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Based on interviews and facility documentation, the facility failed to document and maintain a log for one of one patients reviewed, (Patient #1) who came to the facility emergency department (known as an admissions department at this psychiatric hospital) for an assessment.

Findings included:

Interview on 04/17/2024 with facility Director of Performance Improvement revealed that Patient #1 is not listed on the facility admissions department log.

Interview on 04/21/2024 with Patient #1's mother revealed but was not limited to the following information: Patient #1's mother stated that she had finally obtained an appointment (02/29/2024) at a private psychiatrist's office for her son (Patient #1). She drove him to the appointment and was told by a psychiatric nurse practitioner that he needed to be evaluated for possible inpatient admission due to his current level of mania associated with his bipolar diagnosis. The nurse practitioner gave her the option of calling an ambulance to take him to the facility for the evaluation or driving him there. She chose to drive him to the facility. The nurse practitioner told her she would call the facility and the police to meet them at the facility. It is noted that this surveyor attempted to confirm this with the nurse practitioner and she did not respond to the email asking her if she did contact the facility regarding Patient #1 coming there for an evaluation.

Patient #1's mother stated that when they arrived at the facility, no one knew they were coming for an assessment to determine if he needed inpatient treatment. She stated Patient #1 was given paperwork to complete prior to being assessed. She stated that "almost as soon as they got to the facility, Patient #1 "regretted coming for the evaluation and began freaking out". She stated a young woman in blue scrubs came and told them they would evaluate him but he would have to wait for a bed if it was determined that he needed inpatient admission. She also told Patient #1's mother that in order to get him to stay, he would need a "police escort" referring to an emergency detention. Patient #1's mother stated that emergency detention by the police was not explained to her at this facility.

She and Patient #1 left this facility and drove to another facility (acute care hospital) emergency room where he was evaluated and it was determined that he would benefit from inpatient admission to a psychiatric hospital but he refused to stay. The police were called but they would not instigate an emergency detention to force him to stay for inpatient admission as they did not think he was suicidal or homicidal.

Interview on 04/17/2024 with the facility assistant director of admissions revealed but was not limited to the following: She stated that when a person walks in needing an assessment, the front desk staff give them a "lobby sheet" to complete and they come into the waiting area to complete the "lobby sheet". Once they completed the "lobby sheet", the front desk staff email the admissions staff that the patient is ready for an assessment. She stated that if the patient leaves before completing the paperwork, he is listed on the admissions log as Jane or John Doe.

Review of Admissions Log for 02/29/2024 did not reveal a John Doe listed on this date.
In addition, the review of the Admissions Log from 10/17/2023 to 04/17/2024 did not reveal anyone listed as a Jane or John Doe.

Review of facility EMTALA training summary: What you need to know: revealed but was not limited to the following: The EMTALA log is a legal document we are required to update and keep accurate. Every person in the department is responsible for updating the EMTALA log. Triage is ultimately responsible for making sure the EMTALA log is complete and accurate at the end of a shift.