to come to (Hospital B name) as she had recently been admitted here and all her records were here. Psychiatrist saw her in the ER (Hospital A) and with repeated requests by patient and mom agreed to lift IVC so she could come here ..." Review revealed nursing documentation at 2145 the patient was unwilling to provide discharge paperwork from (Hospital A name) when asked. Review of record revealed Involuntary Commitment Papers were completed by Emergency Department Physician and sent to the magistrate's office on 01/29/2017 at 0225. Review revealed Pt #11 was admitted to observation on 01/29/2017 at 0358 awaiting Psychiatric Bed Placement. Physician interview on 03/02/2017 at 0850 with MD #1, the MD who completed the MSE on Pt #11 at Hospital A, revealed the patient came to the DED after being Involuntary Committed by her family for auditory hallucinations. Interview revealed the patient was lucid, talking and stated she didn't know why she was at the hospital. Interview revealed the patient has no acute complaints, vital signs were stable and patient was mentally competent to make decisions. Interview revealed the DED provider reviewed the patient's previous hospitalization and lab results in Care Everywhere system. Interview revealed patient was medically cleared and psychiatrist was notified for consult. Interview revealed the family were upset that the patient was not taken to Hospital B as requested. Interview revealed DED physician told family he did not see a need for patient transfer or admission to Hospital B but he would try and see if Hospital B would accept patient as a transfer at family request. "I spoke with hospitalist at (Hospital B name) about family's request for transfer, but (Hospital B name) denied patient transfer." Interview revealed "I felt the patient was stable for discharge home." Interview revealed after psychiatric consult and Involuntary Commitment lifted, "the patient was discharged home and was not directed by me to go to (Hospital B name)." Physician interview on 03/02/2017 at 1330 with MD #2, the MD who completed the psychiatric consultation at Hospital A, revealed the patient was not having active hallucinations during his assessment. Interview revealed the patient had no Psychotic Diagnosis. Interview revealed the patient had symptoms of [DIAGNOSES REDACTED]"I did feel some pressure from the family to lift the Involuntary Commitment, but I would not have released her if she was actively hallucinating. The patient was calm with no hallucinations and wanted to go home with her family. The patient knew what she wanted to do." Interview revealed at the time of the Involuntary Commitment removal the patient was "stable to discharge home with follow-up with primary care provider". Interview revealed no follow-up was arranged as patient had been set up with outpatient follow-up appointment from her previous hospitalization at Hospital B. The Hospital failed to ensure that the receiving hospital had available space and qualified personal for treatment of Patient $11 on 1/28/2017. The hospital also failed to ensure that the receiving hospital had agreed to accept and provide to provide appropriate medical treatment to Patient #11 on 1/28/2017. Staff interview on 03/02/2017 at 0938 with RN #3 (Registered Nurse) revealed she was the nurse that discharged patient #11 from Hospital A. Interview revealed the patient stated "I don't want to be here". Interview revealed the patient was drowsy. Interview revealed the family stated she had been this way for a couple of months. Interview revealed the patient was assisted with getting dressed for discharge. Interview revealed the patient transferred from the stretcher to the wheelchair with minimal assistance and was able to ambulate with assistance to the bathroom. Interview revealed "I felt she was okay to send home with family and home health." Interview revealed the patient's mother said she was going to take the patient to Hospital B and have her Involuntary Committed again. Interview revealed the mother did not express her reasons for having the patient Involuntary Committed. Interview revealed the mother was comfortable with the patient being discharged from Hospital A. Staff interview on 03/02/2017 at 1140 with PRA #4 (Patient Relations Advocate) for Hospital A, revealed "my job is to tie everything together between the magistrate, the DED physician and the psychiatrist". Interview revealed Involuntary Committed patients are set up on a "round robin" schedule from the magistrate's office, meaning they are rotated around the area hospitals. Interview revealed the family was not aware the patient was going to be brought to Hospital A as they had requested the magistrate send patient to Hospital B. Interview revealed the family were very insistent that the patient go to Hospital B where they were familiar with her medical and psychiatric problems. Interview revealed after input from DED physician, psychiatrists, charge nurse and house supervisor, a transfer to Hospital B was attempted, but Hospital B refused to accept the patient. Interview revealed the police department offered to take patient to Hospital B, but patient had already been checked in at Hospital A and "I thought it would be a violation if sent to (Hospital B name)". Interview revealed the patient was medically cleared and psychiatrist released the Involuntary Commitment after assessing patient. Interview revealed the psychiatrist met with the family and the patient to discuss decision and plan. NC 830

Based on hospital policy and procedure reviews, Protective Services Officer (PSO) report reviews, patient safety event report reviews, medical record review and staff interviews, the hospital's staff failed to meet the emergency needs for 1 of 1 psychiatric patients (#5) in accordance with the hospital's policy and procedures. The findings include: The hospital's staff failed to ensure coordination and communication between emergency services and security services (PSO) in order to render safe care for 1 of 1 psychiatric patients (#5) with a known history of violent and self-destructive behaviors who was tasered while in the Emergency Department by non-law enforcement security staff. ~cross refer to 482.55)(2) (a Emergency Services Standard - Tag A1103.

Based on hospital policy and procedure reviews, Protective Services Officer (PSO) report reviews, patient safety event report reviews, medical record review and staff interviews, the hospital's staff failed to ensure coordination and communication between emergency services and security services (PSO) in order to render safe care for 1 of 1 psychiatric patients (#5) with a known history of violent and self-destructive behaviors who was tasered while in the Emergency Department by non-law enforcement security staff. The findings include: Review of current hospital policy "Patient Rights And Responsibilities" last revised 08/28/2014 revealed "...Patient Rights and Responsibilities ...16. Be free from abuse, neglect and harassment... 17. Be free from restraint and seclusion that is not medically required or is used inappropriately. ..." Review of current hospital policy "Restraint and Seclusion" revised 06/20/2014 revealed "Areas Affected: All Patient Care Areas PHILOSOPHY STATEMENT: (Name) Hospital is committed to providing a least restrictive, safe, and appropriate environment for all individuals. ...restraint use is limited to those circumstances where the patient is identified as being a t risk for injury to self or others and alternative safety measures have been evaluated and deemed inadequate. ...DEFINITIONS OF RESTRAINT AND SECLUSION: Restraint: the direct application of physical force to a patient, with or without the patient's permission to restrict his or her freedom of movement. The physical force may be human, mechanical devices, or a combination of the two. ...RESTRAINT MANAGEMENT GOALS: A. Restraints are only used when clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff, or others. B. Restraints are not used a s a means of coercion, discipline, convenience, or staff retaliation. C. Restraints are used when less restrictive interventions are ineffective and if used, the least restrictive form of restraint is used to protect the physical safety of the patient, staff, or others. D. Restraints are discontinued at the earliest possible time regardless of the scheduled expiration of the order. E. Restraints will be applied using the proper technique based on the type of restraint. F. The appropriate restraint plan of care will be initiated for the patient. G. Physicians/LIP is responsible for ordering the restraints. PRN restraint orders are not acceptable. ...I. Patients will be monitored, evaluated, and re-evaluated according to the Restraint Protocol. ..." Review of current hospital policy "Restraint Management Protocol, 2466-1" last revised 06/20/2014 revealed "Definitions: A. Physical Restraints: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Examples are a vest, soft wrist or ankle restraints, mittens (if tied), leather restraints... Categories of Restraints/Indications for Use: ...B. Violent or Self-Destructive Behavior (Behavioral) Restraints: 1. A clinical justification, other than those identified as non-violent or non-self-destructive behavior, to protect the patient from injury to self or others because of an emotional or behavioral disorder where the behavior may be violent or aggressive. RESPONSIBILITIES: A. Violent/Self-Destructive Behavior (Behavioral) Restraints: 1. Physician/Licensed Independent Practitioner (LIP)*: a. Order for restraints at initiation. b. Face to face assessment of the need for restraint initiation within one hour and ongoing assessment of the continued need for restraints. c. Renewal order for continued justification for restraints. d. Review and evaluation of current medications to identify and minimize the use of medications that place a patient at risk for restraint use. ...3. Staff Nurse: a. Identification of the patient at risk for restraints, the behavior/symptoms that the patient is exhibiting, and the initiation of pre-restraint alternative interventions that may reduce both the need and duration of restraint use. b. Restraint initiation and management. c. Calls the attending physician/LIP for a restraint order. d. Notifies the attending physician that restraints have been initiated if he/she was not the ordering physician of the restraint as soon as possible**. e. Regular scheduled reassessment of the patient in restraints to justify continued validity of restraint use with the potential to discontinue or reduce the level of restraint evaluated. ...GENERAL RESTRAINT INFORMATION: A. PRN and standing orders for any category of restraint is not acceptable. B. Restraints are not used as a means of coercion, discipline, convenience, or staff retaliation. C. Restraints are used only when other less restrictive interventions are ineffective. If restraints are employed, the least restrictive restraint to protect the patient's/other's physical safety is used. D. The restraint should be discontinued by the staff nurse at the earliest possible time regardless of the scheduled expiration of the order. Discontnued Criteria includes: ...2. Violent/Self Destructive a. No physical aggression b. Rational/compliant/follows directions c. Patient calm/asleep d. Transferred to secure area ...VIOLENT OR SELF-DESTRUCTIVE BEHAVIOR RESTRAINT (BEHAVIORAL) MANAGEMENT: ...Physician Order: 1. A staff nurse may apply restraints in an emergency situation prior to obtaining a physician order but the physician/LIP should be contacted immediately and notified that restraints have been initiated. ...2. Any patient restraint within one hour after the initiation of restraints by a physician/LIP or Specially Trained Nurse who will evaluate the continued need for restraint. ...3. The face to face assessment conducted within one hour includes the following: a. An evaluation of the patient's immediate situation. b. The patient's reaction to the intervention. c. The patient's medical and behavioral condition. d. The need to continue or terminate the restraint. 4. Renewal orders must be obtained every 2 hours for patients 9-17 years of age and every 4 hours for ages 18 and older. Orders may be renewed for a maximum of 24 consecutive hours at which time a physician/LIP reassessment is required. 5. Every 24 hours a physician/LIP must complete a face to face assessment before writing a new order. 6. If a restraint is discontinued prior to the expiration of the order, a new order must be obtained to re-initiate restraints. C. Routine Monitoring/Patient Care: 1. Patients will have continuous, direct one on one observation at all times by a staff nurse, NA, or PCT. Continuous observation and psychological status/visual check (i.e. affect/behavior) will be documented every 15 minutes. 2. Routine checks will be monitored and documented every 2 hours by a staff nurse, NA, or PCT. Routine checks includes: ROM, elimination, fluids, circulation/skin integrity, and food/meal. 3. The continued justification for restraints or a less restrictive form of restraints will be assessed and documented every 4 hours by the staff nurse. ..." Review of current hospital policy "1700-05, Restraints" last revised 04/14/2014 revealed "...1. Restraint Assistance A. A Protective Services officer may be called upon to assist the health care team in restraining a patient. The officer provides assistance within the scope of Patient Care Services Restraint policy (refer to the Patient Care Services Policy Manual). B. Upon arriving at the scene, the officer will make contact with the person(s) requesting assistance. 1. If an officer comes upon a scene with staff struggling with a patient, the officer immediately offers assistance. 2. If an officer comes upon a scene and there appears to be no imminent danger to the patient or the staff, the responding officer(s) will seek guidance from the health care team on the level of physical contact and method of restraint. C. The officer assists the staff by immobilizing the patient's arms and legs while the staff secures the restraints. D. If the staff is unfamiliar with the restraints, then the officer will secure the restraints. ..." Review of current hospital policy "1400-20 Electronic Control Device (TASER®) last revised 04/14/2014 revealed "...Protective Services officers have an obligation to protect all staff, patients, and visitors against violence while on campus. ...Therefore, officers trained in the use of electronic control devices (TASER®) will be allowed to possess, and in accordance with the Protective Service Policy 1400-05, Use of Force Guidelines, deploy the TASER® to subdue violent or resistive subjects as required in the line of duty. ...B. ...2. Only personnel who have completed the departmentally approved class will be allowed to carry and deploy the TASER® devices while on duty. ...C. TASER® and the Use of Force. 1. Deployment of the TASER® constitutes use of force as proved in Protective Services Policy 1400-05, Use of Force Guidelines. 2. The TASER® is an electronic control device utilizing a Neuro-Muscular Incapacitation system. Its use is designed to incapacitate by over-riding and disrupting the sensory nervous system and the motor nervous system (causing uncontrollable contractions of the muscle tissue). ...4. The TASER® may be deployed against a subject only if one or more of the following situations exist: a. Subject is physically assaulting someone. This includes infliction of self-harm. b. Subject is displaying behaviors that would lead a reasonable person to believe that a physical assault will occur imminently, including self-harming behavior. c. If in the officer's opinion, there is a very real possibility of injury occurring to officers, bystanders, or the subject, every effort is made to take the subject into custody by other means. 5. Deployment of the TASER®: d. The subject against whom the TASER® was discharged should always be handcuffed....immediately after discharge. The officer who deployed the TASER® should immediately call for backup if backup is not already present. Allow the other officers to handcuff the subject, and be prepared to further discharge the TASER® if the subject becomes violent before he/she can be handcuffed. If backup is not available, the officer will ensure that the subject has submitted before trying trying to apply handcuffs. If the subject refuses to submit, the officer will maintain a safe distance and control the subject by verbal commands and/or TASER® discharges until backup arrives. If the subject refuses to submit to the officer's commands after being shot with the TASER®, it is possible that the handcuffing may need to proceed while the TASER® is being discharged into the subject. e. An alternative method of deployment is "Drive Stun," where the TASER®, either without a cartridge or with an expended cartridge, is pressed against the subject and TASER® is discharged . ..." Review of current hospital policy "1400-05, Use of Force Guidelines" last revised 05/17/2013 revealed "...The Protective Services Officer has duties that will be performed to provide for the safety of patients, staff, and visitors; and if force is necessary to perform these duties, the minimum amount of force is authorized. Before using physical force, officers must exhaust every other available means of performing their duties. 1. A. Approach every situation with an attitude of confidence, impartiality, and courtesy, The officer's attitude and remarks must not provide anger in the subject. B. A timely call for assistance and a quick response of back-up can also calm a situation. C. In extreme situations, a show of superior numbers is sometimes needed to calm a situation. 2. Evaluating a Situation A. Any decision reached in the evaluation and resolution of a situation requires utilization of skills, training, and knowledge pertinent to the situation. ...B. Officers should not enter confrontations they are certain to lose. In such situations, the officer's primary concern should be for the safe evacuation of patients, staff and visitors from a violent environment to a defensible area and await arrival of backup. ... C. Once safely withdrawn the officer should call for assistance from the (name) Police Department... 3. Use of Force A. Patient-Specific Guidelines 1. Weapons will not be used by Protective Services as means of managing control of a patient for the purposes of medical care. 2. If a weapon is used by Protective Services on a patient to protect people or hospital property from harm, the incident will be handled as a criminal activity. Law enforcement will be called to respond within the intent of placing the patient in their custody. ..." Review on 03/18/2015 of a Protective Services Operations Report revealed, Case Number ; Date/Time Received - 01/29/2015 at 0939; Time Arrived - 0940; Nature of Incident - 38-Patient Restraint; Location of Incident - Emergency Department Treatment Area 25; and Action Taken "OFFICER (PSO #1) USED TASER ON ED BE [sic] 25 (Patient #5). ...PATIENT PLACED IN LEATHER RESTRAINTS." Review on 03/18/2015 of Patient Safety Event Report RTW 11 involving Patient #5, dated 01/29/2015 at 1010; reported by RN #10, revealed on 01/29/2015 at 0930 "At about 9:30am on 1/29/2015 IVC (involuntary commitment) csn# 5 in ER bed 25 was agitated, and verbally aggressive initially. Pt cussing at sitter and staff. Pt stated that he does not like black people. Security was called. Pt then spit on then [sic] spit on [Sitter #1] (the pt's sitter) clothing. Primary RN (RN #8) was aware of the situation and had med (medication) requested pt's PRN (as needed) med that had to come up from the main pharmacy. x1 (times one) Security officer was at bedside awaiting for other officers. Other security officers arrive. Pt stormed outside of the room and assaulted Officer [PSO #1] (pt punched and [sic] him in the face and scratched him in the face) pt was tackled to the ground in the hallway by Security Officers and (RN #9). While pt was being tackled pt punched Officer (PSO #2) in the forehead. Pt had to be tasered by Protective services staff. Team Leader (RN #11); (PSO Director #1); (ED Director #1) were made aware of the situation. ...Dr. (MD #3) was made aware and he gave order for restraint usage. Pt was placed in 4 point restraints. ...". Review revealed the event occurred in the ED Patient Care Area. Review on 03/18/2015 of Patient Safety Event Report CLI 38 involving Patient #5, dated 02/04/2015 at 1325; reported by PSO #1, revealed on 01/29/2015 at 0940 "At 0939 hrs (hours), reporting officer, (PSO #1) was dispatched to assist with patient in ED bed 25. Once arriving I was told IVC patient (Patient #5) spitted [sic] at his sitter and Officer (PSO #4). While I was talking with his nurse (RN #8), (Patient #5) swung and hit Officer (PSO #2) over his left eye causing a bruise. Officer (PSO #4) and I (PSO #1) forced (Patient #5) to the floor and asked him several time to relax and stop kicking. After (Patient #5) wouldn't get under control and kicked Officer (PSO #2) and (RN #9) I deployed my taser and dry stunned (Patient #5) in back of left side. Afterward he complied and stopped kicking and was escorted to bed 25 and placed in four point restraints." Review revealed the event occurred in the ED hallway. Review on 03/18/2015 of a Protective Services Operations Report revealed, Case Number 2; Date/Time Received - 02/03/2015 at 1149; Time Arrived - 1149; Nature of Incident - 04-Disorderly; Location of Incident - ED bed 25; and Action Taken "bed 25 ivc (involuntary commitment) out of control. ...(PSO #3) had to dry stun the pt in the leg to gain control. ..." Review on 03/18/2015 of Patient Safety Event Report KPI 22 involving Patient #5, dated 02/04/2015 at 1325; reported by PSO #3, revealed on 02/03/2015 at 1145 "When approached ED bed 25 I saw the patient swing his left arm towards Team Leader (PSO #1). The patient struck Team Leader (PSO #1) in the face and eye several time [sic]. I approached the patient at that time and dry stun him. After the patient was dry stun Team Leader (PSO #1), Officer (PSO #5), and Charge Officer (PSO #3) was able to put the restraints on the patient arms without further incident." Review revealed the event occurred in the ED Patient Room. Closed medical record review on 03/18/2015 for Patient #5 revealed a [AGE] year old male (MDS) dated [DATE] at 1104 via ambulance. Review revealed the patient was placed into treatment room 25 and was triaged at bedside by a Registered Nurse (RN). The patient was assigned an acuity of "Emergent." Review revealed an arrival complaint of "IVC." Review of a triage note by RN #12 at 1111 revealed "Pt was just released from prison yesterday and sent immediately to (Mental Health Crisis Center). Pt sent to ED due to being too violent as he was verbally aggressive to staff members at (Mental Health Crisis Center). Pt answering questions for nurse. Guard at bedside." Review revealed a past medical history (PMH) of Schizophrenia, Post Traumatic Stress Disorder (PTSD), and Personality Disorder. Review revealed documentation of multiple past psychiatric hospitalization s. Review revealed the patient remained in the ED and was transferred to a Psychiatric hospital on [DATE] at 1427 (17 days later). Review revealed while in the ED a TASER® weapon was used on the patient on 01/29/2015 at ~0940 and 02/03/2015 at ~1145 and the patient was placed into 4 point leather restraints for the management of violent and self-destructive behaviors. Review revealed the TASER® weapon was used on the patient by hospital-employed Protective Services Officers who were not sworn law enforcement officers. Review of ED Provider Notes by MD #15 dated 01/24/2015 at 1111, revealed the patient presented with a chief complaint of "Paranoia." Review of HPI (history of present illness) revealed "(Patient #5) is a 23 y.o. (year old) male who presents after being assessed at the crisis center. It [sic] been in jail and then sent to the crisis center for psychiatric evaluation. He has a history of antisocial personality as well as schizophrenia and poor compliance with his medications. He apparently became agitated after conversation with his mother today and wanted to be sent to the emergency department. Upon my interviewing he is calm and cooperative. He denies any active hallucinations. he denies a desire to harm himself or others at present. Involuntary Commitment. ...PHYSICAL EXAM: ...General: No acute distress. ...Neuro: ...He is alert and oriented x3 (to person, place, time) Psych (Psychiatric): He has somewhat of a flat affect. He is cooperative. ...I've consulted psychiatry to see the patient while here. ...FINAL IMPRESSION: 1 Acute psychosis 2. Schizophrenia. Review of Psychiatric Consult Note by Psychiatrist #1 dated 01/24/2015 at 1217, revealed the reason for consult was "Psychosis." Review of HPI revealed "...ENGLISH speaking male with a history of schizophrenia, PTSD, alcohol use, hx of severely aggressive behavior towards family, hx of assault on EMS (emergency medical services) staff, police officers. Longstanding medication noncompliance. Recently released from jail after 30 day sentence for assaultive behavior towards family. Sent directly to (Mental Health Crisis Center) on a petition due to making threats over the phone to harm father, concern for ongoing psychosis. Subsequently sent to (Hospital A) on IVC due to need for 'higher level of care.' Per my review of available records, he was agitated, yelling after a phone call with mother and decision was made that he needed to be in the ER. RN notes indicated he was threatening staff, yelling and gesturing in a hallway. I saw the patient today in the ER. He was calm and able to talk without yelling or profanity. Tells me the zyprexa and klonopin (psychiatric medications) are helping him with anger, admits he has a problem with anger. ...He does note that he can get overwhelmed with paranoid thoughts about conspiracies against him, ...Currently without specific violent thoughts or inclinations. Past Psychiatric History: Hx of multiple psych hospitalization s at many facilities, with psychotic d/o dx dating back to [AGE]. ...Mental Status Exam: A and O (alert and oriented) to name, place, situation. Able to tell me month and year along with his age. Makes fair eye contact with interviewer. Speech is monotone but normal volume, easily comprehensible. Mood is fair, affect somewhat blunted. No tangentially. Denies AH/VH (auditory/visual hallucinations). Insight limited. Endorses some paranoia but notes thoughts about other being out to hurt him are better on medication. Assessment: ...admitted with schizophrenia, violent behaviors. IVC'd from jail for threatening behaviors towards family. Sent from (Mental Health Crisis Center) due to escalating agitation, felt unsafe to manage in that setting. Currently calm and accepting medications, potential to escalate quickly based on his history... Diagnoses: Axis I Hx of schizophrenia, paranoid type, r/o (rule out) alcohol use d/o. Hx of PTSD. Axis II r/o antisocial personality traits vs (versus) disorder... Plan: ...4) Maintain IVC, initiate search for inpt psych and maintain sitter/suicide precautions while here. Disposition: Recommend transfer to inpatient psychiatric unit as available, indicated, and medically appropriate. Recommendations have been communicated to primary team. ..." Review of an ED Note (Nursing) by RN #12 dated 01/24/2015 at 1505, revealed "...Pt calm with sitter at bedside." Review of an ED Note by RN #13 dated 01/24/2015 at 2000, revealed "Pt expresses want to remain compliant with treatment plans and has agreed to take all prescribed meds and denies aggressive ideation. Pt appears calm and compliant...". Review of an ED Note by RN #14 dated 01/25/2015 at 0730, revealed "Pt eating breakfast and brushing teeth. Sitter at bedside. Safe environment maintained. No needs at this time." Review of an ED Progress Note (Provider) by MD #4 dated 01/25/2015 at 0731, revealed "(Patient #5) remains here in the ED on a psychiatric hold/IVC papers awaiting inpt. (inpatient) psychiatric placement. He has had an uneventful night and is resting this morning. VSS (vital signs stable). Meds have been ordered by Psychiatry. We will continue to follow the patients medical needs and Psychiatry will see to his mental health issues. The pt. was sent from (Mental Health Crisis Center) on IVC papers as a result of aggression and violence, so we presently have a security guard outside pts room." Review of a Psychiatric Progress Note (Provider) by Psychiatrist #1 dated 01/25/2015 at 1012, revealed "...Pt without episode of violent [sic] outburst or aggression overnight. ...He acknowledges that anger is his primary issue and he has to keep the anger under control if he is to stay out of prison or other locked facilities. ...Mental Status Exam: Patient is alert and oriented x3. He has a somewhat intense affect but is fairly pleasant and cooperative with the interviewer. ...Plan: ...2) Continue referral process... I do have some concerns based on my experience over 11 years with attempted referrals in similar cases that it could be quite a lengthy period of time before the patient is accepted to (name) Hospital, we have had cases where it is been over a month before and acceptance is obtained. ..." Review of an ED Note by RN #14 dated 01/25/2015 at 1300, revealed "Pt used PRS (Patient Relations Specialist) phone and called his mother. Pt appropriate. No incident." Review of an ED Note by RN #14 dated 01/25/2015 at 1520, revealed "Pt calling out numerous times for this RN in hallway. This RN has seen pt multiple times and explained to him that yelling out for me into the hallway is not appropriate. Pt singing loudly in his room. Pt calms down when this RN goes into room and speaks with him. No needs at this time. Sitter at bedside. Safe environment maintained." Review of an ED Note by RN #14 dated 01/25/2015 at 1539, revealed "Sitter notified security outside room that he wanted to sit at doorway because he the patient 'is coming at me.' This RN into room. Pt laying in bed. Is having increasing agitation but agreed to take Atarax and IM Benadryl. ...PRS at bedside talking with pt. Pt calmed down with presence of this RN and....PRS." Review of an ED Note by RN #14 dated 01/25/2015 at 1758, revealed "Pt yelled out into the hall 'hey fat ass' calling one of my coworkers. Also told the secretary that 'I am going to kill my father because he put me here.' This RN went in to room to ask him not to call out into the hall and use the call bell instead. Said 'you're hot I want to talk to you' referring to this RN. Calling out multiple times for medication. Notified pt when he could next have meds." Review of an ED Note by RN #14 dated 01/25/2015 at 1848, revealed "See previous notes for pt behavior. Security continues to be at bedside. Sitter at bedside in doorway. Safe environment maintained. Pt appears to be more respectful now after staff notifying pt his behavior was disrespectful and would not be tolerated." Review of an ED Note by RN #15 dated 01/25/2015 at 1922, revealed "Pt is cooperative in room. (name) sitter is outside the room. Security at bedside. ..." Review of an ED Note by RN #15 dated 01/25/2015 at 2123, revealed "Pt stating that he is going to 'hurt the sitter.' Pt states that he is eventually going to 'assault everyone in the ER and go back to jail.' this RN medicated patient. Talked with patient at length about his feelings. Sitters changed. (name), ED tech (technician) is sitting with patient. Pt is agreeable to this. Patient continues to express his feelings but remains non violent." Review of an ED Note by RN #15 dated 01/26/2015 at 0014, revealed "Pt states that he wants to hurt himself and others in the ER. Pt continues to call his sitter 'stupid ni***r.' patient continues to ask for medications. Dr. (MD #5) notified and will go in room to eval (evaluate) pt." Review of an ED Note by RN #15 dated 01/26/2015 at 0023, revealed "Security still at bedside with patient, Dr. (MD #5) will go in room later to eval. Dr. (MD #5) stated only one security guard because others will agitate the patient. Will continue to monitor." Review of an ED Note by RN #15 dated 01/26/2015 at 0037, revealed "This RN also spoke to Dr. (MD #5) about pts increase in agitation and the need for the pt to be seen d/t (due to) pts threats of harm. MD states he is aware and will go see pt." Review of an ED Note by RN #15 dated 01/26/2015 at 0050, revealed "Dr. (MD #5) in to eval patient. New orders placed. Will medicate patient and continue to monitor." Review of an ED Progress Note by MD #5 dated 01/26/2015 at 0057, revealed "I was advised by nursing patient was having increased agitation and aggressive behavior to staff. He has received his scheduled doses of medications. He reportedly was threatening to the sitter. On my examination patient was generally cooperative. He was questioned what was triggering his agitation and he advises that he was told he might be 'here for 30 days'. I reassured him that that's not typically the case. He appeared generally cooperative during this interaction. I asked him if he would like something to 'calm him down'. He agreed that it could help. ...he was in agreement and states he would be cooperative. ..." Review of an ED Note by RN #15 dated 01/26/2015 at 0212, revealed "Patient resting. Assessed safety of the room throughout shift. Patient encouraged to express feelings and talk about why he felt aggressive during this shift. ...Patient is still under IVC paperwork. ..." Review of an ED Progress Note by MD #4 dated 01/26/2015 at 0806, revealed "(Patient #5) remains on an involuntary commitment hold awaiting inpatient psychiatric placement. Patient is awake and is eating breakfast this morning. he states he has no complaints at this time. He states he is hoping to be able to be discharged from here, and is to talk with the psychiatrist regarding getting his medications on an appropriate regimen. The patient did apparently have an episode of increased agitation and aggression last night with the staff. However he is calm at this time. He states he had an uneventful night and has no complaints this morning. ..." Review of an ED Note by RN #16 dated 01/26/2015 at 1020, revealed "Patient self reports increased agitation that is obvious to this RN as well Patient stating 'the black people and racists are making me stay here'. This RN redirected his statements back at his behavior and his actions leading to the current issues. This RN reiterated intolerance for racial slurs and curse words being directed at sitter and staff." Review of an Psychiatric Progress Note by Psychiatrist #2 dated 01/26/2015 at 1149, revealed "...The patient has been intermittently agitated, requiring when necessary's (as needed medications). ...He has been verbally abusive towards the staff. Mental Status Exam: ...Behavior: Calm....and Polite ...Mood: Anxious Affect: Calm and Decreased range ...Orientation: Oriented to person, place, time, and general circumstances ..." Review of an ED Note by RN #16 dated 01/26/2015 at 1227, revealed "Patient hit and struck security officer in the nose and additionally attempted to headbutt him. Patient immediately put in 4 point leather restraints. Patient cursing at staff during process. Patient states 'I want to be in restraints'. Explained to patient that he was now in restraints and would remain in restraints until his behavior improved. Patient states 'when I get out of restraints I am going to kill you all'." Review of an ED Progress Note by MD #4 dated 01/26/2015 at 1253 revealed "The patient became more aggressive at around noon today. He punched a security guard (TS) in the face. The patient had [sic] placed into 4. (4 point) restraints. He was given IM (intramuscular) Zyprexa (antipsychotic). He received IM Benadryl (antihistamine) a few hours ago. We will monitor the patient and provide additional medications or treatments to prevent aggressive behaviors. We will try to get the patient out of restraints and [sic] possible while maintaining the safety of the staff." Review of an ED Note by RN #16 dated 01/26/2015 at 1310, revealed "Patient now spitting at staff and all over the floor. Mask placed on patient. MD aware of situation." Review of an ED Note by RN #16 dated 01/26/2015 at 1530, revealed "Attempted to remove spit mask to allow patient to eat. Patient began spiting at sitter. Spit hood placed at this time." Review of an ED Note by RN #16 dated 01/26/2015 at 1700, revealed "Patient assisted with eating dinner without incident. Spit hood replaced when finished." Review of an ED Note by RN #16 dated 01/26/2015 at 1815, revealed "Patient continuing to fling, curse, spit and scream curse words at staff, sitter and security. Patient able to remove spit mask by maneuvering upper body to get hand to the spit mask and removing it. MD notified and order for posey vest and mittens. Security called and additional restraints placed. Patient continuing to threaten staff. Patient states 'I am going to kill all you f**kers'." Review of an ED Note by RN #16 dated 01/26/2015 at 1854, revealed "Patient asking for restraints and spit mask to be removed. Explained to patient that his behavior was not compatible with that occurring but encouraged patient to continue attempts to remain calm." Review of an ED Note by RN #16 dated 01/26/2015 at 2035, revealed "Pt removed spit mask, spit at sitter, (name), and called him a 'F**king Ni***r'. Spit mask was reapplied. Pt was unsuccessful at making saliva contact with sitter." Review of an ED Note by RN #17 dated 01/26/2015 at 2300, revealed "Release of restraint - limb by limb trial. RUE (right upper extremity) and LLE (left lower extremity) have been released on a trial basis. Pt has also had oral care by brushing of teeth and has voided by use of urinal. pt has agreed to cooperate and understands that any harm against self or others will require the continued use of restraints on those extremities. Sitter at bedside. Will continue to monitor." Revie