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Based on review of Hospital policy and procedure, Hospital documents, medical records and employee interview, it was determined the Hospital failed to ensure a medical screening examination (MSE) was completed by an individual who is determined by Hospital Bylaws or Rules and Regulations to be qualified to complete an MSE. This deficient practice poses a risk to the health and safety of patients if life-threatening or potentially life threatening conditions are not recognized and stabilizing treatment provided.

Findings include:

Hospital policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA), Effective March 2025, " revealed "...Qualified Medical Personnel (QMP) means an individual, in addition to a licensed physician, who is licensed or certified and who has demonstrated current competence in the performance of MSEs, for example: Registered Nurse in Psychiatric Services...Physician Assistant...Advanced Registered Nurse Practitioner...A psychiatric MSE should include a screening assessment by a QMP..."

Hospital document titled "Governing Board Bylaws," Effective August 2023, revealed "...4. Medical Staff and its Relationship to the Governing Board...B. The Governing Board shall approve, in writing, the qualified medical personnel ("QMP") who may perform the medical screening examinations ("MSE") for EMTALA purposes...."

Hospital document titled "Annual Review of Qualified Medical Personnel," dated January 23, 2024, revealed "...The Governing Board designates masters level clinicians (MSW, etc.) and RNs, working within their scope of practice, as Qualified Medical Professionals (QMPs) when they are conducting Medical Screening Exams..."

Hospital document titled "(Hospital) Governing Board Bylaws," Effective December 2024, revealed "...4. Medical Staff and its Relationship to the Governing Board...B. The Governing Board shall approve, in writing, the qualified medical personnel ("QMP") who may perform the medical screening examinations ("MSE") for EMTALA purposes....1. Qualified Medical Person or Personnel ("QMP") means an individual, in addition to a licensed physician, who is licensed or certified and who has demonstrated current competence in the performance of MSEs, for example:...i. Psychiatric Social Worker...ii. Registered Nurse in Psychiatric Services...iii. Psychologist...iv. Physician Assistant...v. Advanced Registered Nurse Practitioner..."

Hospital document titled "(Hospital) Governing Board Bylaws," Effective March 2025, revealed "..."...4. Medical Staff and its Relationship to the Governing Board...B. The Governing Board shall approve, in writing, the qualified medical personnel ("QMP") who may perform the medical screening examinations ("MSE") for EMTALA purposes....1. Qualified Medical Person or Personnel ("QMP") means an individual, in addition to a licensed physician, who is licensed or certified and who has demonstrated current competence in the performance of MSEs, for example:...i. Registered Nurse in Psychiatric Services...ii. Physician Assistant...iii. Advanced Registered Nurse Practitioner..."

Medical record review revealed the following:

Patient #1: Medical Screening Examination, no documented date, contained no documented entries for "...QMP Printed Name...QMP Signature...Date...Time..."

Patient #3: Screening Assessment dated February 18, 2025, completed by an unlicensed employee with the credential Master of Social Work (MSW).

Patient #4: Screening Assessment dated February 26, 2025, completed by an unlicensed employee with the credential Master of Science in Professional Counseling.

Patient #5: Screening Assessment dated April 4, 2025, completed by an unlicensed employee with the credential Master of Science (MS).

Patient #10: Screening Assessment dated March 1, 2025, completed by an unlicensed employee with the credential Master of Social Work (MSW).

Patient #13: Screening Assessment dated February 14, 2025, completed by an unlicensed employee with the credential Master of Social Work (MSW).

Patient #14: Screening Assessment dated December 31, 2024, completed by an unlicensed employee with the credential Master of Social Work (MSW).

Patient #16: Screening Assessment dated October 3, 2024, completed by an unlicensed employee with the credential Behavioral Health Technician (BHT).

Patient #19: Medical Screening Examination dated March 13, 2025, contained only one (1) of two (2) pages, missing documented entries for "...QMP Printed Name...QMP Signature...Date...Time..."

Patient #20: Screening Assessment dated February 6, 2025, completed by an unlicensed employee with the credential Master of Science (MS).

Employee #9 confirmed, during an interview conducted on April 10, 2025, that the employees who completed the MSEs for Patients #1, #3, #4, #5, #10, #13, #14, #16, #19, and #20 were not QMPs for purposes of completion of Medical Screening Examinations or Screening Assessments.

Based on review of hospital policy and procedure, hospital documentation, medical record request and employee interview, it was determined that the hospital failed to ensure a medical record for a patient was established and maintained. This deficient practice poses the risk of patient treatment not being accurate, timely and of continuity of care being compromised.

Findings include:

Hospital policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" revealed "...Treatment...A. A person who comes to (the hospital) will receive a medical screening exam (MSE) conducted by a qualified medical person (QMP) to determine if an emergency medical (including psychiatric) condition (EMC) exists...The chart should document continued monitoring until the patient is stabilized or transferred...Signs & Records...C. Transfer records...(the hospital) will maintain medical and other records related to individuals transferred or discharged to or from the Hospital for six (6) years...."

Hospital document titled "EMTALA Log" revealed Patient #2 arrived at the hospital on February 17, 2025, at 01:48, with a departure at 02:05, "...Recom...Medical Send Out...Dispo...911..."

Hospital document titled "Incident Report Log" revealed "...Incident Date...2/17/2025...Involved Party Name...(Patient #2)...Incident Type...Unscheduled Transfer..."

Hospital document titled "Incident Abstract Report" revealed "...Involved Party Name: (Patient #2)...Incident Date: 2/17/2025...Incident Note: Additional Comments from Intake...(Patient #2) was dropped off via car came in and sat down to have vitals taken, (he/she) stated (he/she) did not feel good then (he/she) started to have a seizure (he/she) came out of it after 2 minutes but then (he/she) had another code was called as well as 911. (he/she) had a couple more seizures after that before the ambulance came and (he/she) was transported to the hospital...."

A request was made on April 9, 2025, for medical records for Patient #2. None were provided.

Employee #9 confirmed in an interview on April 9, 2025, that no medical record or additional documentation for Patient #2 was available for review at the time of the survey.

Based on review of Hospital policy and procedure, hospital documents, medical records and employee interview, it was determined the Hospital failed to ensure a medical screening exam (MSE) was completed for patients coming to the facility to determine whether or not an emergency medical condition exists. This deficient practice poses a potential risk to the health and safety of patients if life-threatening or potentially life threatening conditions are not recognized and stabilizing treatment provided.

Findings include:

Hospital policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" revealed "...Treatment...A. A person who comes to (the Hospital) will receive a medical screening exam (MSE) conducted by a qualified medical person (QMP) to determine if an emergency medical (including psychiatric) condition (EMC) exists...

Hospital document titled "EMTALA Log" revealed the following:

Patient #2 arrived at the Hospital on February 17, 2025, at 01:48.

Patient #11 arrived at the Hospital on March 20, 2025 at 16:21.

Patient #17 arrived at the Hospital on April 5, 2025, at 15:35.

Patient #19 arrived at the Hospital on March 13, 2025 at 12:05.

Hospital medical records revealed the following:

Patient #2 - MSE was requested, none was provided.

Patient #11 - Document titled "Screening Assessment," dated March 20, 2025, did not contain the name or signature of the employee who completed the document.

Patient #17 - Document titled "Screening Assessment," dated April 5, 2025, did not contain patient name or identifying information.

Patient #19 - Document titled "Medical Screening Examination," dated March 13, 2025, did not contain page two (2) of two (2), including the name or signature of the employee who completed the document.

Employee #9 confirmed during interviews conducted on April 9, 2025 through April 10, 2025, that the MSEs for Patients #2, #11, #17 and #19 were either missing or incomplete.

Based on Hospital policy and procedure, hospital documents, medical records and employee interview, it was determined the Hospital delayed examination and/or treatment for two (2) of 20 patients who presented to the Hospital seeking emergency treatment. Failure to provide timely medical examination and treatment poses a potential risk that a patient is denied necessary medical treatment.

Findings include:

Hospital policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" revealed "...Treatment...A. A person who comes to (the Hospital) will receive a medical screening exam (MSE) conducted by a qualified medical person (QMP) to determine if an emergency medical (including psychiatric) condition (EMC) exists...C. If the specific...Hospital does not have the capacity or capability to treat the patient's EMC...the Hospital will stabilize the patient's medical condition within its capacity and capability and appropriately transfer the patient to another facility for further appropriate care...No Delay in Treatment or Examination...Reasonable registration processes may be followed...if those processes do not delay or discourage the person from receiving the emergency care described above...."

A total of 20 patient medical records were randomly selected for review from the Hospital's EMTALA Log, Incident Report Log and Unscheduled Transfer Log. Two (2) out of 20 medical records and related Hospital documents revealed the following:

Patient #19

Hospital document titled "EMTALA Log" revealed Patient #19 arrived at the Hospital on March 13, 2025, at 12:05 as a "walk-in," and that the recommendation was "...Medical Send Out...Dispo...non-911 Transp...."

Medical Screening Examination dated March 13, 2025, stated " ...Diabetic: Yes ...Accucheck: 235 @ 12:45 ...."

Screening Assessment dated March 13, 2025, stated "...Based on discussion with the consulting provider, recommendations for care/follow up: INPATIENT (MENTAL HEALTH) ...."

Interdisciplinary Progress Note dated March 14, 2025, stated "...Patient (Pt) stated (he/she) is a diabetic and stated (he/she) needed insulin early, after arrival...Per Pt, Nurse stated insulin could not be given because (he/she) is not a patient. Pt expressed concerns that (he/she) knew (his/her) blood sugar would increase without being medicated...."

Employee #9 confirmed during interview conducted on April 10, 2025, that Patient #19 arrived at the hospital on March 13, 2025, at 12:05, that he/she was screened to have a psychiatric emergency medical condition but that medical exclusionary criteria existed that the Hospital did not have the capability to provide care for. Employee #9 further confirmed Patient #19 was not able to self-administer insulin until March 13, 2025, at 21:36 and that he/she was transferred "...to the closest emergency room for medical clearance..." on March 13, 2025, at 23:45.

Patient #20

Hospital document titled "EMTALA Log" revealed Patient #20 arrived at the Hospital on February 6, 2025, at 10:15 as a "walk-in," and that the recommendation was "...IPMH (verified by Employee #9 to be defined at Inpatient Mental Health)...Dispo...Referred Out...."

Screening Assessment dated February 6, 2025, was completed at 11:02 and discussed with consulting provider at 11:48, stated "...Based on discussion with the consulting provider, recommendations for care/follow up: Pt. is recommended for inpatient mental health treatment for psychois [sic] and stabilization for safety...."

Employee #9 confirmed during interview conducted on April 10, 2025, that Patient #20 arrived at the hospital on February 6, 2025, at 10:15, that he/she was screened to have a psychiatric emergency medical condition but that medical exclusionary criteria existed that the Hospital did not have the capability to provide care for. Employee #9 further confirmed Patient #20 and his legal representative "...were provided referrals for other facilities...and allowed to leave the hospital...," departure time was 16:20.

Based on Hospital policy and procedure, Hospital documents, medical records and employee interview, it was determined the Hospital failed to ensure patient transfers occurred pursuant to Hospital policy. This deficient practice poses the potential risk that patients will receive inappropriate transfers and health needs will not be met as a result.

Findings Include:

Hospital policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" revealed "...Transfers...A. When a patient is being transferred from (the Hospital) to another medical facility because it does not have the capacity or capability to treat the patient's EMC (defined in the policy as Emergency Medical Condition), the following procedure will be followed:...1. Contact the on-call physician to initiate the Consent to Transfer EMTALA Form;...2. Call the Emergency Department able to provide appropriate care to the patient and obtain a verbal acceptance of transfer, including the name of the accepting physician;...3. Discuss transfer and risks with the patient;...4. If the patient consents for transfer call EMS for transfer;...5. Complete and send a copy of the Consent to Transfer EMTALA Form and assessment to the receiving hospital..."

Hospital document titled "Consent to Transfer EMTALA Form" revealed the following elements: "...1. Patient Condition, Risks and Benefits of Transfer and including Physician Certification...2. Reason for Transfer...3. Receiving Hospital of Procedural Area Acceptance...4. Mode of Transport...5. Medical Records Sent...6. Patient Consent to Transfer..."

A total of 20 Hospital medical records were randomly selected for review including patients who were transferred to another facility due to Hospital lack of capacity or capability to treat patient EMC. Medical records for Patients #2, #5, #7, #10, #11, #19, and #20 contained missing or incomplete Consent to Transfer EMTALA Forms.

Employee #9 confirmed, during interviews conducted from April 9, 2025 through April 10, 2025, that Patients #2, #5, #7, #10, #11, #19, and #20 were transferred from the Hospital due to Hospital lack of capacity or capability to treat patient EMCs and that Consent to Transfer EMTALA Forms for each were either incomplete or missing from the patients' medical records.