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This STANDARD is not met as evidenced by:
Based on interview and review of Emergency Department (ED) Central Log, ED medical records and policies, the facility failed to provide a medical screening exam (MSE) sufficient todetermine the presence if either an emergency medical condition (EMC) and/or emergency psychiatric condition existed within the facility's capability and capacity for three patients (#13, #21 and #23) out of 24 randomly selected patient records reviewed from 07/01/18 through 01/07/19. The facility also failed to document in the ED Central Log, two patients (#13 and #21), that presented for care and treatment. The facility's ED saw an average of 162 cases per month.

Refer to the 2567 for additional information.

This STANDARD is not met as evidenced by:
Based on interview, record review and policy review, the facility failed to maintain the Emergency Department (ED) Central Log with all required information for two patients (#13 and #21) who presented to the facility's ED seeking care out of 24 sampled ED patients selected from 07/01/18 through 01/07/19. This failed practice had the potential to lead to patient's presenting to the ED without documentation necessary for tracking purposes. The facility's ED saw an average of 162 cases per month.

Findings included:
Review of the facility's policy titled, "EMTALA, Emergency Medical Treatment and Active Labor Act," dated 2/27/18, showed a central log of all patients presenting to the ED must include where the person first presented, the Medical Screening Examination (MSE) and disposition (discharge status). The disposition should reflect whether the person left without being seen (LWBS), refused treatment, received treatment, was transferred or discharged.

Review of the facility's ED Central Log showed on 9/21/18 at 9:06 PM, Staff I, ED Registered Nurse (RN), documented that Patient #21 presented to the ED with the nature of injury, "Passed out/not seen by provider due to mother did not want this. Blood sugar 119 mother only wanted blood sugar done." The central log's columns included areas to document the patient's name, age, services of the physician, time the patient was placed in an ED room (bay), time the patient left the ED and disposition, all which were left blank.

During an interview on 01/08/19 at 1:40 PM, Staff A, Director of Patient Care Services, stated that all patients who presented to the ED should be on the central log, and the log should be filled out completely.

Review of the facility's ED Central Log showed that on 12/20/18, there was no entry for Patient #13, who presented in the ambulance bay (area where an ambulance parks and loads and unloads patients) by Emergency Medical Services (EMS, ambulance and ambulance staff). EMS was enroute to Hospital B (nearby hospital), when ambulance staff were unable to initiate intravenous (IV, in the vein) access to administer IV fluids (for hydration), EMS stopped at the facility's ambulance bay to have ED staff access
the patient's Port-A-Cath (Port, small medical appliance that is inserted beneath the skin in the chest region, and connects the port to a vein used to draw blood and/or administer medications and fluids) and after the port was accessed, EMS continued to transport the patient to Hospital B.

During a telephone interview on 01/08/19 at 3:24 PM, Staff C, ED RN, stated that she did not log the patient into the facility's ED Central Log since the patient did not present to the facility's ED.

This STANDARD is not met as evidenced by:

Based on interview, record review and policy review, the facility failed to provide, within its capability, an adequate medical screening examination (MSE), to include the appropriate consults and/or other diagnostic studies, to determine if there was an emergency medical/psychiatric condition (EMC) for three
Patients (#13, #21, and #23) that presented to the facility's Emergency Department (ED) seeking care out of 24 sampled ED patient records selected from 07/01/18 through 01/07/19. These failed practices had the potential to delay treatment to stabilize, and increased a patients risk for a negative outcome, including death, for all patients presenting to the ED seeking care for an EMC. The facility's ED saw an average of 162 cases per month.

Findings included:
1. Review of the facility's policy titled, "EMTALA Emergency Medical Treatment and Active Labor Act," dated 12/27/18 showed the following:
- Any person, regardless of ability to pay or for any other reason, who presents to Sullivan County Memorial Hospital (SCMH) seeking or needing emergency care, will be provided a screening examination by a qualified healthcare provider to determine if an emergency medical condition exists.
- With respect to any person requesting examination and treatment for a possible emergency medical condition, or requested on behalf of such person, means "is on the hospital premises or property."
- A psychiatric (psych) patient is considered stable for discharge when the patient no longer presents a threat to self or others.

Triage is not equivalent to an MSE.
- Documentation of a refusal of the MSE, by a Leaving Hospital Against Medical Advice (AMA) form will occur.

Record review of an ambulance report dated 12/20/18, showed that ambulance staff arrived to a local nursing home at 1:37 AM, to transport Patient #13 to Hospital B (hospital approximately 30 minutes away). The patient was a 57 year old male who had vomited "bright red blood" for one hour and complained of weakness. The patient's assessment included abdominal "pain/tenderness," and at 1:43 AM, the patient's blood pressure was documented as 81/58 (low, normal range is between 90/60 to 120/80), even though the patient's history included high blood pressure. Intravenous catheter (small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream)
access was unsuccessful by ambulance staff, so the patient's Port-A-Cath (Port, a small medical appliance that is inserted beneath the skin in the chest region and connects the port to a vein used to administer medications, fluids and to draw blood) was accessed at 2:05 AM by SCMH (nearest hospital) Emergency Registered Nurse (RN). At 2:06 AM, the patient's blood pressure continued to be low at 85/59, and the patient was transported to Hospital B.. On 12/20/18, Patient #13 presented in the ambulance bay (area where an ambulance loads and unloads patients) per Emergency Medical Services (EMS, ambulance and ambulance staff). The patient had been picked up by EMS from a local nursing home with complaints of gastrointestinal bleeding (GI bleed, bleeding that can occur in the stomach and/or intestines). The EMS crew notified SCMH that they were transporting the patient to Hospital B for a GI bleed, but needed to stop at SCMH because they were unable to initiate IV access to administer IV
fluids. EMS requested for ED staff to access the patient's port, since accessing the port was out of their scope of practice. When EMS arrived, Staff C, ED RN, went to the ambulance and accessed the patient's port. After Staff C accessed the port, EMS continued to Hospital B. The patient was not provided a MSE by the facility to rule out if he had an EMC and if he was stable to continue to travel to Hospital B, which was approximately 30 miles away.

During an interview on 01/08/19 at 2:44 PM, Staff B, Physician, ED Medical Director, stated that:
- He was the backup ED physician scheduled on 12/20/18.
- He received a call from ED staff that the local EMS crew had called the ED and requested assistance with accessing a patient's port because they were unable to establish an IV on the patient.
- EMS reported that the patient needed IV fluids because he had an active (occurring at the present time) GI bleed, they were unable to initiate IV access, the patient had a port but accessing the port was out of their scope of practice, and therefore, they needed assistance from the facility's ED staff to access the patient's port so IV fluids could be administered.
- ED staff asked him for an order to access the patient's port and reported that EMS was transporting the patient to Hospital B nearly 30 miles away because Hospital B had GI services SCMH did not have.
- He gave ED staff a verbal order to access the patient's port so fluids could be administered.

During a telephone interview on 01/08/19 at 3:24 PM, Staff C, ED RN, stated that:
- She worked the night shift on 12/20/18, when the patient arrived per EMS in the ambulance bay.
- The ED received a call from a local nursing home that a patient was vomiting blood and she heard local EMS dispatched (sent out for) for the patient.
- She was familiar with the patient and knew he had a port, so she gathered supplies and set up a room in anticipation for his arrival.
- EMS called and informed ED staff that they experienced difficulty starting an IV on the patient, they needed to administer fluids because he had been vomiting blood but were unable to start an IV and requested ED staff to assist them with the patient's port access, so IV fluids could be administered.
- She called Staff B, Physician, ED Medical Director, for permission to access the patient's port.
- When EMS arrived in the ambulance bay, she went out to the ambulance and accessed the patient's port.
- She was not requested by EMS to assess the patient when she entered the ambulance to access his port.
- The patient was alert, breathing normally and did not show any signs or symptoms of distress.
- She asked the next day what she needed to do about accessing the patient's port and was instructed to put the verbal order from Staff B onto an Outpatient Treatment form.

Review of the Outpatient Treatment form dated 12/20/18 at 1:20 AM, showed Staff C, ED RN, documented that she received a physician's order to access the right chest port for EMS. Nurse's Notes showed Staff C documented that the right chest port-a-cath was accessed. The form did not include an assessment of the patient or the patient's vital signs.

During an interview on 01/09/19 at 12:30 PM, Staff F, Chief Executive Officer (CEO) stated that:
- He did not consider helping EMS with accessing the patient's port as an EMTALA violation.
- His ED staff responded to the EMS request to assist them by accessing the port so the patient
could receive IV fluids.
- He expected every person that presented to the facility's ED to receive a medical screening exam.

The facility failed to perform a MSE on the patient to ensure he was stable to continue to Hospital B,
approximately 30 miles away.

2. Review of Patient #23's ED record showed that she first presented to the ED on 09/25/18 at 11:07 PM, with complaints that she wanted to hurt herself. Review of the ED Summary dated 09/25/18 at 11:10 PM showed that:
- Patient #23 presented to the facility's ED, accompanied by her mother, with complaints that she wanted to hurt herself, feeling sad and depressed (a long period of feeling worried or empty with a loss of interest in activities once enjoyed) over the past two days. She reported that something happened at work that day, and she was stressed.
- The suicide screen (a comprehensive evaluation to confirm suspected suicide risk) showed that the patient experienced suicidal ideations (thoughts of harming self), had feelings of anxiety (fear and worry are constant and overwhelming), sense of isolation and that bad dreams scared her.
- The patient scored low risk on the suicide risk level assessment since she reported vague ideations without either a clear plan or intent and without a recent attempt to commit suicide.
- The depression screen showed that the patient experienced feelings of fatigue (extreme tiredness), insomnia (inability to sleep), appetite change, low energy, weight loss, crying spells and poor concentration.
- Staff B, Physician, ED Medical Director, ordered a psychiatric consult from telepsychiatry (telepsych, delivery of psychiatric assessment and care through telecommunications technology, usually videoconferencing) services contracted by the facility. Review of Staff B's documented assessment of Patient #23, dated 09/27/18, showed that the patient presented to the facility's ED, accompanied by her mother, on 09/25/18 and reported she felt quite depressed. The patient had a flat affect (absence of emotional expression) and reported problems at work that caused stress and coping difficulty. The patient
stated that she had some thoughts of hurting herself but did not have a plan. She reported frustration because she had three appointments set up for counseling and all three appointments had been canceled by her counselor. The patient had a past medical history for depression. Recommendations included counseling, a psych evaluation, and contract for safety (agreement between the patient and contractor that the patient will not self-harm). dated 09/26/18 at 12:30 AM, showed the contracted mental health assessor began a mental health assessment on the patient per telepsych method. The assessor reported that the patient had a flat affect, experienced sadness for a few days, had lost weight and was not eating or sleeping well. The patient reported that her family had a history of suicide. Her father committed suicide three to four years ago and she had an uncle and cousin that also committed suicide. The patient stated that she started having suicidal thoughts three years ago, was having current thoughts of suicide now and had these thoughts for a couple of months, but did not know why she had them. The patient admitted that she had thoughts of "killing'' herself now, but did not have a plan and had never attempted to kill herself. The patient denied previous hospitalizations for her suicidal thoughts. The patient reported that she had made three appointments with her counselor, but the counselor had canceled all three appointments, and therefore, she had never seen a therapist. Because the patient's mother could be with the patient for 24-hours, and because the patient reported she felt safe with her mother, the mental health assessor recommended for the patient to contact her case manager (someone who assesses and coordinates care according to care needs) the following morning (09/26/18) because the patient needed therapy as soon as possible, to get a therapist and call a psychiatrist (09/26/18) to report that she was seen in the ED with suicidal thoughts.

Review of the Telehealth Consult dated 09/26/18 at 12:58 AM showed:
- The patient was calm and cooperative and displayed a flat affect with sad mood. Her speech was somewhat monotone (unvaried tone) and did not provide detailed responses to questions asked. She experienced some difficulty describing how she felt and would respond, "I don't know" to several questions asked. Her thought process was linear (progression from one stage to another in a single series of steps; sequential) and goad directed. Her thought content was positive for self-harm but without a plan or intent and was unable to describe her thoughts of self-harm. She reported that she had these thoughts in the past but did not have a history of suicide attempts or psychiatric hospitalizations. She voiced her primary stressor was her job, she did not like her job and felt she was not given proper breaks. She has only had the job for a couple of days and she began feeling suicidal after work today. She has a family history of suicide with her father committing suicide three to four years ago and a maternal uncle and cousin that also committed suicide. She reported she first started thinking about s icide three years ago. The patient's assessment revealed she was at risk for suicide.
- The patient's behavior was positive for helpless and hopelessness.
- Both patient and mother felt the patient was safe to return home. The mother reported that she would be with the patient for the next 24-48 hours and agreed to bring the patient back to the ED if the patient's symptoms worsened. The patient agreed to inform her mother if she could not be safe.
- Staff B, Physician, ED Medical Director (SCMH), reported he did not believe the patient required inpatient admission at this time.
- Consult between Staff B and telehealth agreed that the patient could safely be discharged to home with her mother. Discussed with the patient's mother the need to immediately contact the patient's case manager and psychiatrist, and inform them the patient was seen in the ED and needed to be seen within the week for therapy, and the patient's mother verbalized she understood.

Review of the ED Discharge Instructions dated 09/26/18 at 1:00 AM, showed the patient was discharged home with her mother with the Suicide Prevention Hotline number, instructions to call the psychiatrist and case manager first thing in the morning (09/26/18) to get an appointment to be seen, and the patient was to report to her mother if her feelings worsened.

During an interview on 01/08/19 at 2:15 PM, Staff B, Physician, ED Medical Director, stated that:
- He was the ED physician on 09/25/18 when the patient presented to the ED.
- He received a verbal report from the contracted telepsych assessor.
- He had the patient contract for her safety.
- The contract for safety was a verbal contract between him and the patient not to harm herself.

During a telephone interview on 01/09/19 at 11:15 AM, Staff H, ED RN, stated that:
- She was working the night shift on 09/25/18 when the patient presented to the ED with her mother.
- The patient reported that she had thoughts of hurting herself but was not in immediate harm.
- She utilized the contracted telepsych services to perform a mental health assessment on the patient.
- She felt like the patient was safe to go home with the mother.

Review of Patient #23's ED record showed the patient presented to the ED a second time on 09/26/18 at 5:05 PM, 16 hours after her first presentation, with continued complaints of suicidal thoughts. Review of the ED Summary dated 09/26/18 at 5:05 PM, showed that the patient presented to the ED with continued thoughts of suicide, had a sad affect and was seen last night for the same reason. No tests or procedures were performed during the ED visit. The patient was given the Suicide Prevention Hotline, instructed to call the psychiatrist office the following day (09/27/18) to make an appointment and explain her history over the past few days. The patient was given educational information related to depression and was discharged home with her mother on 09/26/18 at 5:50 PM (45 minutes after she presented).

Review of Staff B's assessment of Patient #23, dated 09/27/18, showed the patient was seen on 09/25/18 in the ED with depression and suicidal thoughts, which were fleeting (lasting for a very short time) and
without a plan. She stated that she continued to feel depressed and had suicidal thoughts, but denied any plan. She voiced frustration that they (patient and mother) had called her mental health provider and that appointments had now been canceled four times by this resource. The mother and patient voiced frustration and did not know what to do. The patient had good eye contact and exhibited appropriate insight but affect was flat. The patient was diagnosed with depression, and she was provided with the number for a psychiatrist and needed to make her own appointment. The patient and mother agreed to
follow closely with her family physician. The patient contracted for safety and stated that she felt safe with her mother and was discharged in stable and satisfactory condition, to be observed and cared for by
her mother.

During an interview on 01/08/19 at 2:15 PM, Staff B, stated that:
- He was the ED physician on 09/26/18 when the patient returned to the ED.
- He did not do a suicide risk assessment (a tool used to evaluate the severity of suicidal ideations a person has) on the patient when she returned to the ED.
- He did not think the patient was at risk and did not recall if he requested another mental health assessment with her second presentation.
- He did an assessment, provided her with referral resources (psychiatrist phone number)
and at that time he felt she was stable to be discharged with the referrals and her mother.
- She verbally contracted for her safety and identified stressors in her life, especially the conditions at work.
- She requested time off work and was given a note to be off one to two weeks.

During an interview on 01/09/19 at 10:31 AM, Staff A, RN, Director of Patient Care Services, stated that:
- She worked in the ED on 09/26/18 when the patient presented to the ED a second time with complaints of suicidal thoughts.
- The patient reported to her that it was the patient's second presentation to the ED seeking help and she was concerned about the patient because she had returned to the ED a second time with suicidal thoughts.
- The patient reported that she did not have a plan but needed help.
- She did not perform a suicide risk assessment on the patient.
- The patient stated that she would not kill herself, but she could not take the stress at work.
- She did not feel like the patient needed another mental health assessment because she thought the patient was more concerned about her job.
- Her expectation was for the patient to get in touch with the referral psychiatrist the following day.
- She was not aware of how a patient could contract for safety and to her knowledge the facility did not have a process for contracting for patient safety.
- She was not aware that the patient had a family history of suicide and did not know that the patient's father, uncle and cousin had committed suicide.
- Even if she would have known about the family history of suicide, she probably would not have changed her mind about the patient because the conversation between her and the patient was "solid".
- ED nursing staff do not have any specific suicide assessment tools they used when a patient presented with suicidal thoughts.

The facility failed to provide the patient with a mental health assessment performed by a Qualified Mental Health Professional, when she presented to the ED 16 after her first presentation, with continued suicidal thoughts. The patient expressed to the facility staff that she needed help for continued thoughts of
self-harm. She did not receive a proper psychiatric assessment and was discharged home approximately 45 minutes after she presented the second time. This failure by the facility placed the patient at increased risk for harming herself and/or death.

3. Review of Patient #21's triage notes dated 09/21/18, showed Staff I, RN, documented that::
- The minor patient was accompanied by her mother with complaints of, "Passed out, has happened three times in past year. Wants blood sugar (a test that shows the level of sugar in the blood) checked."
- The triage assessment was focused on the complaint only and included Staff I's observation of normal airway, breathing, circulation (indicates adequate blood flow through the body), no bleeding, and the fact that the patient was conscious. No vital signs were documented.
- The patient's blood sugar was 119 (normal is 80-120).
- The disposition showed the patient was "Ready for nurse."

During an interview on 01/09/19 at approximately 3:00 PM, Staff I, RN, stated:
- He remembered Patient #21's presentation and approximated her age at 8-10 years old.
- Patient #21 had a history of diabetes and the mother did not have any blood sugar monitoring
supplies.
- He told the ED provider on duty at the time about the patient's presentation and complaint, and the provider said, alright, good. However, the provider did not see the patient. - The patient left the ED without a MSE.

Review of the ED schedule for 09/21/18, at the time the patient presented, showed Staff E, Nurse Practitioner and Staff D, ED Physician, were responsible for the ED.

During interviews on 01/09/19 at 10:10 AM and 10:25 AM, Staffs E and D stated they knew nothing about Patient #21's presentation to the ED on 09/21/18.

Even though requested, the facility staff failed to provide an AMA form, or Left Without Being Seen (LWBS) documentation for the patient's visit to the ED.
The facility failed to provide evidence that the patient received an MSE or that the patient was stable at the time she left the ED.