HospitalInspections.org

Based on record review, interview, document review and policy review the Hospital failed to follow policy and ensure an appropriate medical screening examination (MSE) was performed for one of 13 patients (Patients 3) with a psychiatric condition, to determine whether an emergency medical condition (EMC) existed. Failure of the hospital to conduct an appropriate MSE for all patients who come to the Emergency Department (ED) seeking assistance, has the potential for all patients to be discharged with an unidentified EMC which causes delays in necessary stabilizing treatments, may lead to deterioration of the person's condition, and including death.


Findings Include:


Review of the Hospital's document titled, "Rules and Regulations of Medical Staff of McPherson Hospital, INC.," dated 10/2015, showed " 1) The hospital must provide an appropriate medical screening examination, to determine if an emergency medical condition exists, on all patients presenting to the emergency room. The following individuals have been determined to be qualified medical personnel to perform the medical screening examination: registered nurses assigned the responsibilities and duties of the emergency department and obstetrics, physician assistants who are members of the McPherson Hospital Allied Health Care Staff and McPherson Hospital staff physicians. MICT's [mobile intensive care technician] have been determined to be qualified to perform in the field in accordance with written protocols.


Review of the Hospital's policy titled, "EMTALA," dated 01/2000, showed "whenever an individual comes to McPherson Hospital's ED requesting an examination or treatment, the individual shall be screened without delay to determine whether an EMC exists" ...the patient shall be examined promptly ...the screening is to be recorded in the patient's medical records ...EMC which is defined under federal law as a medical, psychiatric ...condition ...expected to result in placing the health of the individual ...in serious jeopardy. "If, in the professional judgement of a physician, the patient's EMC has been stabilized" ..." the physician shall fully and clearly document the basis for this determination in the medical record."


Review of the Hospital's policy titled, "Plan of Care for the Emergency Department Patient," dated 05/2015, showed "every patient entering the ED will be triaged and priorities of care determined in accordance with physical and psychosocial needs" ... "All persons presenting to the ED requesting medical treatment will be registered as an ED patient. Everyone is entitled to a MSE."


Review of the Hospital's policy titled, "Psychiatric Patients," dated 09/2018, showed "all patients who presented to the ED demonstrating psychiatric disorders will be evaluated for appropriate treatment, referral, admission, or transfer" ... "The ED process for the patient undergoing psychiatric screening should be explained to the patient which includes clearance studies" ...process for psychiatric facility placement. "The ED physician will complete a MSE on the psychiatric patient to determine treatment. Medical clearance reflects short term medical stability and indicates that as far as it is possible know, there is not a medical cause for the patient's presenting psychiatric complaints" ... The ED physician will order ...psychiatric consult. When an inpatient psychiatric admission is necessary ..." the ED physician and nurse will work together to find an admitting hospital.


Review of the hospitals document titled, Hospital/CAH Database Worksheet" dated 07/12/21 showed the Hospital provided "Psychiatric - Emergency" services by arrangement or agreement.


Review of the Hospital's document titled, "Psychiatric Consultation Agreement Between [Facility AA] and McPherson Hospital," dated 01/07/16, showed Facility AA "shall render behavioral health services consisting of a psychiatric consultation."

Services rendered by Facility AA and reimbursable by McPherson Hospital for the psychiatric consultation may include but is not limited to one or any combination of the following:

-face to face contact with patient/client
-chart review
-collateral contact with staff such as but not limited to face to face, by phone, by email or -other electronic means
-collateral contact with patients/clients, family members or other person significantly invoiced with the patient/client. Such contact can include but it is not limited to face to face, by phone, by email or other electronic means.
-documentation
-collaboration with other professionals

...7. Facility AA and McPherson Hospital shall ensure that they will not discriminate in the
treatment or delivery of services based on race, color, national origin, sex, age, religion,
ancestry, marital status, sexual orientation, place of residence or health status.


Review of medical records showed the hospital failed to ensure an appropriate MSE including a mental health screening (MHS) was completed for one of the 13 patients (Patient 3) who presented to the emergency department (ED) with psychiatric concerns or suicidal ideation (SI). (Refer to tag 2406).

Based on record review, interview, document review and policy review the Hospital failed to ensure an appropriate medical screening examination (MSE), including a mental health screening (MHS) performed by a Qualified Mental Health Professional (QMHP) was completed for one of the 13 patients (Patient 3) who presented to the emergency department (ED) with psychiatric concerns or suicidal ideation (SI). The hospital's failure to ensure an appropriate MSE was completed has the potential for all patients to be discharged with an unidentified EMC which causes delays in necessary stabilizing treatment and may lead to deterioration of the person's condition, including harm and death.


Findings Include:


1. Review of Patient 3's medical record showed he presented to the ED on 07/11/21 at 1:05 AM, for suicidal ideation (SI). The medical record showed Patient 3, a15-year-old male who presents to the emergency department with mother at order of local police with concern for suicidal thoughts. Patient 3 had gotten into a fight with his father earlier that evening. Patient 3 then went online to a gaming platform and made statements that he wished he was not alive. A friend informed police, who visited the patients home. Patient 3 stated that he did not want to harm himself. A consult for a mental health screen was ordered at 1:31 AM. The medical record showed at 2:45 AM, "Patient was discussed with behavioral health team by nursing staff. We are instructed that they do not do screening. They will contact patient on Monday." The medical record showed Patient 3 had a prior history of suicidal ideation with hospitalization and history of suicide of a family member.

Review of the ED summary showed, "Pt states he has a lot going on at home. Pt calls it "overstimulating" his brain. Pt states he has thought about hurting himself "a little" but he has no plan to hurt himself. He feels mostly safe except when his father is angry. He states he has been threatened by his dad."

Review of a document from Facility AA titled, "Shift Reports Report" entered by a Facility AA, Licensed Masters Social Worker (LMSW) dated 07/11/21 at 2:42 AM, showed, the hospital requested a mental health screen or possible safety plan. The clinician contacted Staff R, Register Nurse (RN) who reported Patient 3 and parents did not wish to pursue inpatient treatment, but ED doctor did not feel that Patient 3 should discharge home. The report showed the clinician explained that Patient 3 a minor and that for him to be inpatient the parents would have to give consent and that he could not be sent involuntarily. The report showed Staff R, RN stated that he would let ED doctor know. The clinician provided crisis contact information to be given to parents if needed and requested contact information by fax for parents to follow up with, but the information was not provided.

Although the ED doctor did not feel Patient 3 should be discharged home as documented in Facility AA's report, Patient 3 was discharged to home on 07/11/21 at 3:03 AM. Patient 3 was given instructions that the behavioral health team would follow up with him, and to return to the ED if symptoms persist. He was provided the crisis hotline
number and the note showed Patient 3 contracted a safety plan with the physician. There was no documented safety plan in the medical record.

The hospital failed to ensure Patient 3 received an appropriate MSE that was sufficient to determine that Patient 3 was safe from self-harm. There was no documented evidence in the record to show why the behavioral health team did not perform a mental health exam and there was no documented evidence Patient 3, or his parent refused consent for a mental health exam.

During an interview on 10/28/21 at 1:24 PM, Staff R, Registered Nurse (RN) stated that he called Facility AA (a community mental health center) and they refused to do a mental health screen for Patient 3. Staff R stated that he remembered Facility AA saying they would contact the patient to set up an appointment to see a counselor on Monday. Staff R stated that he notified the physician and they determined Patient 3 would be okay to see the Counselor on Monday and would be safe under his mothers watch.

During an interview on 07/13/21 at 12:46 PM, Staff B, RN ED Director stated that psychiatric screenings that involve involuntary admission, uninsured, or pediatric patients; are referred to Facility AA for screening, and placement. All other patients, voluntary, and insured; are at the physician's discretion. Facility AA will do a screening with patients on video. If the ED physician does the screening, they are responsible for finding placement, there is a list of facilities available in the state at the nurse's station. If placement cannot be obtained for a patient, they will hold them in the ED until the physician can determine that the patient is no longer in crisis, or if there is a medical reason the patient could be admitted to the hospital. If the patient, MD, and RN determine the patient is safe to go home; a safety plan will be documented in the discharge instructions, provide resources in the community, if the patient has a mental health provider, a follow-up appointment is made, and the patient is instructed to return to the ED if needed.


During an interview on 08/06/21 at 3:45 PM, Staff C, MD, ED Medical Director, stated that mental health screenings are done by the ED provider or Facility AA. When asked how they determine whether a mental health screen will be completed by the ED provider or Facility AA, she stated that they have a flow chart (algorithm) that they follow, based on the patients age, if they are going to be a voluntary/involuntary admission and where they will be admitted. She stated that the hospital does not have a certain protocol or procedure for mental health screening and that the provider would document mental health concerns in the History of Present Illness (HPI) or physical exam
section of the medical record. Things that would be documented include, behavior, irrational thoughts, and sleep patterns. She stated that the mental health screen would absolutely be a part of the medical screening exam MSE for patients who present with mental health concerns.

During an interview on 08/10/21 at 11:18 AM, Facility AA's, Access Services staff stated that if Facility AA didn't do a mental health screen for patients presenting to the hospital ED with mental health concerns, the ED physician would be responsible for assessing the patient. He stated that they would refuse to do a screen if it wasn't warranted and there was no justification to do a screen. He stated that if a physician is wanting another opinion, and has already determined the patient is depressed, anxious or suicidal, they would not do the screen, however they would work with the hospital to find inpatient placement if needed or set up a same day out patient appointment for the patient.

Review of the Hospital's document titled, "Psychiatric Consultation Agreement Between [Facility AA] and McPherson Hospital," showed that it did not specify criteria, such as, involuntary admission, uninsured or pediatric patients as a requirement to do a mental health consults/screening.