HospitalInspections.org

Based on observation, document review, record review, policy review and interview the hospital failed to ensure the Emergency Medical Treatment and Labor Act (EMTALA) requirements were met by failing to post adequate signage; failing to perform an appropriate medical screening exam (MSE) and failing to provide stabilizing treatment for patients who presented to the emergency department seeking medical care. Failure to perform an appropriate MSE and stabilizing treatment places patients at risk for unidentified emergency medical conditions resulting harm injury up to an including death.

Findings Include:

1. The hospital failed to comply with posting of signs which specify the rights of individuals with EMCs and women in labor in a place or places likely to be noticed by all individuals. (Refer to tag A2402)

2. The hospital failed to ensure an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) exists was completed for 4 of 22 patients (Patient 7, 9, 11, and 20) who presented to the emergency department (ED) seeking emergency medical care. (Refer to tag A2406)

3. The hospital failed to provide stabilizing treatment for 1 of 22 patients (Patient 7) who presented to the emergency department seeking emergency medical care. (Refer to tag A2407)

Based on observations, interviews and policy review, the hospital failed to ensure that Emergency Medical Treatment and Labor Act (EMTALA) signage was posted and noticeable in the Emergency Department (ED) and ED locations where patients may have to wait, and the Obstetric Unit (OB), which is an extension of the ED, for two of three observation days. This failure puts all patients seeking emergency medical care at risk.

Findings Include:

Review of the hospital's policy titled, "Emergency Medical Treatment & Active Labor Act (EMTALA) (Common Spirit Mountain Region)" dated 09/20/18, revealed, "...Posting Signs 1. The hospital will post conspicuously, in the dedicated emergency departments (including off-campus provider-based departments that qualify as dedicated emergency departments) and labor and delivery and psychiatric units as well as all areas defined above and all areas in which patients routinely present for treatment of emergency medical conditions and wait prior to examination and treatment (such as entrance, including ambulance bays, admitting areas, waiting room or treatment room), signs in the format of Attachments B and C that specify rights of an individual under the law with respect to examination and treatment for emergency medical conditions and of women who are pregnant and are having contractions. 2. The hospital will conspicuously post signs stating whether or not the hospital participates in the Medicaid program. 3. All signs must be posted in all the major languages that are common to the population of the hospital's service area."

On 11/12/24 at 12:30 PM when entering the ED, one EMTALA sign in both English and Spanish that had a brown background color with white lettering was located on the left side wall walking to the ED under overhead lights that had reflective glare making the sign hard to read. No other signage was noted in the area. No signage was observed on the walls in the patient waiting area, or around the Triage desk.

On 11/12/24 during a tour of the ED at 1:15 PM, there was no EMTALA signage found in the ED ambulance bay, or the area identified as the "Fast Track" where eight additional rooms for ED patients was located.

During an interview on 11/12/24 at 1:25 PM Patient Access Representative (registration) Staff C confirmed there was no other EMTALA sign posting at the ED patient registration desk/area.

On 11/12/24 at 1:30 PM during a tour of the OB unit confirmed one EMTALA sign in both English and Spanish on a side wall outside the OB triage room with brown background color and white lettering.

During an interview and review of the hospital's EMTALA policy on 11/13/24 at 11:20 AM with the ED/Intensive Care Unit (ICU) Manager B (also present was Director of Quality Staff D), revealed the policy had attachments Attachment B and C that included their EMTALA requirement for "sign posting" and attachment B (example in English) and C (example in Spanish), of the EMTALA sign to be posted , revealed the sign attached to the hospital EMTALA policy to be posted had a white background and bold black lettering.

During an walk through observations and interview on 11/13/24 at 11:25 AM ED/Intensive Care Unit (ICU) Manager B (also present was Director of Quality Staff D) of the locations listed in the hospital's EMTALA policy there was no signage on or in the Registration area, the patient waiting area, the Triage room, or the Ambulance Bay entrance that are all listed on the policy as required to have EMTALA signage. This observation was confirmed during the ED walk through by ED/Intensive Care Unit (ICU) Manager B and the Director of Quality Staff D.

During an interview on 11/13/24 at 11:25 AM ED/ICU Manager Staff B (also present was Director of Quality Staff D), ED/ICU Manager Staff B confirmed that the one sign posting on the wall to the left of the entrance was not as easy to read as the signs (Attachment B and C) in their EMTALA policy.

During an interview on 11/13/24 in the OB department next to the Triage room door with the OB Manager Staff E (also present was Director of Quality Staff D) confirmed that the OB Triage had one sign on the wall with a brown background that did not standout not the White background and bold black letter as defined in their EMTALA policy. OB Manager Staff E confirmed the one sign in the OB Triage area was posted high on a side wall that was that makes it difficult to read, and if a pregnant woman was brought in a wheelchair or on a gurney would likely not be able to see or read that EMTALA notice sign. OB Manager Staff E confirmed there were no other signs in the Triage room or at the entrance to the OB department.

Based on record review, policy review, document review and interview the hospital failed to ensure an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) exists for 4 of 22 patients (Patient 7, 9, 11, and 20) who presented to the emergency department (ED) seeking emergency medical care. The hospital's failure to ensure an appropriate MSE has the potential for patients to be discharged with an unidentified emergency medical condition (EMC) which delays necessary stabilizing treatment.

Findings Include:

Review of a document titled "Medical Staff Rules and Regulations" Approved 03/21/23 showed, " ... B. Medical Screening Examination The Hospital will provide an appropriate medical screening examination (MSE) within the capability of the Hospital's dedicated Emergency Medicine Department (ED) and Obstetrics/Gynecology (OB) Department to determine whether an emergency medical condition exists. Medical screening examinations may only be conducted by Qualified Medical Providers, as designated by the Medical Executive Committee (MEC). These Providers include physicians, Emergency Medicine Advanced Practice Nurses, Emergency Medicine Physician Assistants and Certified Nurse Midwives. Or, when a patient presents to the ED, without additional injuries/complaints, the medical screen examination may be performed by alternative Qualified Medical Providers, which may include Sexual Assault Nurse Examiner (SANE) and Obstetric Registered Nurses'. In accordance with the Emergency Medical Treatment & Active Labor Act - [The Hospital] Policy, the physician or QMP will determine within reasonable clinical confidence whether the individual has an emergency medical condition, utilizing the services within the capability of the emergency department, using ancillary services and resources routinely available in the emergency department for individuals with similar symptoms ..."

Review of a policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" Publication Date 09/20/18 showed, " ... It is hospital policy that if an individual comes to the Emergency Department (ED) (as defined below): 1. The hospital will provide an appropriate medical screening examination (MSE) within the capability of the hospital's dedicated emergency department, including ancillary services routinely available to the dedicated emergency department, to determine whether or not an emergency medical condition exists. The examination will be conducted by an individual(s) determined qualified by hospital Bylaws or rules and regulations; and 2. If it is determined that the individual has an emergency medical condition, the hospital will provide further medical examination and treatment as required to stabilize the emergency medical condition, within the capability of the hospital, or to arrange for Transfer of the individual to another medical facility in accordance with the procedures stated below; ...3. The MSE will be performed by a physician or a Qualified Medical Person (QMP) as designated by Medical Executive Committee and the governing body. The physician or QMP will determine within reasonable clinical confidence whether the individual has an emergency medical condition, utilizing the services within the capability of the emergency department, using ancillary services and resources routinely available in the emergency department for individuals with similar symptoms ...4. The MSE is an ongoing process. The medical record must reflect an ongoing assessment of the patient's condition. Monitoring must continue until the individual is stabilized or appropriately admitted or transferred. There should be evidence of this prior to discharge or transfer. The MSE must be documented in the electronic health record (EHR). a. Medical records should contain documentation such as medically indicated screenings, tests, mental status, impressions, and diagnoses (supported by a history & physical (H&P), laboratory and other tests), as appropriate. b. For pregnant women, the medical records should show evidence that the screening exam included ongoing fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation and status of the membranes. c. For individuals with psychiatric symptoms, the medical records should indicate an assessment of suicide or homicide attempt or risk, orientation or assaultive behavior that indicates danger to self or others ..."

Review of the hospital's policy titled "Assessment, Reassessment, Vital Signs, and Documentation of Patient Care - Epic (CommonSpirit (sic) Mountain Region)" dated 01/26/23 revealed "The Purpose: To outline the standards of care for assessment, reassessment, vital signs (VS) and procedures to document and maintain an accurate record of the patients' assessments, progress, treatments, medications, and condition within the electronic health record (EHR). ... under the pathway titled "Applicable Units: Emergency Department (ED): Emergency Severity Index (ESI) Level 1, 2, 3, 4, and 5" requires that the "Initial VS, Room Set-up, and Safety Screening" indicates the initiation assessment is completed "Upon arrival".

During an interview on 11/13/24 at 11:20 AM, Staff B, ED/Intensive Care Unit (ICU) Manager confirmed that the hospital uses the Emergency Severity Index (ESI) system for triaging ED patients.

Review of the standards of practice for "Emergency Severity Index (ESI)" fifth edition for Emergency Nurses Association dated 2023, revealed, "The first decision the triage nurse makes is regarding stability. If a patient does not meet high risk instability criteria (ESI level 1 or 2), the triage nurse then evaluates expected resource needs to help determine a triage level. ...Signs of instability requiring immediate, lifesaving intervention include unresponsiveness, active seizure, occluded airway, ineffective gas exchange, and ineffective/decreased perfusion. When these signs are present, the patient is assigned an ESI level of 1. ESI level 2 patients remain a high priority, and placement and treatment should be initiated rapidly. ESI level 2 patients have the potential to be very ill and at high risk for decompensation. Usually, rather than move to the next patient, the triage nurse determines that the charge nurse or staff in the patient care area should be immediately alerted that they have an ESI level 2 patient."



Patient 7

Review of a policy titled, "Suicide Risk Screening and Assessment" publication date 07/22/24 showed, " ... PROCEDURE 1. All patients should be medically assessed first. 2. Use the Columbia Suicide Severity Rating Scale (CSSRS) initial screening tool for all patients ages 10 and above ...4. Initiate the screening: a. During emergency department (ED) triage, or as soon as patient is capable of participating b. Within four hours of admission, or as soon as the patient is capable of participating. c. Repeat the screening at any time during the hospital encounter if the patient expresses or states suicidal ideation or makes a suicidal or self-harm gesture ..."

Review of a policy titled, "Detainable/Ex parte/Emergency Commitment - Kansas (CommonSpirit Mountain Region)" publication date 08/03/22, showed,

PURPOSE
To provide a safe environment for patients that are considered acutely dangerous to self and/or
others due to psychological or non-psychological conditions.

POLICY
Centura Health is committed to providing a safe environment while maintaining compliance with all federal and state regulations. When a patient is deemed "detainable", the patient will not be permitted to leave without a safe discharge plan. Detainment will be accomplished with the least restrictive means possible. We are unable to detain patients that are suicidal and choose to leave. A call to law enforcement for a welfare check will he support the safety of the patient.

PROCEDURE:

DETAINABLE PATIENT
1. If a patient chooses to leave the hospital against medical advice and does not meet criteria
for a Detainable patient, they have the right to leave.
2. In Kansas, a hospital may detain a patient who is brought in by law enforcement or any
individual who reasonably believes a patient is a danger to self or others due to mental illness for emergency evaluation.
a. If no physician or psychologist can examine the patient at the time the patient is brought to
the hospital, the hospital can detain the patient for up to 17 hours so that a physician or
psychologist may examine the patient. The physician or psychologist should evaluate and initiate the appropriate clinical orders as promptly as possible for any patient involuntarily detained on
such grounds
b. Once a physician/psychologist has determined the patient is a risk of harm to self or others
due to mental illness, the individual or law enforcement officer who brought the patient to the
hospital must file a petition with the court in order for the court to order the hospital to hold the patient.
3. If a high risk for suicide patient leaves, call 911 and ask for a welfare check. Document in the
Electronic Health Record (EHR) and complete occurrence report ..."

Further review of the policy showed a table titled "PROCEDURE FOR DETAINABLE PATIENT" under the column "Psychiatric Reasons for Detainment" "Indications for Detainable Status Physician/Advanced Practice Provider (APP) will determine if patient is "detainable." showed " ...a. Mentally ill person, who lacks capacity to make and informed decision concerning treatment AND b. is likely to cause harm to self or others AND c. Whose diagnosis is not solely one of the following mental disorders: alcohol or chemical abuse; antisocial personality disorder; intellectual disability, organic personality syndrome; or and (sic) organic mental disorder." "Mental Health Evaluation Psychiatric Reasons for Detainment" showed, a. Evaluation performed and managed by community mental health partner b. Signed ex parte form by community mental health partner c. Refer to Kansas ED Mental Health Consult Flowchart appendix d. Inpatient Behavioral Health at SCH-Garden City has criteria for admitting patients. Refer to Kansas ED Behavioral Health Evaluation Decision Tree Appendix."

Review of the policy titled, "Detainable/Ex parte/Emergency Commitment - Kansas (CommonSpirit Mountain Region)" publication date 08/03/22, Appendix A: Kansas ED Behavioral Health Evaluation Decision Tree" showed, "Is patient at imminent risk of danger to self or others (including overdosing)?" if this question is answered yes the decision tree showed, "Once medically cleared, call Kansas ED Mental Health Consult to complete psychiatric evaluation."

Further review of the Appendix A showed: "Please Note: Patient does not have to actively state that they are homicidal or suicidal to be considered a danger to self or others.

BAL [blood alcohol level] must be <200 before calling Kansas ED Mental Health Consultant
If pre-authorized for BHS [behavioral health services] admit, can be moved directly to BHS once medically cleared ..."

Review of "Appendix B Kansas Mental Health Consult Flowchart" showed, " ...Person Presents to ER with Suicidal Thoughts, Suicide Attempt, Homicidal thoughts, Psychosis, and/or Requests BHS Admit - ER Completes Medical Screen/UA [urinalysis] for Drug/Alcohol use, All Labs, patient medically stable, BAL must be below 200 - If the patient wants to go to BHS -complete BHS pending ..."


Review of Patient 7's medical record showed, a 42-year-old female, presented to the Emergency Department (ED) on 06/09/24 at 12:16 PM. Chief complaint of overdose with suicidal ideation.

Review of a document titled, "Emergency Department Encounter Note" date of service 06/09/24 at 12:16 PM signed by Staff J, MD showed, " ... 42-year-old female with prior self-harm attempt presents by EMS for believed ingestion of Benadryl Upon initial presentation is hypertensive and tachycardic and was given IV fluids with improvement ...Poison control was contacted agrees with current plan ...Plan is to observe for 6 hours. Has remained stable. However patient now wishes to leave. Does not want to be evaluated by [Community Mental Health] ..."

Review of a document titled, "Emergency Department Encounter Note" date of service 06/09/24 at 12:16 PM signed by Staff J, MD showed, "HPI/History [History of Present Illness] Drug Overdose and Suicide Attempt ... Family seems to believe that she ingested ten 25 mg tablets but after further discussion that she had a handful someone (sic) on the floor somewhere on the ground that was from a bottle that may have had 200-250 and they may have been full ... Apparently she was hitting herself with a spatula at some point on the neck ..." Further review of the ED Encounter Note showed Staff J documented, "Severity: Severe."

Review of the "Deferential diagnosis includes but not limited to: Depression, suicidal ideation, psychosis, mania, electrolyte disturbance, meningitis, intoxication, hallucination, thyroid disorder, delirium tremors"

Review of a document titled, "ED Notes" dated 06/09/24 at 5:10 PM, signed by Staff Y, RN showed, " ...Patient requested to be discharged from the ER at this time. Explained to patient that she took some Benadryl and the poison control center is recommended 6 hours observation in the ER. After 6 hours of observation, we will contact [community mental health provider] behavioral health for plan. Patient insisted on leaving the ER at this time ..."

Patient 7 discharged Against Medical Advice (AMA) on 06/09/24 at 5:25 PM, 5 hours and 9 minutes after arrival.

The medical record failed to include an initial or subsequent CSSRS per the hospital policy "Suicide Risk Screening and Assessment."

The hospital allowed Patient 7 to leave the hospital without providing an appropriate MSE within their capability for Patient 7 who presented with suicide attempted by drug overdose.

During an interview on 11/15/24 at 8:26 AM, Staff W, Doctor of Medicine (MD) stated, " ...we will not hold a patient at this facility, we cannot hold the patient regardless if they are suicidal or homicidal ..."

During an interview on 11/15/24 at 4:30 PM, Staff D, Director of Quality stated that patients that are suicidal or homicidal cannot be held in the ED due to the county restrictions.

During an interview on 11/15/24 at 4:33 PM Staff V, Chief Medical Officer (CMO) stated that patients should be placed on a temporary hold in the ED if they are a threat to themselves or others, but the county won't allow.


Review of Patient 7's medical record showed Patient 7 was returned to the ED by police on 06/09/24 at 5:54 PM, approximately 30 minutes after leaving AMA.

Review of "ED Notes" dated 06/09/24 at 6:55 PM, showed Staff Y, RN, documented, "[LMSW] from [community mental health] behavioral health returned call and will be here in an hour."

Review of a document titled, "ED Provider Note" dated 06/09/24 filed at 8:08 PM by Staff Y, MD showed, "18:00 [6:00 PM]- Patient received in sign out from [Staff J, MD]. Briefly, this is a 42 y.o. [year old] female with suicidal ideation, non-lethal ingestion of Benadryl (antihistamine medication). She is awaiting Evaluation with Behavioral Health. 20:00[ 8:00 PM] - Case discussed with [Behavioral Health]. Patient commits to a safety plan. Involvement in patient care: Minor involvement.

Patient 7 discharged home on 06/09/24 at 8:28 PM following a mental health screen by the community mental health staff with a safety plan in place.

During an interview on 11/14/24 at 3:28 PM Staff J, MD stated that if a patient can walk and talk and reason with me, "they can sign out." If the patient is a true danger to themselves we will call the police. Case management is never called to place the patient on a 72-hour hold. The hospital does not have a psychiatrist on call. The hospital does not call behavioral health to evaluate the patient until they are medically cleared. Staff J went on to state, " ...We do not have a contract, it's just the behavioral health team that assesses our patients ..."

During an interview on 11/15/24 at 8:26 AM, Staff W, MD stated, " ...all patients presenting with suicidal or homicidal ideation needing an evaluation must be medically cleared before [Behavioral Health] will come evaluate the patient ..."


Patient 9

Review of Patient 9's medical record showed, a 40-year-old female, presented to the Emergency department accompanied by police department on 06/10/24 at 10:28 AM, but deferred to Obstetrics (OB) unit due to gestation of pregnancy on 06/10/24 at 10:41 AM. Patient 9 was triaged at 11:03 AM in the Labor and Delivery unit. Patient 9 had a chief complaint of abdominal pain.

Review of document titled, "Clinical Notes" dated 06/10/24 at 11:43 AM, showed Staff B2 documented, "While this RN attempted to acquire patient information, [Registered Nurse] attempted to find FHR [Fetal Heart Tones] using a US [Ultrasound]. She was unable to do so."

Review of Patient 9's record showed negative serum (blood) pregnancy test and negative drug screen.

Review of the "Clinical Notes" dated 06/10/24 at 12:16 PM showed Staff B2 RN documented Patient 9 was "dismissed off unit with an officer per provider order after he explained HCG results and the fact that she is not pregnant at the moment. ... If she still feels movement or pressure in her pelvis that she needs to contact her PCP [Primary Care Provider] and follow up. Patient verbalized understanding. No further questions verbalized per patient report. AVS [After Visit Summary] reviewed prior to discharge from unit."

The medical record documentation failed to demonstrate that Patient 9 was provided an appropriate MSE by a QMP credentialed by the governing body to perform the MSE for a non-pregnant patient.

Patient 11

Review of the ED EMR for Patient 11 who presented to the ED on 11/01/2024 at 10:49 AM with a chief complaint of stomach pain. Patient 11 was not triaged by the nursing staff, did not receive an MSE for this ED presentation and was logged into the EMR as left without being seen (LWBS).

Review of an incident report titled "Risk Management Worksheet" shows an encounter entered on 11/01/24 at 11:09 AM by Regional Patient Access Representative Manager Staff L, that revealed, "Patient [11] came in with his/her son. Nurse [K] called [Patient 11] back but stopped him/her and said no one under 12 in the ED rooms and stated that the patient [11] ... needed to call someone to pick up his/her son and refused service until someone picked up his/her son. The patient [11] ended up leaving the facility [ED].


During a telephone interview on 11/14/24 at 1:33 PM, Staff F, ED Medical Director, when asked about Staff K, ED Registered Nurse (RN) not allowing Patient 11 back to Triage or ED because of a child, Staff F confirmed that is not the hospital policy. Staff F was asked if this case was reviewed as an EMTALA violation. She replied that she was not told about this case until today (11/14/24). Staff F when asked what the triage criteria was for ED RNs to triage ED patients stated she was not aware of what the policy has but, it should be done immediately.

During an interview on 11/14/24 at 2:16 PM Staff K, ED RN, denied not Triaging Patient 11 because he/she brought a child along. Staff K stated they were busy, and "I asked her to find someone." When asked about the training and education prior to this incident, Staff K stated, "None, I didn't even get a preceptor when I came here with no ED experience. I have been here a year and a half. EMTALA is discussed a lot, but no official training that I remember. Staff K stated their ED has no assigned Triage Nurse, so RNs assigned to care for ED, trauma or critical patients must rotate to conduct ED Triage."

During an interview on 11/14/24 at 4:41 PM, Staff B, ED/ICU Manager, when asked if the hospital's ED had a designated ED Triage RN stated "no" they have not had one for over a year. When asked if the staff were accurate that the hospital ED staff get EMTALA Triage Training once during orientation, he/she stated "Yes, that is correct one time" during their orientation.

During an interview on 11/15/24 at 8:49 AM, Staff T, Patient Access Representative (ED registration) confirmed "I was the registration staff that day and I registered [Patient 11] with complaint of stomach pain. Yes, [Patient 11] did have a child. I called back and let the RN (Staff K) know, and within 15 minutes or so, [ED RN K] came out through the triage door and stood in the open doorway and called the patient [11] to her so everyone at the registration desk [Staff T, S and our boss L] could hear [ED RN K]'s conversation with [Patient 11]. [Staff K] asked if [Patient 11] had someone to watch the child, and told the patient 'you have to find someone to watch the child and then they would take her back.' [Staff K] said [to Patient 11] they do not allow patients under the age of 12 in the ED." Staff T stated the ED does see pediatrics in the ED. Staff T stated Staff K then came out to the registration area and stated, "we have to set boundaries." Staff T stated "patient [11] immediately started texting, and I assumed (sic) trying to get someone to come and watch her child, but after an hour got up and left." Staff T stated, "I called [Staff K] and told her, and Staff K asked me to take the patient [11] off the ED log but we told Staff K we could not, and that the ED would have to put [Patient 11] in as a LWBS."

During an interview on 11/15/24 at 9:03 AM Staff S, Patient Access Representative (ED registration) stated that ED RN Staff K came out of the Triage door (on 11/01/24) and stood in the doorway with the door open and called for the patient (11) "do you have anyone to sit with the child." When patient (11) said no the Staff K, ED RN told her that she "would have to find someone and then we will come back to get you." The patient (11) sat in the lobby on his/her phone I assumed trying to find someone to take her child and then got up and left the ED after an hour or so." Staff S stated "we [The ED] did not have a full board, there were maybe four or five patients in the ED at that time [Patient 11 presented] and none of them were traumas, and there were no ambulances back." Staff S stated that do not refuse any patients care in the ED and do not remove them from the ED log.

Patient 20

Review of Patient 20's medical record showed a 22-year-old female who presented to the ED on 11/12/24 at 11:09 PM with a chief complaint of abdominal pain with an episode of nausea/vomiting. She denied vaginal bleeding or leaking fluids. Patient 20 was sent to OB Triage and was not triaged for this admission. The OB RN Staff H was identified as a Qualified Medical Professional (QMP) and conducted a Medical Screening Examination (MSE) to rule out an Emergency Medical Condition (EMC) at 11:16 PM, however, there was not history of a physical documented for Patient 20, and the MSE scoring tool used by the OB RN QMP Staff H scored Patient 20's pain on the MSE scoring tool as a "1" and it should have been a "5" based on a pain score of "8." However, Patient 20's pain level was not documented until 41 minutes after arrival 11/12/24 at 11:50 PM. There was no ultrasound completed for Patient 20 who was identified as being 29 weeks pregnant and had not sought pre-natal care prior to this visit.

During an interview on 11/14/24 at 4:02 PM Staff H, OB RN QMP stated he/she had worked in the capacity of an OB RN for 10 years, and had received MSE training once 10 years ago, and the competency involved the OB RN Charge Nurse Staff R ensuring that Staff H's training was completed and checked off the competency without conducting visual audits of MSE skills, then handed off to their OB physician to sign off without observations of MSE skills. Staff H confirmed that she had never had anyone check her skills conducting an MSE as an approved QMP. When asked why Patient 20 had not received nursing Triage, Staff H stated "they do not provide triage in the OB."

During an interview on 11/15/24 at 10:11 AM Staff R, OB RN Charge Nurse stated that within the past six months the OB department has been given criteria by "Common Spirit" to start conducting audits for "hemorrhage, Newborn Sepsis Screen, and Edinberg", however for over 12 months there has been no audits or oversight to the OB department. When asked what qualified Staff R to check off other RNs to perform MSEs as a QMP, she stated that she takes the "LEARN" training and gets updates on MSE, the same information as all RNs in the OB. Staff R stated, "regarding our competency, we do not have the MSE as a check-off." Staff R stated, "Yes, I did sign off Staff H on performing MSE to be a QMP. Staff R reviewed the list of 33 OB staff QMPs listed as taking the MSE "LEARN" training and competency and signed off by the OB Medical Director and Chief of Medical Executive Committee [MEC] committee as approved to perform MSE as a QMP were 13 Certified Nursing Assistants [CAN] some who are also OB technicians."

When asked if there is any specific training, certification, or credentialing for OB RNs to perform as a QMP to conduct MSE. Staff R stated "No."

During a telephone interview 11/15/24 at 11:25 AM, Staff U, OB Medical Director and Chief of Staff for the hospital's MEC stated he was given a list of RNs the training department had identified as training and competent to perform MSE. When asked what kind of MSE training the OB RNs are receiving to qualify them as a QMP, he stated, "I do not know" the RNs should be able to identify reassuring and non-reassuring stress test." When asked if CNAs or OB Technicians are qualified to conduct MSEs, he stated, "I do not even know if we have OB CNA or OB Technician, but they are not the ones who evaluate a patient for an MSE. No CNAs are not qualified to perform MSE." OB Medical Director and Chief of Staff for the hospital's MEC Staff U stated, " ...Yes, I signed off on RN competency for RNs to do MSE, but I do not know what MSE training they are getting."

Based on record review, document review and interview the hospital failed to provide stabilizing treatment for 1 of 22 patients (Patient 7) who presented to the emergency department seeking medical care. Failure to provide stabilizing treatment has the potential to place patients at risk for deterioration of the emergency medical condition (EMC) causing harm or injury up to and including death.

Findings Include:

Review of a policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" Publication Date 09/20/18 showed, " ... It is hospital policy that if an individual comes to the Emergency Department (ED) (as defined below): 1. The hospital will provide an appropriate medical screening examination (MSE) within the capability of the hospital's dedicated emergency department, including ancillary services routinely available to the dedicated emergency department, to determine whether or not an emergency medical condition exists. ...2. If it is determined that the individual has an emergency medical condition, the hospital will provide further medical examination and treatment as required to stabilize the emergency medical condition, within the capability of the hospital, or to arrange for Transfer of the individual to another medical facility in accordance with the procedures stated below; ...Monitoring must continue until the individual is stabilized or appropriately admitted or transferred. There should be evidence of this prior to discharge or transfer ..."


Patient 7

In addition, cross reference A2406 policies.

Review of a policy titled "Suicide Risk Screening and Assessment" Publication Date 07/22/24 showed, " ...3. In Kansas, a hospital may detain a patient who is brought in by law enforcement or any individual who reasonably believes a patient is a danger to self or others due to mental illness for emergency evaluation.
a. If no physician or psychologist can examine the patient at the time the patient is
brought to the hospital, the hospital can detain the patient for up to 17 hours so that a physician or psychologist may examine the patient. The physician or psychologist should evaluate and initiate the appropriate clinical orders as promptly as possible for any patient involuntarily detained on such grounds.
b. Once a physician/psychologist has determined the patient is a risk of harm to self or others
due to mental illness, the individual or law enforcement officer who brought the patient to the
hospital must file a petition with the court in order for the court to order the hospital to hold the patient ..."

Review of Patient 7's medical record showed, a 42-year-old female, presented to the Emergency Department (ED) on 06/09/24 at 12:16 PM by police. Chief complaint of overdose with suicidal ideation.

Review of a document titled, "Emergency Department Encounter Note" dated 06/09/24 at 12:16 PM signed by Staff J, MD showed, " ... 42-year-old female with prior self-harm attempt presents by EMS for believed ingestion of Benadryl Upon initial presentation is hypertensive and tachycardic and was given IV fluids with improvement ...Poison control was contacted agrees with current plan ...Plan is to observe for 6 hours. Has remained stable. However, patient now wishes to leave. Does not want to be evaluated by [Community Mental Health] ..."

Review of a document titled, "Emergency Department Encounter Note" dated 06/09/24 at 12:16 PM signed by Staff J, MD showed, "HPI/History [History of Present Illness] ... Family seems to believe that she ingested 10 25 mg tablets but after further discussion that she had a handful someone (sic) on the floor somewhere on the ground that was from a bottle that may have had 200-250 and they may have been full ... Apparently she was hitting herself with a spatula at some point on the neck ..."

Review of a document titled, "ED Notes" dated 06/09/24 at 5:10 PM signed by Staff Y, RN showed, " ...Patient requested to be discharged from the ER at this time. Explained to patient that she took some Benadryl and the poison control center is recommended 6 hours observation in the ER. After 6 hours of observation, we will contact [Community Mental Health] behavioral health for plan. Patient insisted on leaving the E.R at this time ..."

Review of a document titled, "Hospital Bill of Rights" dated 06/09/24 at 12:38 PM showed, Patient 7 was " ...unable to sign ..."

Patient 7 discharged Against Medical Advice (AMA) on 06/09/24 at 5:25 PM 5 hours and 9 minutes after arrival.

The hospital allowed Patient 7 to leave the hospital without providing an appropriate MSE and failed to provide stabilizing treatment within their capability for Patient 7 who presented with attempted suicide.

During an interview on 11/15/24 at 8:26 AM, Staff W, Doctor of Medicine (MD) stated, " ...we will not hold a patient at this facility, we cannot hold the patient regardless if they are suicidal or homicidal ..."

During an interview on 11/15/24 at 4:30 PM, Staff D, Director of Quality stated that patients that are suicidal or homicidal cannot be held in the ED due to the county restrictions.

During an interview on 11/15/24 at 4:33 PM Staff V, Chief Medical Officer (CMO) stated that patients should be placed on a temporary hold in the ED if they are a threat to themselves or others, but the county won't allow.

Review of Patient 7's medical record showed Patient 7 returned to the Emergency Department (ED) on 06/09/24 at 5:54 PM by police approximately 30 minutes after leaving AMA.

Review of a document titled, "ED Care Timeline" on 06/09/24 showed, " ...18:51 [6:51 PM] First Provider Evaluation of Patient ..." Approximately one hour after arrival to the ED.

Review of a document titled, "ED Provider Note" dated 06/09/24 filed at 8:08 PM by Staff Y, MD showed, "18:00 [6:00 PM]- Patient received in sign out from [Staff J, MD]. Briefly, this is a 42 y.o.[year old] female with suicidal ideation, non-lethal ingestion of Benadryl (antihistamine medication). She is awaiting Evaluation with Behavioral Health. 20:00[ 8:00 PM] - Case discussed with [Behavioral Health]. Patient commits to a safety plan. Involvement in patient care: Minor involvement. Vital Signs BP [blood pressure] 112/85 Pulse 93 Temp 36.2 °C (97.2 °F) (Temporal) Resp [respirations] 16 SpO2 [oxygen level] 98% No orders ..."

During an interview on 11/14/24 at 3:28 PM Staff J, MD stated that if a patient can walk and talk and reason with me, "they can sign out." If the patient is a true danger to themselves, we will call the police. Case management is never called to place the patient on a 72-hour hold. The hospital does not have a psychiatrist on call. The hospital does not call behavioral health to evaluate the patient until they are medically cleared. Staff J went on to state, " ...We do not have a contract, it's just the behavioral health team that assesses our patients ..."

During an interview on 11/15/24 at 8:26 AM, Staff W, MD stated, " ...all patients presenting with suicidal or homicidal ideation needing an evaluation must be medically cleared before [Behavioral Health] will come evaluate the patient ..."