Cedar County Memorial Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 50151 Based on policy review, the hospital failed to follow their policies and provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#19) and failed to ensure that an emergency medical condition (EMC) was stabilized for one patient (#8), who was allowed to leave against medical advice (AMA) after presenting to the ED with suicidal ideation (SI, thoughts of causing one’s own death) of 21 Emergency Department (ED) records reviewed from 07/13/24 through 01/13/25. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy, “Emergency Medical Treatment and Active Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition),” revised 06/2023, showed: - When an individual presented to CCMH requesting emergency care, the hospital was responsible to provide an appropriate MSE, within the scope of the institution’s capability and capacity. - If the MSE indicated the individual has an EMC, then the hospital must, provide further medical examination and treatment required to stabilize the EMC; transfer the individual to another facility but only when the EMTALA transfer requirements were satisfied; or admit the individual as an inpatient. Review of the hospital’s policy, “Care of the Suicidal/ Homicidal (having thoughts or attempts to cause one’s death or another’s death) Patients in the Emergency Room (ER),” dated 06/2024, showed: - After the ED nurse completed the initial triage, a clinical hold (CCMH’s internal status designation in which a clinical determination was made that the patient should not be permitted to leave the hospital) may be initiated when there was a likelihood the patient may cause serious harm to themselves or others. - A clinical hold designation was to help ensure patient safety and is not a legal process and does not require a court order. - Any medical staff member, RN or other staff member with knowledge that the patient was placed on a clinical hold or on a temporary clinical hold, would be authorized to detain the patient at CCMH for the patient’s safety. - A patient on a clinical hold may not leave AMA and should be kept at CCMH using the least restrictive effective means to ensure patient safety. Review of the hospital’s policy, “Involuntary Commitments (a legal process through which a person is hospitalized and treated for mental health disorders without their consent),” revised 12/2020, showed: - All patients who presented to the ED, were examined for emergency medical commitment (both medical and psychiatric). - Patients who presented with complaints or conditions which suggested a psychiatric disturbance must receive a MSE in the ED. - Once trauma, medical drugs, and toxic effects have been ruled out to be the cause of the symptoms/complaints the patient presented with; the patient’s psychosocial (relating to the interrelation between social factors and individual thought and behavior) conditions were evaluated. - Patients determined to be a danger to themselves or others by the ED physician, were transferred for an involuntary evaluation. Transfer procedures for an involuntary evaluation included a physician certificate for transfer, informed consent from the patient or legal guardian, and a completed transfer sheet. In addition, all state-mandated forms for an involuntary commitment, must be completed. This included, a completed affidavit from each professional staff person involved. - Minors transferred for psychiatric care required, written consent of the parent or guardian. Review of the hospital’s policy, “Refusal of Services,” dated 06/2023, showed when a patient elected to leave the facility prior to an appropriate MSE being completed, every reasonable attempt to educate the patient or their guardian/caregiver on the risks of leaving without the appropriate exam should be made. Please refer to 2406 and 2407 for further details.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 50151 Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#19) of 21 Emergency Department (ED) records reviewed from 07/13/24 through 01/13/25. This failed practice had the potential to cause harm to all patients who presented to Cedar County Memorial Hospital (CCMH) ED seeking care for an EMC. Findings included: Review of the hospital’s policy, “Emergency Medical Treatment and Active Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC),” revised 06/2023, showed: - The hospital had the responsibility to provide an appropriate MSE, within the scope of the institution’s capability and capacity to an individual who presented to CCMH and requested emergency care. - The MSE must determine any further medical examinations and/or treatments needed to stabilize the patient. The MSE determined when the patient needed to be transferred to a different hospital with the capabilities required to provide stabilizing treatment. Review of the hospital’s policy, “Involuntary Commitments (a legal process through which a person is hospitalized and treated for mental health disorders without their consent),” revised 12/2020, showed: - Patients who presented to the hospital with complaints or conditions which suggested a psychiatric (relating to mental illness) disturbance, received a MSE in the ED. - The ED physician will evaluate the patient’s psychosocial (relating to the interrelation between social factors and individual thought and behavior) conditions. - Transfer of minors for psychiatric care require written consent of the parent or guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves), if available. If not available, the record should reflect reasonable efforts to contact the parent and to obtain written consent. Review of the hospital’s policy, “Care of the Suicidal (thoughts of causing one’s own death)/ Homicidal (having thoughts or attempts to cause one’s own death or another’s death) Patients in the Emergency Room (ER),” dated 06/2024, showed: - After the initial triage was provided, a clinical hold may be initiated as a patient safety measure. - Definition of Clinical Hold: A Clinical Hold is an internal patient status designation at CCMH where a physician or RN, until the arrival of a physician, has made a clinical determination that a patient should not be permitted to leave the hospital against medical advice (AMA). Such clinical determination shall be based on the patient’s psychiatric disturbance or substance abuse and the patient’s likelihood of serious harm to self or others. For example, a patient may present a likelihood of serious harm if there is a substantial risk that a patient may inflict serious physical harm on him/herself, as evidenced by recent threats or attempts to commit suicide or inflict physical harm, or inflict harm on others, as evidenced by recent overt acts, behavior, or threats. A Clinical Hold is a designation to help assure patient safety, it is not a legal process, and does not require a court order. - Patients who may have a psychiatric disturbance or substance abuse condition and who may present a likelihood of serious harm should be evaluated by the Emergency Department physician. Compass Health may be called by the Emergency Department Physician to evaluate and assist in obtaining acceptance for a patient at a behavioral health facility that has the capability and capacity to care for a behavioral health patient. Review of the hospital’s policy, “Treatment of Minors - Emergent and Non-Emergent,” dated 06/2024, showed: - A minor shall be defined as any person under 18 years of age and a parent or guardian may give consent to treat via the telephone. In some cases, consent by telephone may be the only way consent can be obtained. Although requested there was no policy that stated a parent or guardian must be at the hospital with the minor or pediatric patient to initiate a clinical hold or 96-hour hold or what to do if a parent/guardian was not available. Review of the hospital’s policy, “Refusal of Services,” dated 06/2023, showed, when a patient elected to leave the facility prior to an appropriate MSE being completed, every reasonable attempt to educate the patient or their guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves)/caregiver on the risks of leaving without the appropriate exam should be made. Review of Patient #19’s medical record, dated 12/12/24, showed: - At 3:49 AM, he was a 16-year-old who presented to the ED with two law enforcement (LE) officers for a chief complaint of a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) and alcohol intoxication (to be affected by alcohol or drugs where physical and mental control is markedly diminished). - The ED nurse placed the patient in the waiting room without an initial triage or vital signs. - At 3:50 AM, the ED nurse obtained phone consent for treatment from the patient’s mother. - LE was given initial paperwork for a 96-hour hold, which LE filled out. - At 4:20 AM, the ED nurse informed law enforcement officers of the 96-hour hold process for a pediatric (pertaining to children) patient. They were informed that a parent needed to be with the patient. In response, the law enforcement officers informed the ED nurse they were leaving with the patient to go to Hospital B. - LE officers were allowed to leave with the patient from the ED prior to a MSE. There was no documentation in the medical record where the parent was asked to come to the ED to be with the minor. There was no documentation in the medical record of a provider or RN explanation to the parent about a required MSE. There was no documentation the parent was notified that LE would be taking the patient to another hospital. There was also no documentation of a provider or RN giving the parent the risks and benefits of leaving without being seen by a provider. There was no attempt to have the parent sign a Patient Refusal of Services form. Review of Patient #19’s medical record from Hospital B, dated 12/12/24, showed: - At 4:50 AM, Patient #19 presented to the ED with law enforcement for a psychological evaluation (observes and measures a patient’s behaviors, thoughts, and emotions to determine a diagnosis and appropriate treatment plan). - When they arrived, law enforcement officers reported Patient #19 was originally taken to CCMH but when they arrived, ED staff instructed them to go elsewhere due to the long wait time. - The patient reported to the triage nurse he was not suicidal. He had stated he was going to kill himself because he didn’t want to return to Division of Youth Services. - At 5:06 AM, the patient’s mother arrived at the hospital. - After he spoke to the patient, the ED physician spoke with the patient’s mother about the patient’s continued aggressive behavior and being uncooperative. He explained that for the patient to be properly evaluated, laboratory testing was needed on his blood and urine. They also discussed how the patient’s behavior had escalated and his mother was concerned he was at risk of harming himself or others. The benefit of inpatient psychiatric care was discussed. - At 5:45 AM, the patient’s mother and law enforcement completed affidavits (a written statement confirmed by oath, for use as evidence in court). - A psychiatric assessment was performed and showed he was agitated and hostile. His behavior was abusive, threatening, attention-seeking, manipulative (characterized by unscrupulous control of a situation or person) and uncooperative. - At 6:05 AM, the patient’s blood alcohol level (BAL, the amount of alcohol in the blood. Normal was zero) was 73 and his urine drug screen (UDS, a test that analyzes urine for the presence of certain illegal drugs and prescription medications) was positive for marijuana. - At 7:49 AM, the ED physician diagnosed the patient with alcohol intoxication, oppositional defiant disorder (ODD, a disorder marked by defiant and disobedient behavior to authority figures) and aggression (behavior that is intended to harm another individual). - The ED physician planned for an inpatient psychiatric admission once accepted to a hospital that offered inpatient psychiatric services to pediatric patients. - At 1:55 PM, the patient was transferred to Hospital D by Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.). Review of Patient #19’s medical record from Hospital D, showed: - On 12/12/24, he was a 16-year-old, admitted for concerns of suicidal ideations (SI, thoughts of causing one’s own death). - He was admitted with a history of disruptive mood dysregulation disorder (DMDD, condition of extreme irritability, anger, and frequent, intense temper outbursts); autism spectrum disorder (developmental disorder that impairs communication and social interaction); and attention deficit/hyperactive disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors). - On 12/19/24, the patient was discharged home with his mother. Although requested, the police report from Police Department C for Patient #19 was not provided. During an interview on 01/13/25 at 1:00 PM, Staff F, ED Nurse Manager, stated that CCMH does not have the ability to provide psychiatric evaluations. Patients who presented to the ED, with psychiatric complaints, would be medically cleared by the ED physician. Once medically cleared, the patient would be transferred to a hospital with behavioral health services. When the ED physician determined a 96-hour hold was required, the paperwork was completed and faxed to the county clerk. The judge makes the determination if an involuntary hold was indicated. When the ED physician determined an application for a 96-hour hold was not appropriate, the hospital cannot hold or physically restrain the patient from leaving. During an interview on 01/14/25 at 6:30 PM, Staff H, Registered Nurse (RN), stated that he was working in the ED when Patient #19 was brought into the ED by law enforcement. The law enforcement officers reported the patient had assaulted his mother and stated he wanted to kill himself. When the patient arrived, he was belligerent, was yelling and cussing. He was placed in the waiting room due to his behavior. Normally, when a psychiatric patient presents to the ED, they would be triaged and placed in a room. Patient #19 remained in the waiting room because he was disruptive and there were other patients in the ED treatment area. Staff H called the administrator on call (AOC) to find out what is required for a 96-hour hold on for a minor patient. The AOC instructed him that since Patient #19 was a minor, the hospital’s 96-hour hold process required a parent to be at the hospital with the patient. He spoke with the patient’s mother on the phone when he obtained a consent to treat. He did not remember if he asked the parent to come to the hospital. When he attempted to explain to the law enforcement officers the process for obtaining a 96-hour hold for a minor patient and that a parent/guardian needed to be at the hospital with the patient, they did not want to wait. The law enforcement officers instructed the patient to, “Get up! We are going to Vernon County.” Staff H stated that he attempted to educate the officers on the risks of leaving without being seen by the ED physician and not having a MSE, they were unwilling to listen. During an interview on 01/15/25 at 11:00 AM, Staff B, Chief Nursing Officer (CNO) stated that when a patient presented to the ED for a 96-hour hold, the provider must be notified that the patient needed to be medically cleared. The nurses were expected to perform an assessment and gather information about the situation. Once the assessment was completed, the nurse filled out an affidavit based upon the assessment findings. For Patient #19, she believed law enforcement were within their scope to remove the patient from the ED before a MSE was completed. The patient was already in law enforcement custody before they arrived at the hospital. She expected the ED staff to educate law enforcement on the risks of taking a patient from the hospital prior to a MSE being performed. The education provided to law enforcement was expected to be documented in the medical record. The 96-hour hold process was the same for patients of all ages, which included those under the age of 18. Although requested, law enforcement officers that transported Patient #19 to the ED, were unable to be interviewed.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 50151 Based on interview, record review and policy review, the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for one patient (#8) of 21 Emergency Department (ED) records reviewed from 07/13/24 through 01/13/25, who was allowed to leave against medical advice (AMA) after presenting to the ED with suicidal ideation (SI, thoughts of causing one’s own death). This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy, “Emergency Medical Treatment and Active Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition),” revised 06/2023, showed: - When an individual presented to Cedar County Memorial Hospital (CCMH) requesting emergency care, the hospital was responsible to provide an appropriate MSE, within the scope of the institution’s capability and capacity. - If the MSE indicated the individual has an EMC, then the hospital must provide further medical examination and treatment required to stabilize the EMC; transfer the individual to another facility but only when the EMTALA transfer requirements were satisfied; or admit the individual as an inpatient. Review of the hospital’s policy, “Involuntary Commitments (a legal process through which a person is hospitalized and treated for mental health disorders without their consent),” revised 12/2020, showed, patients deemed to be a danger to themselves or others, were stabilized to the extent of the capabilities of the facility, prior to being transferred. When the ED was unable to stabilize an EMC, the patient was either admitted or appropriately transferred to another facility. Review of the hospital’s policy, “Care of the Suicidal/ Homicidal (having thoughts or attempts to cause one’s own death or another’s death) Patients in the Emergency Room (ER),” dated 06/2024, showed: - CCMH was obligated to protect patients who presented with psychiatric (relating to mental illness) disturbances or substance abuse (relating to the misuse of drugs and/ or alcohol) and who presented a likelihood of causing serious harm to themselves or others. - After the ED nurse completed the initial triage, a clinical hold may be initiated when there was a likelihood the patient may cause serious harm to themselves or others. - Definition of Clinical Hold: A Clinical Hold is an internal patient status designation at CCMH where a physician or RN, until the arrival of a physician, has made a clinical determination that a patient should not be permitted to leave the hospital against medical advice (AMA). Such clinical determination shall be based on the patient’s psychiatric disturbance or substance abuse and the patient’s likelihood of serious harm to self or others. For example, a patient may present a likelihood of serious harm if there is a substantial risk that a patient may inflict serious physical harm on him/herself, as evidenced by recent threats or attempts to commit suicide or inflict physical harm, or inflict harm on others, as evidenced by recent overt acts, behavior, or threats. A Clinical Hold is a designation to help assure patient safety, it is not a legal process, and does not require a court order. - A registered nurse (RN) may initiate a clinical hold based on the patient psychiatric symptoms and likelihood of serious self-harm determined the patient should not be permitted to leave the hospital AMA. - Any medical staff member, RN or other staff member with knowledge that the patient was placed on a clinical hold or on a temporary clinical hold, would be authorized to detain the patient at CCMH for the patient’s safety. - A patient on a clinical hold may not leave AMA and should be kept at CCMH using the least restrictive effective means to ensure patient safety. - When a medical staff member determined a patient needed ongoing inpatient psychiatric care, beyond what CCMH can provide, CCMH will pursue an appropriate transfer to an inpatient psychiatric facility that may initiate a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others). Review of Patient #8’s medical record, dated 08/22/24, showed: - At 1:35 PM, she was a 33-year-old, who presented to the ED with SI. She requested to be admitted to a behavioral health (BH) unit. She reported having suicidal thoughts due to family stressors. - She had been self-cutting on her arms. The wounds were superficial. - She requested to be transferred to a BH unit at a facility other than Hospital B. The ED physician informed her that she would need to be transferred to the closet facility that had a bed available. When she transferred, Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc) would be required to transport her to the facility. - At 1:43 PM, elopement precautions (EP, interventions to prevent someone from leaving who may be at risk for self-harm or injury) were ordered. - At 1:45 PM, a one to one (1:1, continuous visual contact with close physical proximity) sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety) was ordered due to the patient’s threats of self-harm. - At 1:56 PM, her urine drug screen (UDS, a test that analyzes urine for the presence of certain illegal drugs and prescription medications) was positive for morphine (an opioid pain medication). She was not prescribed morphine by a provider. - She was diagnosed with depression, anxiety disorder, SI, laceration (a deep cute or tear in the skin) of the left upper arm, and intentional self-harm. - At 4:16 PM, the ED physician re-evaluated the patient. He informed her that the ED staff had requested a BH bed at numerous facilities. Hospital B was the only facility with a BH bed that accepted her. - At 4:35 PM, the ED physician re-evaluated the patient. The rationale for transfer, reasons and benefits of being transferred, and risks of transfer were discussed with the patient. The patient accepted the risks and agreed to a planned transfer. - Shortly after, the patient decided to refuse the transfer to Hospital B. She informed the ED physician, that she refused the transfer and would be leaving AMA. She reported she would be following up with her outpatient counselor in the morning. - The ED physician informed the patient that if she attempted to leave AMA after she presented to the ED with SI, the local police department would be notified. Once in police custody, they would take her to whichever facility they wanted to. - At 4:55 PM, she refused to go to Hospital B and left the ED AMA. She was educated on the risks of leaving AMA and signed the refusal of services form. - Hospital staff notified Police Department C that she had left the hospital AMA. Review of the hospital’s document, “Event Report 00096,” dated 08/22/24, showed: - Patient #8 present to the ED with SI. - After ED staff attempted to obtain a bed for inpatient psychiatric care, Hospital B was the only facility that accepted the patient. - Patient #8 began yelling and crying. She stated she was not going to Hospital B. - She informed the ED staff that her guardian was coming to pick her up. - ED staff advised her that local law enforcement would be notified if she left AMA. - The patient left AMA. - Police Department C was notified. Although requested, the police report from Police Department C for Patient #8’s AMA departure on 08/22/24 from the ED was not provided. During an interview on 01/14/25 at 4:15 PM, Staff G, RN, stated that once a patient was medically cleared, the hospital was able to initiate a clinical hold for a patient with SI. The clinical hold may be placed to hold the patient at the hospital until the judge determined if a patient needed a true 96-hour hold. She felt that Patient #8 was appropriate for a clinical hold since she had attempted to slit her wrist but wanted to leave AMA. However, the ED staff was not able to hold patients against their will, but local law enforcement was notified a patient presented to the ED with SI left AMA. During an interview on 01/13/25 at 1:00 PM, Staff F, ED Nurse Manager, stated, CCMH does not have the ability to provide psychiatric evaluations. Patients who presented to the ED with psychiatric complaints, would be medically cleared by the ED physician. Once medically cleared, the patient would be transferred to a hospital with behavioral health services. When the ED physician determined a 96-hour hold was required, the paperwork was completed and faxed to the county clerk. The judge made the determination if an involuntary hold was indicated. When the ED physician determined an application for a 96-hour hold was not appropriate, the hospital cannot hold or physically restrain the patient from leaving. During an interview on 01/15/25 at 9:30 AM, Staff J, Physician, stated that, Patient #8 presented to the ED with suicidal statements. He educated her on why she needed to be transferred for inpatient psychiatric care. When patients came into the ED and reported they were suicidal, he took them at face value. He doesn’t feel he was qualified to determine if a patient can leave AMA once they reported they were suicidal. He didn’t feel Patient #8 needed a clinical hold. He understood the hospital cannot hold a patient unless a court-ordered 96-hour hold was obtained. He believed doing so would have violated a patient’s rights. When law enforcement were notified of a patient with SI who left AMA, he understood law enforcement went and performed a wellness check on the patient. He was unsure what occurred after that. During an interview on 01/15/24 at 10:00 AM, Staff I, RN, stated that she believed Patient #8 was appropriate to be discharged. The patient did not like Hospital B’s physician and didn’t want to go there. After some time in the ED, the patient reported she felt better when she discovered she would be transferred to Hospital B. During an interview on 01/15/25 at 11:00 AM, Staff B, Chief Nursing Officer (CNO), stated that when a patient presented to the ED for a 96-hour hold, the provider must be notified that the patient needed to be medically cleared. The nurses were expected to perform an assessment and gather information about the situation. Once the assessment was completed, the nurse filled out an affidavit based upon the assessment findings. She expected ED staff placed a clinical hold on a patient that presented with SI and were at risk of harming themselves. When a patient with SI wanted to leave AMA and was not placed on a clinical hold, she expected the reason a clinical hold was not initiated to be documented in the medical record. Since the hospital was not a locked unit, the hospital would be unable to stop a patient from leaving the hospital.”