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Based on interview and review of Emergency Department (ED) logs, 72 Hour Return logs, Medical Records, Staff and Physician On-Call Schedules and video surveillance, the facility failed to enter one patient (#22) into the ED log, and failed to provide the patient with a medical screening examination (MSE) sufficient to determine the presence of a medical and or psychiatric emergency, within its capacity and capability, of 21 patients' ED records reviewed (no record found for Patient #22). The Emergency Department has an average of 2025 visits per month. The facility census was 37.

The facility had the capability and capacity to enter the patient on the ED log, and to provide an appropriate MSE.

Please refer to A2405 and A2406 for details.

Based on interview, record review and video review, the facility failed to enter into the Emergency Department (ED) log one patient (#22) of 21 patients' medical records reviewed (no record found for Patient #22), who presented to the ED for treatment. This failure had the potential to affect all patients who presented to the ED. The Emergency Department has an average of 2025 visits per month. The facility census was 37.

Findings included:

1. Record review of the facility's undated policy titled, "Emergency Medical Treatment and Labor Act - EMTALA Requirements," showed that when a patient presents to the ED, all patients are asked only demographic patient information in order to establish a medical record for the patient's current emergency department encounter.

2. Review of video surveillance dated 03/20/17 showed that at 9:55 PM, a woman (identified as the mother of Patient #22 based on the description from Staff F, time estimations, and actions noted from Staff F) presented to the ED front desk and spoke with Staff F. Staff F left the desk (facility staff present during observation confirmed that the area she exited from went to the main ED and nurses station) at 9:55:33 PM and returned at 9:56:53 PM. Staff F could be seen speaking with the woman identified as Patient #22's mother until 9:58:12 PM when the woman left the ED out of the main doors and did not return.

3. Review of the ED log printed on 04/03/17 that contained the date 03/20/17 showed no evidence of Patient #22's arrival to the ED.

During an interview on 04/04/17 at 11:20 AM, Staff C, Director of Risk Management, confirmed that Patient #22 had not been entered on the ED log.

Based on policy review, video surveillance and interview, the hospital failed to provide a medical screening examination sufficient to determine the presence of a medical and or psychological emergency, within its capacity and capability, for one patient (#22) of 21 patients' Emergency Department (ED) records reviewed (no record found for Patient #22). This failure had the potential to affect all patients who presented to the ED by risking the possibility of injury or death for those who required immediate medical or psychiatric care. The Emergency Department has an average of 2025 visits per month. The facility census was 37.

Findings included:

1. Record review of the facility's undated policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)," showed that any individual who comes to the Emergency Department and requests examination or treatment (or a request made on their behalf) will receive an appropriate medical screening exam, beyond medical triage provided by qualified medical personnel. "Comes to the Emergency Department" means an individual who has presented to the designated ED and requests examination or treatment, or has presented on the facility property other than the designated emergency department and requests examination or treatment.

2. Review of video surveillance dated 03/20/17 showed that at 9:55 PM, a woman (identified as the mother of Patient #22 based on the description from Staff F, time estimations, and actions by Staff F) presented to the ED front desk and spoke with Staff F (identified by facility staff present during the video observation). Staff F left the desk (facility staff present during observation confirmed that the area she exited from went to the main ED and nurses station) at 9:55:33 PM and returned at 9:56:53 PM. Staff F could be seen speaking with the woman identified as Patient #22's mother until 9:58:12 PM when the woman left the ED out the main doors and did not return.

During an interview on 04/04/17 at 12:35 PM, Staff F, Patient Access Staff, stated that the ED was not her full time position, and that she worked there on evenings and weekends for extra hours. She reported she had not received EMTALA training. On the night of 03/20/17 she stated that the mother of Patient #22 came to the desk very upset, and reported her daughter was in the car and wanted to hurt herself. Staff F then went to the nurse's station to ask for help in what to do for the mother. She observed multiple staff members sitting at the desk, but spoke directly with one nurse (identified later through interview as Staff H, ED Registered Nurse (RN) Charge Nurse) who she relayed that the mother was upset and the patient in the car was suicidal. Staff F reported that the nurse informed her, "Until the patient is in the room we can't force treatment on anyone." Staff F then was told the name of a local inpatient behavioral health facility that will take people out of a car. Staff F returned to the front desk and relayed the information to the mother that if her daughter wouldn't come in, they couldn't take care of her and a local behavioral health facility would be willing to take her daughter from the car. Staff F reported the mother was upset, and stated that she would go outside and try again to get her daughter to come into the department. The mother never returned.

During a telephone interview on 04/03/17 at 12:45 PM, the mother of Patient #22 stated that she had gone to the front desk of the ED and left her daughter in the car. Her daughter had stated that she wanted to hurt herself, and she knew she needed to get her help. When she told the person at the desk, they left and then came back and told her that they don't make people get out of the car and would be better served at Wentzville (local facility with inpatient behavioral health).

During an interview on 04/04/17 at 1:55 PM, Staff L, ED RN, stated that she was sitting at the desk when Staff F came to the nurses station and asked about a patient that would not get out of the car. She overheard Staff H inform Staff F that they can't force anyone out of a car.

During an interview on 04/04/17 at 2:45 PM, Staff G, ED Technician, stated that she was in the nurse's station when the conversation happened. She noted that since they thought the person "was not a patient", then they didn't know what to do. They hadn't thought about the woman's daughter being a patient because they were just on the property and not in the ED.

During an interview on 04/05/17 at 8:20 AM, Staff H, ED RN, stated that:
-She was the charge nurse for the shift on 03/20/17;
-Staff F came back and told her that a mother was at the desk and wanted them to come out and get her daughter inside;
-She did not remember any other details of what Staff F had said, but that the situation was not portrayed that the daughter needed help;
-They can't force anyone to come in and be seen;
-She didn't ask any details; and
-If she was able to go back to that night, she would have gone out herself to evaluate the situation.

During an interview on 04/04/17 at 12:15 PM, Staff M, Pediatric ED Medical Director, stated that all physicians and advanced practice providers (Physician Assistants and Nurse Practitioners) were aware of the need to assist in patients being seen, and were fully aware of the expectations of EMTALA. They utilize telehealth (a video feed that allows for a behavioral health professional at another location to assess the patient in the ED) for their behavioral health assessments, so have constant access to that resource.

During an interview on 04/04/17 at 2:35 PM, Staff P, ED Medical Director, stated that he was aware of the situation that occurred with Patient #22, but that the night of the event the physician on duty had not been involved in the situation or made aware of what had happened. In regards to the event on 03/20/17, he would have expected a clinical nurse do a face to face assessment of the situation.