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Based on policy review, medical record review and interview, the facility failed to provide an appropriate medical screening examination (MSE) for two of 20 (Patient #1 and #15) sampled patients and failed to appropriately transfer two of 10 (Patient #6 and #10) sampled patients requiring a higher level of care, out of 20 total patients.

The findings included:

1. Medical record review revealed Patient #1 was a 13 year old male who presented to Hospital #1's ED on 7/18/2024 at 1:57 PM with chief complaint of medication overdose.

A MSE was initiated at Hospital #1's ED on 7/18/2024 at 1:58 PM by ED Physician #2. ED Physician #2 documented Patient #1 presented with an intentional overdose of Focalin (used to treat Attention Deficit/Hyperactivity Disorder). Patient #1 was given an Emergency Severity Index (ESI) rating of "3". (ESI of 3 designates these patients could potentially progress to having a serious problem requiring emergency intervention. An ESI of 2 would designate a patient needed rapid intervention due to possible loss of life).

Vital signs were obtained at 1:57 PM with the following: Heart rate 115.

Poison Control was contacted at 2:35 PM with recommendations to monitor the patient for 16 hours from time of last ingestion for stomach upset, tremors, tachycardia (elevated heart rate) and hypertension.

Review of 7/18/2024 Hospital #1's "DEPART DOCUMENTATION" revealed Patient #1 left with his Mother, Against Medical Advice (AMA) at 5:43 PM.

There was no documentation Patient #1 was screened for suicide risk after presenting with an intentional overdose of medication. There was no documentation the hospital attempted to obtain a psychiatric evaluation for Patient #1. Patient #1 was given an ESI designation of "3" after a possible suicide attempt. The MSE was not complete or appropriate.

2. Medical record review revealed Patient #15 was a 32-year-old male who presented to Hospital #1's ED on 3/10/2024 at 3:37 PM with chief complaint of audible hallucinations.

A MSE was initiated at Hospital #1's ED on 3/10/2024 at 4:18 PM by ED Physician #2. ED Physician #2 documented Patient #15 presented to Hospital #1's ED with a psychiatric problem. Symptoms were documented as hearing voices for 4 days.

Vital signs were obtained at 5:01 PM with the following: Heart rate 108, Blood pressure 209/181.

Hospital #1's Laboratory (lab) testing for Patient #15 was obtained on 3/10/2024 that included a urine drug screen with results at 5:15 PM were positive for cocaine. The blood alcohol level results at 5:45 PM were 62 milligrams/deciliter (mg/dl) (normal is 0 - 10. Clinical signs and symptoms for a blood alcohol level from 50-100 mg/dl include euphoria, sedation, impaired coordination, decreased sensory responses to stimuli, and decreased judgment).

The MSE "Impression and Plan" on 3/10/2024 revealed Auditory hallucinations, Cocaine use and Alcohol use.

Review of 3/10/2024 Hospital #1's ED "DEPART DOCUMENTATION" revealed Patient #15 discharged home with family at 8:40 PM via private vehicle.

In an interview on 7/31/2024 at 9:40 AM, the Director of Quality at Hospital #1 verified a blood pressure of 209/181 should have been monitored and rechecked.

There was no documentation Patient #15's blood pressure was addressed by ED Physician #2 at Hospital #1 on 3/10/2024 at 5:01 PM when the result was 209/181. There was no documentation Patient #15's blood pressure was rechecked after 5:01 PM and before discharge at 8:40 PM to determine if the blood pressure was still elevated and in need of further monitoring and treatment. There was no documentation Hospital #1 performed a suicide screening for Patient #15. There was no documentation Patient #15 was evaluated by a Psychiatrist. The MSE was not complete or appropriate for a patient presenting with new onset of hallucinations and with elevated blood pressure .

Cross Refer to C2406

3. Medical record review revealed Patient #6 was a 24-year-old female who presented to Hospital #1's ED on 6/5/2024 at 12:35 PM via private vehicle. A triage assessment beginning on 6/5/2024 at 12:45 PM documented the chief complaint for Patient #6 was suicidal and homicidal ideations.

A MSE was initiated on 6/5/2024 at 1:38 PM by ED Physician #1 at Hospital #1 with documentation that revealed Patient #6 presented to Hospital #1 with suicidal ideation, depression and anxiety. Hospital #1's ED Physician #1 documented Patient #6 had been at work where she became very anxious and paranoid and felt the need to drive her vehicle into a tree.

Hospital #1's ED Physician #1 documented the Impression and Plan on 6/5/2024 for Patient #6 was "Depression with suicidal ideation... Condition "stable". Disposition documented was "Medically cleared, Transfer to: Facility name: [named psychiatric facility]...Accepted by: [named physician]". ED Physician #1 signed the document on 6/5/2024 at 5:40 PM.

Hospital #1 allowed Patient #6 to be transported to a higher level of care (psychiatric inpatient facility) with a family member, instead of being transported by a qualified, trained professional.

4. Medical record review revealed Patient #10 was a 10-year-old male who presented to Hospital #1's ED on 5/2/2024 at 4:08 PM via private vehicle. A triage assessment beginning on 5/2/2024 at 4:35 PM documented the chief complaint of Patient #10 was wanting to stab himself in the heart.

A MSE was initiated on 5/2/2024 at 4:50 PM by Hospital #1's ED Physician #2 with documentation that revealed Patient #10 presented with suicidal ideation, history of multiple ED visits and history of thoughts of hurting himself that began at age 5.

Review of "Depart Documentation" dated 5/3/2024 for Patient #10 revealed, "Reason for Transfer: Medically indicated transfer ...Transfer Requirements Met: Patient has received a medical screening, Patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary appropriate life support measures...Hand Off Details: PT. DISCHARGED WITH MOTHER TO BE TRANSFERRED VIA POV [PRIVATE OWNED VEHICLE] TO [NAMED FACILITY]. PT'S MOTHER VOICED VERBAL UNDERSTANDING OF DISCHARGE AND PAPERWORK GIVEN TO MOTHER...Patient Left ED: 05/03/24 05:30 [5:30 AM]..."

Hospital #1 allowed Patient #10 to be transported to a higher level of care (psychiatric inpatient facility) with a family member, instead of a qualified, trained professional.

Cross Refer to C2409

Based on policy review, medical record review and interview, the facility failed to provide a complete and appropriate medical screening exam (MSE) for two of 20 (Patient #1 and #15) sampled patients who presented to the facility's Emergency Department (ED) seeking medical care.

The findings included:

1. Review of the facility's "EMTALA [The Emergency Medical Treatment and Labor Act]-Medical Screening Examinations" policy (6/21/22) revealed, "...All individuals presenting to a Hospital Emergency Department ("ED") or other Hospital property requesting examination or treatment are entitled to receive an appropriate Medical Screening Examination...For individuals who are determined to have an Emergency Medical Condition, the Hospital will provide, within its capabilities, the individual with such further medical examination and treatment as required to stabilize his/her Emergency Medical Condition ..."

2. Review of the facility's "Emergency Department Standards of Care" policy (2024) related to vital signs revealed, "... Abnormal VS [vital signs]- minimum every 2 hours x 4 hours, then every 4 hours (when stable)...Discharged Pt [patient] Requirements...Current- within 30 minutes of discharge ..."

3. Medical record review revealed Patient #1 was a 13 year old male who presented to Hospital #1's ED on 7/18/2024 at 1:57 PM with chief complaint of medication overdose.

A triage assessment was initiated at 1:57 PM with vital signs as follows: Heart rate 115. ESI was documented as "3".

A MSE was initiated at Hospital #1's ED on 7/18/2024 at 1:58 PM by ED Physician #2. ED Physician #2 documented Patient #1 presented with an intentional overdose of Focalin (used to treat Attention Deficit/Hyperactivity Disorder). ED Physician #2 documented the ingestion was not suicide and Patient #1 had no prior episodes of overdose. Patient #1 informed the ED Physician he got mad at his parents for questioning if he had taken his Focalin so he took 4 additional tablets. Differential Diagnosis was documented as Intentional overdose, suicide attempt, suicide gesture, anger reaction.

Poison Control was contacted at 2:35 PM with recommendations to monitor the patient for 16 hours from time of last ingestion for stomach upset, tremors, tachycardia (elevated heart rate) and hypertension.

A nursing note on 7/18/2024 at 2:45 PM revealed "no psych [psychiatric] concerns".

Hospital #1's ED Physician #2 documented "Impression and Plan" for Patient #1 on 7/18/2024 as Deliberate medication overdose.

Review of Hospital #1's 7/18/2024 "DEPART DOCUMENTATION" revealed Patient #1 left with his Mother, Against Medical Advice (AMA) at 5:43 PM.

In an interview on 7/31/2024 at 9:20 AM, ED Physician #2 verified Poison Control was contacted. Also stated they had plans to have (named behavioral health assessment group) talk with the patient, but the patient left with his Mother AMA before that could be done.

There was no documentation Patient #1 was screened for suicide risk upon presenting with an intentional overdose of medication. There was no documentation the hospital attempted to obtain a psychiatric evaluation for Patient #1. Patient #1 was given a lower ESI designation of "3" after a possible suicide attempt. There was no documentation Patient #1's Mother was informed of Poison Control's recommendation to monitor patient for 16 hours. Patient #1 did not receive a complete or appropriate MSE.

4. Medical record review revealed Patient #15 was a 32-year-old male who presented to Hospital #1's ED on 3/10/2024 at 3:37 PM with chief complaint of audible hallucinations.

A triage assessment was initiated at 3:56 PM with vital signs as follows:
Heart rate 116,
Blood Pressure (BP) 159/101.
ESI was documented as "3".

A MSE was initiated on 3/10/2024 at 4:18 PM by Hospital #1's ED Physician #2. ED Physician #2 documented Patient #15 presented to the ED with a psychiatric problem that began 4 days ago. The symptoms were reported to fluctuate in intensity. The character of symptoms was hearing voices. Hospital #1's ED Physician #2 documented on the Physical Examination Patient #15 was alert and oriented to person, place, time and situation with no focal neurological deficit observed and was cooperative with appropriate mood and affect. Hospital #1's ED Physician #2 signed the MSE on 3/10/2024 at 8:31 PM.

Patient #15's Vital signs were obtained at 5:01 PM as follows:
Heart rate 108,
Blood pressure (BP) 209/181.

Laboratory (lab) testing for Patient #15 was obtained. At 5:15 PM the urine drug screen results were positive for cocaine (normal result would be negative) and at 5:45 PM the blood alcohol level results were 62 milligrams/deciliter (mg/dl) (normal range 0-10; clinical signs and symptoms for a blood alcohol level from 50-100 mg/dl include euphoria, sedation, impaired coordination, decreased sensory responses to stimuli, and decreased judgment).

Hospital #1's ED Physician #2 documented "Impression and Plan" for Patient #15 on 3/10/2024 Auditory hallucinations, cocaine use and alcohol use. Hospital #1's ED Physician #2 documented under "Calls-Consults" on 3/10/2024, "[named mobile crisis center]...they are going to dispatch someone". Hospital #1's ED Physician #2 signed the document on 3/10/2024 at 8:31 PM.

Hospital #1's ED Physician #2 documented on 3/10/2024 "Plan" for Patient #15 was condition stable, disposition would be to home and Patient would follow up with primary care physician.

Review of Hospital #1's ED "DEPART DOCUMENTATION" revealed Patient #15 was discharged home with family at 8:40 PM on 3/10/2024 via private vehicle. There was no documentation Patient #15's BP of 209/181 had been rechecked prior to discharge.

In an interview on 7/31/2024 at 9:40 AM, Hospital #1's Director of Quality verified a blood pressure of 209/181 should be monitored and rechecked.

In an email correspondence on 8/1/2024 at 4:34 PM, Hospital #1's Clinical Manager and ED Physician #2 verified a blood pressure of 209/181 should be addressed.

There was no documentation Patient #15's blood pressure was addressed by Hospital #1's ED Physician #2 on 3/10/2024 at 5:01 PM when the result was 209/181. There was no documentation Patient #15's blood pressure was rechecked after 5:01 PM and before discharge at 8:40 PM to determine if the blood pressure was still elevated and in need of further monitoring and treatment. There was no documentation Patient #15 was evaluated by a Psychiatrist due to new onset of hallucinations. The MSE was not complete or appropriate for Patient #15.

Based on policy review, medical record review and interview, the facility failed to appropriately transfer patients requiring a higher level of care for two of 10 (Patient #6 and Patient #10) sampled patients requiring a higher level of care, out of 20 total patients reviewed.

The findings included:

1. Review of the facility's "EMTALA [The Emergency Medical Treatment and Labor Act], Stabilization and Transfer" policy (11/14/19) revealed, " ...Patient transfers will be performed according to procedures and within the guidelines of EMTALA ...Transfer Procedures-Stable and Unstable Patients ...Arrange for Transfer: When the Receiving Facility has agreed to accept the transfer, ED personnel will: a. arrange for qualified transfer personnel and transportation equipment, including the use of necessary and appropriate life support measures during transfer; and b. continue providing the patient with medical treatment within the ED's capability to minimize the risks to the patient's health ...pending and during the transfer ...The ED physician, in consultation with any appropriate specialist physicians, will determine the appropriate mode of transport, equipment needed and care providers (such as physicians, nurses, respiratory therapists, or other non-physician personnel) to accompany the patient to the Receiving Facility ...Transfer Documentation: a. Acute Care Transfer Form: For any patient care transfer involving a potentially emergent condition, each section of the Acute Care Transfer Form must be completed to document that the Hospital followed both its policies and procedures and the requirements of EMTALA ..."

2. Medical record review revealed Patient #6 was a 24-year-old female who presented to the Emergency Department (ED) at Hospital #1 on 6/5/2024 at 12:35 PM via private vehicle.

A triage assessment beginning on 6/5/2024 at 12:45 PM documented the chief complaint for Patient #6 was suicidal and homicidal ideations. Further triage assessment revealed Patient #6 stated her Mother was sick and her fiancé left her. Patient #6 stated she had thoughts of harming her fiancé and ramming her car into something to kill herself. Patient #6's affect and behavior was documented as "crying" and distress was "mild". Patient #6's Suicide Risk Assessment was "High Risk".

A Medical Screening Exam (MSE) was initiated on 6/5/2024 at 1:38 PM by Hospital #1's ED Physician #1 with documentation that revealed Patient #6 presented with suicidal ideation, depression and anxiety. ED Physician #1 documented Patient #6 had been at work where she became very anxious and paranoid and felt the need to drive her vehicle into a tree. Patient #6 informed Hospital #1's ED Physician #1 she had had thoughts of suicide since she was 14 years old. ED Physician #1 documented the character of the symptoms as "depressed, anxious, paranoid, suicidal thoughts and nightmares of someone trying to kill her baby". The degree of symptoms were documented as "moderate". The Relieving factors were documented as "none". The Physical examination revealed the patient as "Cooperative, normal judgment, Mood and affect: Anxious, depressed, tearful, Abnormal/Psychotic thoughts: Suicidal".

Hospital #1's ED Physician #1 documented the Impression and Plan for Patient #6 on 6/5/2024 as "Depression with suicidal ideation". Patient #1's disposition was documented as "Medically cleared, Transfer to: Facility name: [named psychiatric facility] at [named neighboring county], Accepted by: [named physician]". ED Physician #1 signed the document on 6/5/2024 at 5:40 PM.

Hospital #1's ED notes on 6/5/2024 at 5:56 PM revealed "called [Staff Member #1 from Mental Health Clinic #1] who is now on-call for [Staff Member #2 from Mental Health Clinic #1]. [Family Member #1 (cousin)] - cousin is here to transport patient to [Mental Health Clinic #1] but we were told the brother was [going to transport Patient #6 to Mental Health Clinic #1]. Needing to get approval from [named mobile crisis facility] that [Family Member #1] can transport patient to [named psychiatric facility] ...5:59 PM [Family Member #1] is on the safety list [list from mobile crisis facility of individuals who can transport Patient #6] for [named mobile crisis facility] to transport patient to [Mental Health Clinic #1] when room is available".

Review of 6/5/2024 "Discharge Transfer" notes beginning at 6:07 PM revealed, "Discharged to: Psychiatric facility... [Hospital #1's] ED Transferred to ...Psychiatric Facility: [Mental Health Clinic #1]".

Review of ED "Details of Transfer" notes beginning on 6/5/2024 at 6:08 PM revealed, "pt [patient] left ED with cousin who is taking pt to [Mental Health Clinic #1] and was approved by MD [Medical Doctor] and [named mobile crisis facility]." Hospital #1's ED Physician #1 signed the documentation on 6/5/2024 at 5:41 PM. There was no documentation from [named mobile crisis facility] that they approved the transfer of Patient #6 to Mental Health Clinic #1 by Family Member #1.

Further record review revealed there no documentation a "Transfer For Acute Care Services" form was completed for Patient #6 to transfer to an inpatient psychiatric facility on 6/5/2024.

In an email correspondence interview on 8/7/2024 at 3:10 PM, Hospital #1's Director of Quality stated Patient #6 was discharged from the ED and taken to (Mental Health Clinic #1) via private vehicle, therefore no Acute Care Transfer Form was completed. Hospital #1's Director of Quality stated the mobile crisis counselor coordinated the transition from the sending facility to the receiving facility and provided the receiving facility with the appropriate clinical documents.

Patient #6 was discharged from Hospital #1 on 6/5/2024 at 6:06 PM. Patient #6 had diagnoses of Suicidal Ideation and Homicidal Ideation and needed a higher level of care not available at Hospital #1. Hospital #1 allowed Patient #6 who was at High Risk for homicidal ideations with moderate degree of symptoms to be transported to a higher level of care (Mental Health Clinic #1) with a family member, instead of being transported by a qualified, trained professional.

3. Medical record review revealed Patient #10 was a 10-year-old male who presented to the ED at Hospital #1 accompanied by his mother on 5/2/2024 at 4:08 PM via private vehicle.

A triage assessment began at 4:35 PM and documented the chief complaint as Patient #10 wanted to stab himself in the heart with a knife or scissors. Further triage assessment revealed Patient #10 was brought to the ED by his Mother who stated they were sent by (named counseling center). The Mother stated Patient #10 had been having suicidal thoughts for two days prior and voiced wanting to stab himself during his counseling visit on 5/2/2024. Patient #10's suicide risk assessment was "high risk".

A MSE was initiated on 5/2/24 at 4:50 PM by Hospital #1's ED Physician #2 with documentation that revealed Patient #10 presented with suicidal ideation, history of multiple ED visits and history of thoughts of hurting himself that began at age 5. Hospital #1's ED Physician #2 documented Patient #10 saw (named counseling center) that day (5/2/2024).

Review of 5/2/2024 Hospital #1's ED nursing notes at 8:08 PM revealed Patient #10 was being evaluated by (named mobile crisis facility). The Nursing notes dated 5/2/2024 at 10:16 PM revealed mobile crisis was looking for placement (inpatient treatment) for Patient #10.

A Psychiatric physical exam documented on 5/2/2024 revealed Patient #10 as "Cooperative, Abnormal/Psychotic thoughts: Suicidal". Hospital #1's ED Physician #2 documented medical decision making rationale on 5/2/2024 as "admission indicated ...transfer for a higher level of care". ED Physician #2 signed the document on 5/2/2024 at 11:26 PM.

Review of Hospital #1's ED "Depart Documentation" dated 5/3/2024 revealed, "Reason for Transfer: Medically indicated transfer ...Transfer Requirements Met: Patient has received a medical screening, Patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary appropriate life support measures... Mode of Transfer: Private vehicle ...Discharged to: Psychiatric facility ...Patient Left [Hospital #1's] ED: 05/03/24 05:30 [5:30 AM] ...Discharge Transportation: Private vehicle/car seat ...ED Transferred to ...Transfer to Psychiatric Facility: [named psychiatric facility] ...Hand Off Details: PT. DISCHARGED WITH MOTHER TO BE TRANSFERRED VIA POV [PRIVATE OWNED VEHICLE] TO [NAMED PSYCHIATRIC FACILITY]. PT'S MOTHER VOICED VERBAL UNDERSTANDING OF DISCHARGE AND PAPERWORK GIVEN TO MOTHER...Patient Left ED: 05/03/24 05:30 [5:30 AM]..."

Review of "TRANSFER FOR ACUTE CARE SERVICES" form revealed Patient #10 was transported by "POV" with his Mother accompanying him. Patient #10's diagnosis was documented as "SI" (suicidal ideation). Patient #10 departed Hospital #1 on 5/3/24 at 5:30 AM.

In an interview on 7/31/24 at 9:20 AM, Hospital #1's ED Physician #2 stated psychiatric patients needing transfer were usually transported by Emergency Medical Services or the Sheriff's Department.

In an interview on 7/31/24 at 9:25 AM, Hospital #1's Director of Quality stated sometimes pediatric patients would be transported by a parent if the parent was "a good one". The Director of Quality verified Patient #10 was a transfer.

Patient #10 was discharged from Hospital #1 on 5/3/24. Patient #10 was a 10 year old with diagnosis of Suicidal Ideation and needed a higher level of care not available at Hospital #1. Hospital #1 allowed Patient #10 to be transported to a higher level of care (psychiatric inpatient facility) with a family member, instead of a qualified, trained professional.