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Based on review of facility policy, review of Medical Staff Bylaws Rules and Regulations, medical record review and interviews, the facility failed to provide an appropriate Medical Screening Examination and failed to provide an appropriate transfer for one patient (#8) who presented with behavioral and safety concerns of 21 medical records reviewed.

The findings include:

Patient #8, an 18-year-old nonverbal and autistic male, presented to the ED on 11/16/2024, accompanied by his mother, for behavioral and safety concerns. His mother stated about a week prior to the ED visit he started refusing his medications which included: Sertraline (increases serotonin levels/mood enhancing), Fanapt (schizophrenia in adults and the acute treatment of manic or mixed episodes associated with bipolar 1 disorder in adults), and Vyvanse (attention deficit disorder hyperactivity disorder). Since refusing these medications, the mother reported her son's behaviors became more aggressive. He started hitting his head against the floor, attempted to attack his mother and tried to knock down a door on his mother. He was seen by the ED physician and no laboratory or imaging testing were completed. The ED physician telephoned an ED physician at Facility B and discussed the case with him. There was a discussion related to discharging Patient #8 and sending him to Facility B with his mother. The patient was discharged from Facility A. A Medical Screening Examination was not completed. There were no EMTALA form or documentation of risks and benefits of the transfer documented.

Please see A-2406 and A-2409

Based on review of facility policy, Medical Staff Bylaws and Rules and Regulations, medical record review and interviews, the facility failed to provide an appropriate and ongoing Medical Screening Examination for 1 patient (#8) who presented to the Emergency Department (ED) with behavioral and safety concerns of 21 medical records reviewed.

The findings include:

Review of the facility policy, "Patient Transfer Policy and Procedure (Interinstitutional)," revised 4/14/2023, showed "... No patient shall be transferred from [Facility A] to another facility before completion of an appropriate medical screening examination and stabilization treatment of an emergency medical condition..."

Review of the facility policy, "Patient Transfer Policy and Procedure (Interinstitutional), " revised 12/21/2023, states the definition of Emergency Medical Condition is defined as "... A medical condition which manifests itself by acute symptoms of sufficient severity (including pain, psychiatric disturbances, and or symptoms of substance abuse) such that the absence of immediate medical attention could ... reasonably be expected to result in: placing the patient's health in immediate jeopardy..."

Review of Medical Staff Rules and Regulations, revised 12/21/2023, showed "...The hospital accepts patients up to the age of 21 years suffering from most types of diseases requiring inpatient or outpatient hospital services..."

Medical record review for Patient #8 included a Nursing Triage Record dated 11/16/2024 at 12:10 AM, and showed the patient's vital signs were as follows: Temperature 97.4° (degrees) Fahrenheit; Pulse 120 [normal 60 to 100]; Respirations 20; Blood Pressure 112/86; and Pulse Oxygen 97%. The patient's Emergency Severity Index (ESI) score was 2, which indicated emergent needs.

Medical record review of the ED physician's record dated 11/16/2024 at 12:34 AM, showed Patient #8 was evaluated by the ED physician. The patient's heart rate was 120 beats per minute (tachycardia-an abnormally high rate). The ED physician documented Patient #8 had several episodes of aggressive and bizarre behavior in the ED.

There were no laboratory or imaging testing performed. No medication was administered. No medical workup was performed to evaluate the tachycardia or his change in behavior. The physician deemed Patient #8 to be in stable condition.

Discharge records showed that Patient #8 was discharged to the care of his mother on 11/16/2024 at 3:40 AM.

During an interview on 1/22/2025 at 9:20 AM, with the ED Medical Director, he stated the ED physician could not have given a thorough psychiatric assessment since the patient was autistic.

During an interview on 1/22/2025 at 12:59 PM, with the Chief Medical Officer, she stated she was notified of a possible EMTALA violation.

Based on review of facility policy, Medical Staff Bylaws Rules and Regulations, medical record review and interviews, the facility failed to provide an appropriate transfer, failed to inform the patient of the risks and benefits related to the transfer, and failed to provide an Emergency Medical Treatment and Labor Act (EMTALA) transfer certification for 1 patient (#8) who presented to the Emergency Department (ED) with behavioral and safety concerns of 21 medical records reviewed.

The findings include:

Review of the facility policy, "Patient Transfer Policy and Procedure (Interinstitutional)," revised 4/14/2023, showed "...No patient shall be transferred from [Facility A] to another facility before completion of an appropriate medical screening examination and stabilization treatment of an emergency medical condition..."

Review of the facility policy, "Patient Transfer Policy and Procedure (Interinstitutional)," revised 12/21/2023, showed the following documentation must be provided by the sending hospital "...(a) a chronology of events that have taken place; (b) measures taken or treatment implemented; (c) a description of the patient's response to treatment; (d) the results of measures that have been taken to prevent further deterioration. For those patients in an "emergency medical condition" or labor who are appropriately transferred, hospitals should document the transfer in a manner which indicates each of the following: a. the identity of the facility accepting patient; b. the availability of space and qualified personnel for treatment of the patient at the receiving facility; c. agreement by the receiving facility to accept the patient and to provide appropriate medical treatment; d. transmittal of appropriate medical records of the examination and treatment of the patient to the receiving facility; the means of transportation to the receiving facility including a description of qualified personnel, equipment, and medically appropriate life support measures to be used..."

Review of the facility's Medical Staff Rules and Regulations, revised on 12/21/2023, showed "...Discharge shall be in accordance with [Facility A] policies and EMTALA requirements..."

Medical record review for Patient #8 of an ED physician's note dated 11/16/2024, showed the physician documented he was told further psychiatric services could not be provided for the patient since Patient #8 was 18 years old. The physician noted it would be best for the patient to be seen in an adult facility and he discussed this patient's case with an ED physician, on staff at Facility B. The ED physician informed Facility B's ED provider Patient #8 would be coming to Facility B for evaluation.

Medical record review of the Discharge Disposition record showed Patient #8 was discharged in stable condition via private vehicle on 11/16/2024 at 3:40 AM, to his mother with a discharge diagnosis of Aggressive Behavior. The mother and patient were directed to Facility B.

Medical record review showed there was no EMTALA form or risks and benefits of the transfer documented in the medical record.

During an interview with the ED Medical Director on 1/22/2025 at 9:20 AM, he confirmed an EMTALA form was not completed. He stated the problem is not systemic but rather an issue with only one ED physician.

During a telephone interview on 1/22/2025 at 9:50 AM, with Physician #2, he stated it was a stupid mistake on his part and it wouldn't happen again.