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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

A-2406: Applicability of Provisions of this Section (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph (b) of this section, the hospital must-(i) Provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. Based on interviews and document review, the facility failed to provide an appropriate medical screening exam (MSE) to determine whether or not an emergency medical condition (EMC) existed as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to determine whether or not a medical EMC existed and utilize ancillary services routinely available within the emergency department (ED) to determine whether or not a psychiatric EMC existed for one of one patients reviewed who presented to the ED five times in a 48 hour period with psychiatric concerns. (Patient #14)

Based on interviews and document review, the facility failed to provide an appropriate medical screening exam (MSE) to determine whether or not an emergency medical condition (EMC) existed as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to determine whether or not a medical EMC existed and utilize ancillary services routinely available within the emergency department (ED) to determine whether or not a psychiatric EMC existed for one of one patients reviewed who presented to the ED five times in a 48 hour period with psychiatric concerns. (Patient #14)

Findings include:

Facility policies:

The Emergency Medical Treatment and Labor Act (EMTALA) policy read the purpose of the policy is to ensure the facility complies with the requirements of EMTALA and the regulations implementing EMTALA. It is the policy of the Hospital that it shall provide an MSE by a physician or other QMP to any individual who comes to the ED to determine if the individual has an EMC. Individuals who arrive at the ED and request an examination or treatment for any medical condition shall be given an MSE by a physician or qualified medical professional (QMP). An MSE is the screening process required to determine with reasonable clinical confidence whether an EMC exists. It is not appropriate to merely "log in" or "triage" an individual and not provide an MSE. The purpose of the MSE is to determine whether an EMC exists. The MSE shall be documented in the medical record.

The Medical Screening Exam policy read an MSE will be provided to determine whether a patient has an EMC as legally defined by EMTALA. Any individual who presents or representative who presents on behalf of an individual to the ED will be provided an appropriate MSE within the capabilities of the ED including ancillary testing and services which are routinely available to the ED to determine whether or not an EMC exists. In performing the MSE the emergency department physician (EDP), nurse practitioner (NP), physician assistant (PA) or other physician on medical staff member will provide an evaluation that permits them to decide based on clinical judgment whether further evaluation and treatment are necessary for stabilization, admission is necessary because the patient's condition appears to be medically unstable or, the patient may be safely referred for outpatient follow-up. The MSE must contain the following elements: ED record and log entry into medical record system, patient vital signs, oral history, focused physical exam of affected system, physical exam of potentially affected systems or known chronic conditions, vital signs at the time of discharge or transfer, any ancillary testing necessary and performed to rule out the presence of an EMC, use of call-in personnel to complete the above as needed, and use of call-in physicians to diagnose and/or stabilize patients as needed. An individual is considered stable for discharge when, within reasonable clinical confidence, the treating physician or QMP determines that the individual has reached the point where his or her continued care, including diagnostic work-up and/or treatment, can be reasonably performed as an outpatient or later as an Inpatient. In such cases, the individual shall be given a plan for appropriate follow-up care as part of the discharge instructions.

The Management of Psychiatric Patients in the ED policy read all patients who present with symptoms of psychiatric disturbances or substance abuse will receive a MSE. An MSE is required for all patients prior to admission, discharge, or transfer to assure that no EMC exists.

The Psychiatric Evaluation Team (PET) policy read, the PET provides mental health evaluations for patients at the facility. PET interventions include assistance with drug use cessation, discussion of drug treatment options, and assistance with the management of behavioral crisis situations. A PET consult is initiated by a physician/licensed practitioner (LP). All PET assessments are done by a PET staff member unless the request is specific for a psychiatrist. PET assessments are for patients presenting with alcohol and/or drug abuse, suicidal/homicidal ideation/intent/grave disability, acute psychiatric issues related to medical diagnosis, psychiatric non-compliance issues, chronic mental illness, patient mental status and competency, evaluation, and monitoring of psychiatric medication, and evaluation and determination of the need for initiation or termination of a psychiatric hold for patients. All PET documentation is located in the "notes" section of patient medical records.

Reference:

The Medical Staff Clinical Rules read, a satisfactory consultation includes examination of the patient and the record. The attending Practitioner or Advanced Practice Registered Nurse (APRN) is responsible for supplying the consultant with all available and relevant information regarding the patient and the need for the consultation. The consultant's opinion must be entered into the patient's electronic record by the consultant. All medical screening examinations shall be performed by Qualified Medical Personnel in a manner consistent with the System EMTALA Policy. All medical screening examinations of psychiatric or chemical dependency patients shall be supervised by a Physician and conducted by mental health personnel.

1. The facility failed to ensure Patient #14 was provided an MSE to determine whether or not an EMC existed.

A. Document and medical record review revealed Patient #14 did not receive an MSE after she presented to the ED on 4/13/23.

i. Facility documents and medical record review revealed on 4/13/23 at 9:41 p.m., Patient #14 was transported by ambulance to the ED. According to the triage data entered at 9:45 p.m., Patient #14 reported she believed someone at the homeless shelter she stayed at had drugged her. Additionally, the triage data revealed Patient #14 claimed she had been raped while at the shelter and she felt unsafe there.

According to a nursing note on 4/14/23 at 5:01 a.m., Patient #14 was found outside looking in vehicle windows. At 5:03 a.m., two minutes after the nursing note was entered, Patient #14 was documented as being discharged to home or self-care.

Upon request, the facility was unable to provide evidence of an MSE performed by a QMP to rule out an EMC, ED provider notes, ED provider medical decision making, the patient's ED course, review of the patient history and present illness, a physical exam, any ancillary procedures and labs performed for the patient, ED disposition, EDP authorization to discharge the patient, vital signs performed prior to the patient being discharged, an after visit summary, and patient discharge instructions.

This was in contrast to the EMTALA and Medical Screening Exam policies which read, MSEs must contain the following documentation in the medical record by the EDP: the patient's history, EDP's physical exam, in addition to focused exams, review of the patients chronic medical condition, and ancillary testing necessary and performed to rule out the presence of an EMC. The policy further read that a patient would be discharged after the EDP determined the patient was stable and discharge instructions were provided to the patient. Additionally, the policy read that merely logging a patient in and performing only a patient triage did not constitute an MSE and would not be considered as an MSE.

B. Interviews with staff revealed there was no evidence of an MSE was performed for Patient #14 on 4/13/23.

i. On 8/10/23 at 12:31 p.m., an interview was conducted with Physician #1. Physician #1 stated every patient who presented to the ED was expected to receive an MSE. Physician #1 stated the MSE would be performed by a physician, NP, or PA. Physician #1 stated MSEs were documented in the ED Provider note. Physician #1 stated he was unable to locate an ED provider note for Patient #14 on 4/13/23.

Physician #1 stated EDPs performed MSEs to determine if an emergent medical condition (EMC) existed for the patient. Physician #1 stated EMCs were detrimental and could cause irreparable and irreversible harm to the patient when not conducted.

ii. On 8/9/23 at 12:20 p.m., an interview was conducted with director of quality (Director) #3. Director #3 stated all patients who presented to the ED were provided MSEs. Director #3 stated the MSE would be located in the "provider notes" section of the patient's medical record. Director #3 stated she was unable to locate evidence of an MSE and an ED provider note for Patient #14's ED visit on 4/13/23. Director #3 was unable to provide an explanation for why the MSE had not been performed.

2. The facility failed to utilize ancillary services available within the emergency department (ED) to determine whether or not a psychiatric EMC existed. Specifically, a psychiatric evaluation was not performed for Patient #14 to determine if Patient #14 had a psychiatric emergent medical condition (EMC).

A. A review of Patient #14's medical record revealed psychiatric ancillary services (mental health and behavioral health services) were not utilized to determine if Patient #14 had a psychiatric emergent medical condition (EMC) when she presented to the ED with active psychiatric and behavioral symptoms on five separate occasions within a 48 hour period (from 4/13/23 through 4/15/23). Examples included:

i. Review of the ambulance report sheet on 4/13/23 at 9:09 p.m. revealed paramedics were dispatched to a parking lot to assess and assist Patient #14. According to the ambulance report sheet Assessment Exam and Narrative, paramedics arrived at a parking lot where Patient #14 appeared to be experiencing a mental health crisis.

EMS transported Patient #14 to the ED and at 9:41 p.m., Patient #14 presented to the ED. A review of the triage data revealed at 9:45 p.m., Patient #14 disclosed she had stopped taking her psychiatric medication.

Upon further review of Patient #14's ED visit on 4/13/23, there was no evidence Patient #14 was seen or evaluated for a psychiatric EMC.

ii. On 4/15/23 at 10:41 a.m., Patient #14 was transported to the ED by ambulance. According to the ambulance report sheet Assessment Exam and Narrative, Patient #14 was experiencing a mental health crisis and Patient #14 did not have active medical or trauma related signs or symptoms. Further review of the ambulance report sheet revealed Patient #14 thought she had poison on her hands after retrieving clothing out of a donation box.

Review of the ED Provider Notes on 4/15/23 at 11:22 a.m. revealed Patient #14 had a psychiatric history and was bipolar (a mental illness that causes changes in a person's mood, energy, and ability to function). According to the note, Patient #14 was not taking her prescribed psychiatric medication which included lithium (a mood-stabilizing medication that treats psychotic symptoms, such as hallucinations or delusions) and Abilify (antipsychotic medication used to manage psychosis). Additionally, a new prescription for Abilify was provided to the patient during this visit. Patient #14 was then documented as discharged to home/self care at 11:44 a.m.

Further review of Patient #14's medical record revealed a psychiatric evaluation team (PET) evaluation was ordered for the patient, however, there was no evidence a PET evaluation was conducted.

iii. On 4/15/23 at 1:33 p.m., paramedics were dispatched to a thrift store to assist Patient #14. A review of the ambulance report sheet revealed when paramedics arrived Patient #14 was lying on the ground in front of the thrift store and informed paramedics she had been poisoned by the air vents in the store. According to the narrative in the ambulance report, Patient #14 appeared to be experiencing psychiatric related symptoms. At 1:53 p.m., Patient #14 was transported by ambulance to the ED.

According to the ED Provider Notes entered at 2:13 p.m., Patient #14 had repeatedly presented to the ED concerned about being poisoned. The ED Provider Notes read Patient #14 requested to speak with a psychiatric social worker (PET staff member) as she was concerned she had been sexually assaulted. Additionally, the patient had lost the Abilify prescription she had been provided at her prior ED visit.

Upon further review of Patient #14's ED visit, there was no evidence a PET staff member had met with the patient before she was discharged from the ED at 3:22 p.m.

iv. At 4:03 p.m., paramedics were dispatched to a public library where Patient #14 was seated on a bench awaiting their arrival. According to the ambulance report sheet Patient #14 appeared to be experiencing a mental health crisis and believed she had been poisoned. Patient #14 informed paramedics she had stopped taking her psychiatric medication and she also believed her fiance had enlisted random people to assist him in poisoning her.

Patient #14 arrived by ambulance to the ED at 4:22 p.m. According to the ED Provider Note at 4:44 p.m., Patient #14 was experiencing signs and symptoms of paranoia which were related to her psychiatric disease. Additionally, Physician #1 requested a member of the psychiatric evaluation team (PET) to evaluate Patient #14 as he had determined Patient #14 was medically stable.

Review of the Mental Health Counselor note at 5:12 p.m. revealed Patient #14 was unable to independently utilize outpatient mental health resources due to Patient #14's continual belief she was being poisoned. The Mental Health Counselor note further read outpatient housing and transportation services were contacted to assist Patient #14, and a staff member from the outpatient service "arrived and took" Patient #14. At 5:18 p.m., six minutes after the note was entered, Patient #14 was discharged. There was no evidence of an evaluation of Patient #14 as requested by Physician #1 to rule out a psychiatric EMC.

During an interview with licensed professional counselor (LPC) #2 on 8/9/23 at 4:26 p.m., LPC #2 stated Patient #14 was unable to readily access clinical mental health resources or services and frequently presented to the ED with paranoid delusions. LPC #2 verified that a PET evaluation was not performed for Patient #14 during this ED visit.

v. At 8:57 p.m., three hours and 35 minutes after Patient #14 was discharged from the ED for the fourth time, Patient #14 was transported back to the ED by ambulance. The ambulance report sheet read, Patient #14 "believed she had a razor blade in her calf", however, Patient #14 refused to have her calf assessed by paramedics.

According to the nursing note entered at 11:13 p.m., Patient #14 accused ED staff of poisoning her. At 11:25 p.m., Patient #14 became combative and verbally abusive with staff and informed staff she wanted to leave. The nursing note further read that staff was unable to redirect or calm Patient #14 down and nine minutes later, at 11:34 p.m., Patient #14 was discharged as left without being seen (LWBS) from the ED. There was no evidence in the medical record of the patient being assessed for a psychiatric medical emergency prior to allowing the patient to leave without being seen.

These examples were in contrast to the Management of Psychiatric Patients in the ED and the PET policy which read the PET team would provide mental health evaluations for patients which include evaluation and assistance for psychiatric patients and the management of psychiatric crises. Additionally, the policy read ancillary services including consultations and evaluations which were routinely available to the ED were performed based on the patient's presenting signs and symptoms to determine whether the patient had an EMC.

B. Interviews with staff revealed psychiatric patients seen in the ED were not provided consistent psychiatric medical screening examinations. Specifically, psychiatric ancillary services routinely available in the ED were not utilized to determine if psychiatric patients were experiencing an emergent psychiatric condition.

i. On 8/10/2023 at 8:44 a.m., an interview was conducted with licensed clinical social worker (LCSW) #4. LCSW #4 stated psychiatric evaluation team (PET) evaluations were documented as a Behavioral Health Assessment note in the medical record. LCSW #4 stated the PET staff performed PET evaluations for patients who presented to the ED with psychiatric symptoms to ensure the patient was not experiencing a psychiatric crisis. LCSW #4 stated PET evaluations contained the reason for the evaluation, the patient's psychiatric history, the patient's suicide risk, a mental status exam, the clinical impression of the patient, behavioral health recommendations, and recommended disposition for the patient.

LCSW #4 stated not every psychiatric patient who presented to the ED needed a PET evaluation, however, LCSW #4 stated psychiatric patients who repeatedly presented to the ED on the same day should have been evaluated. LCSW #4 stated psychiatric patients repeatedly presenting to the ED needed to be evaluated to ensure the patient was not experiencing a psychiatric crisis. LCSW #4 stated patients experiencing a psychiatric crisis were unable to care for themselves regardless of the resources available to them which could result in harm to the patient.

ii. On 8/9/23 at 4:26 p.m., an interview was conducted with LPC #2. LPC #2 stated as a member of the PET team she performed psychiatric evaluations on patients. LPC #2 stated a psychiatric evaluation was performed to ensure patients who presented to the ED were not actively experiencing a psychiatric crisis.

LPC #2 stated she had spoken to Patient #14 multiple times on 4/15/23. LPC #2 stated a PET evaluation had been ordered for Patient #14, however, she had not performed a PET evaluation on the patient. LPC #2 stated EDPs were able to order a PET evaluation, but it was up to the discretion of the PET team member whether or not a PET evaluation was needed and would be performed for a patient.

LPC #2 stated Patient #14 had presented to the ED five separate times within a 48 hour period. LPC #2 stated she did not think Patient #14 needed a PET evaluation on 4/15/23. LPC #2 stated psychiatric patients who repeatedly present to the ED multiple times in a day could indicate the patient's psychiatric condition was worsening. LPC #2 further stated she would have performed a PET evaluation on Patient #14 on 4/15/23 during the fifth ED visit had the patient not been allowed to leave the ED without being seen.

iii. On 8/10/23 at 12:46 p.m., an interview was conducted with Physician #1. Physician #1 stated behavioral health staff provided ED physicians with additional information about a patient's psychiatric condition and stability. Physician #1 further stated behavioral health staff assistance occurred at the discretion of the ED Physician. Physician #1 stated he cared for Patient #14 on 4/15/23 during her ED visit at 4:22 p.m. Physician #1 stated Patient #14 had presented with psychiatric and medical concerns. Physician #1 stated he had medically cleared Patient #14 and verbally requested LPC #2 to speak with the patient. Physician #1 stated he had not requested a psychiatric evaluation for Patient #14 as he had determined the patient was not at risk of harming herself. Physician #1 stated unless psychiatric patients posed a danger to themselves or others or an emergent medical condition was present, the patient was considered stable and could be discharged.