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Based on a review of Emergency Department (ED) documents, ED logs, Medical Records, policies and procedures, and interviews, the facility failed to ensure that two patients (#7 and #9) out of 25 emergency department (ED) records reviewed received a complete medical screening exam (MSE), in order to determine whether or not an emergency medical/psychiatric condition (EMC) existed. The facility failed to ensure compliance with 42 CFR 489.24. Please refer to citation at A-2406.

Based on interview, record review, and policy review, the facility failed to ensure a complete Medical Screening Examination (MSE) within the facility's capacity and capabilities to determine if an Emergency Medical Condition (EMC) existed for two patients (#7 and #9) out of 25 Emergency Department (ED) patient records reviewed. This had the potential to affect all patients who presented to the ED. The ED average daily census was 165, the average monthly census was 4959, and the total transfers for the past six months were 389. The facility census was 181.

Findings included:

1. Record review of the facility's policy titled, "Examination, Treatment, and Transfer of Patients with Emergency Medical Conditions," dated 05/21/14, showed the following:
- The ED offered an appropriate MSE to any individual that requested treatment to determine if an emergency medical condition exists, and shall provide treatment within its' capability to stabilize any individual who is determined to have an EMC.
- Medical screening and treatment of an individual determined to have an EMC was provided by Qualified Medical Personnel (QMP).
- QMPs designated to complete an MSE were physicians, qualified advanced practice registered nurses (APRN), and qualified mental health nurses.
- An EMC included a psychiatric disturbance (mental or behavioral disorder), suicidal or homicidal thoughts or gestures or symptoms of substance abuse that places the individual in a condition where they may cause harm to self or others.

2. Record review of a Case Report by a police department showed:
- On 05/07/15 at 12:00 PM Police responded to a call from a psychiatrist at his office. Police were informed that an 18 year old patient (#9) had displayed aggressive behavior by throwing a chair and attempting to jump out of a car.
- On arrival, office staff advised the police that the psychiatrist had completed a 96-hour hold (affidavit, a legal document to support the need for an involuntary admission of a person, not to exceed 96 hours) on Patient #9.
- A police officer transported the patient to the ED and the psychiatrist's affidavit (96 hour) paperwork was handed over to the facility.

3. Record review of Patient #9's medical record showed the following:
- The patient presented to the ED on 05/07/15 at 1:02 PM. There was no documentation that the patient arrived to the ED by a police officer and with an affidavit.
- Staff K, Triage Nurse, documented that the patient was admitted to the ED for a psychiatric evaluation and checked a box on the form that the patient had not been previously seen by a psychiatrist.
- Staff I, APRN, checked a box on a form that indicated the patient arrived by private vehicle. The mother brought the patient in for evaluation stating that he was threatening to her at home, physically and verbally, and the patient was denying her report.
- Staff J, ED Nurse, documented that the patient was brought to the ED for agitation and reports of throwing things at his mother and that he was non-compliant with his medication. The patient denied having any mental health problems, and stated that his mother was very controlling and trying to get guardianship over him because he had some medical problems. The patient reported that he had asthma (a chronic lung disease that inflames and narrows the airways), short gut syndrome (a malabsorption disorder caused by a birth defect or surgical removal of the small intestine), a chiari malformation (a birth defect in the cerebellum that can affect balance and coordination). He reported that he had been staying with a friend and his mother refused to give him medication to take there.
- Staff L, MHNL, documented that the patient was seen by an outpatient psychiatrist on the same date (05/07/15) and per an affidavit the patient "threw a chair at his mother and tried to get out of a moving car." The patient's appearance was disheveled, he had depressive symptoms, and severe stressors. The patient stated that his mother was lying, over exaggerating and trying to get guardianship over him. He admitted to some depression following his father's death but denied suicidal or homicidal thoughts. There was no affidavit present in the medical record and no documentation was found of the mother's specific concerns.
- A laboratory report showed a positive drug screen for cannabinoids (chemicals found in cannabis/marijuana).
- The Staff I, APRN, documented in the Emergency Room Report that she consulted with the on-call psychiatrist (Staff M) who recommended discharge and the patient was discharged on 05/07/15 at 2:16 PM (one hour and 14 minutes from admission to discharge).

During an interview on 05/27/15 at 1:30 PM, Staff K, Triage Nurse, stated that:
- A police officer escorted Patient #9 to the ED in handcuffs, he removed the handcuffs and informed them that the patient was there for a mental health screening.
- Staff K triaged (obtained information from the patient for decision-making) and moved him to an ED room in an area known as Psychiatric Emergency Section (PES).

During an interview on 05/29/15 at 4:40 PM, Staff L, MHNL, stated that:
- She reviewed the affidavit with the on-call psychiatrist (Staff M) and told him of the mother's concerns.
- The patient did not meet admission criteria and he was discharged with a referral to the outpatient psychiatrist for follow-up.
- She had no record that she communicated the information with the psychiatrist and stated that details of her mental health screening and her contact with the physician were not well documented.
- She did not know the patient was brought in by the police.
- Affidavits were usually scanned into the Electronic Medical Record (EMR) by the secretary before she (MHNL) saw patients. When she completed the screening evaluation, she disposed of the affidavit assuming it was already scanned and in the EMR. There was no other copy found.

During an interview on 05/28/15 at 8:50 AM, Staff M, Psychiatrist, stated that:
- He was the on-call psychiatrist on 05/07/15.
- He received information about a patient from the MHNL. He recalled that the patient was deemed not suicidal or homicidal and was discharged.
- He did not recall that he received any information of an affidavit completed by a psychiatrist.
- He usually admitted patient with affidavits.

During an interview on 05/27/15 at 11:40 AM, Staff I, APRN, stated that on 05/07/15:
- Patient #9 came to the emergency room for a MSE.
- The patient reported that he was brought in against his wishes and his mother had mal-intentions and was trying to seek guardianship over him.
- Staff L, MHNL, stated that the patient was not in need of admission and the MHNL had consulted with the on-call psychiatrist.
- Based on her own assessment, information from the triage (assessment), the ED nurse, the MHNL and the psychiatrist, the patient was discharged with no homicidal or suicidal ideations.
- She did not know the patient was seen by an outpatient psychiatrist immediately prior to the ED visit.
- She did not know that the patient was brought to the ED by the police, and had an affidavit completed by the outpatient psychiatrist. She was concerned and would have reviewed the affidavit if she had known there was one.

4. Record review of Patient #7's medical record showed that an 11 year old patient (#7) presented to the ED on 05/08/15 at 5:22 PM. The patient's grandmother was listed as her guardian.

Record review of a document titled, "Application for 96 Hour Imminent Harm Admission to a Mental Health or Alcohol and Drug Abuse Facility", dated 05/08/15, showed that Patient #7 had been having extreme mood changes with anger, violent acts, and threatened to break her grandmother's neck. A doctor stated the patient was in a manic state (an abnormally elevated mood) and stopped her new medication. The document was signed by the Deputy Sheriff and notarized.

Record review of the document titled, "Affidavit in Support of Application for Detention, Evaluation, and Treatment/Rehabilitation - Admission for 96 Hours," dated 05/08/15, showed the following:
- Patient #7 had extreme mood changes and had threatened to break her grandmother's neck.
- She had inappropriate outbursts at school, had risky behaviors, and on a field trip she placed herself in a position to be physically injured.
- On 05/08/15, after she arrived home from school she became very angry, refused to follow directions, fought with her grandmother, and ran into the highway.
- The grandmother was very concerned that the patient would end up hurting herself or the risky behaviors will cause her to get hurt.
- The document was signed by the Deputy Sheriff and notarized.

Record review of Patient #7's Emergency Room Report documented by Staff Q, APRN, showed the following:
- The APRN initiated the report on 05/08/15 at 6:07 PM.
- The patient arrived by police escort who stated that someone made fun of the patient today and that upset her. Today she had an argument with her grandmother and tried to choke her, she became increasingly more violent, and ran into traffic trying to elude police. The police officer stated the patient started taking Ziprasidone (an antipsychotic medication used to treat disorders of thought and mood) two days ago and was abruptly stopped today.
- The course and duration of symptoms was worsening and the character of symptoms was agitated. Risk factors consisted of a long history of agitated behaviors.
- She was cooperative, anxious, conversive, and answered all questions willingly.
- A bed was secured at the psychiatric adolescent facility with a plan to be admitted the next day, 05/09/15.
- The patient was discharged to the grandmother who agreed to provide transportation to the facility the next day. Until then, the patient was able to return to the ED for any concerns. The grandmother agreed with the plan and had no questions.
- The patient was discharged on 05/08/15 at 8:54 PM to home with grandmother who would observe her until she was admitted to the psychiatric facility. The bed was being held for the patient's admission.

During an interview on 05/28/15 at 1:05 PM, Staff G, ED Medical Director, stated that:
- MSE's were completed by a physician or advanced practice nurse.
- A MHNL conducted mental health screening evaluations, when indicated.
- The MHNL completed the screening evaluation, consulted with the on-call Psychiatrist by telephone, and the MHNL communicated their determination to the Physician or Advanced Practice Registered Nurse (APRN).
- A patient that arrived with an affidavit or an application for imminent harm may or may not be admitted dependent upon their evaluation.
- When questioned how he was assured that the information contained in an affidavit or other legal documents was conveyed to the psychiatrist, he responded, that it occurred through the MHNL. He further stated that the ED physicians do not usually see the documents.
- When questioned who can negate (nullify, cause to be ineffective) an application for imminent harm, he responded, the psychiatrist only could make that decision.

During a telephone interview on 05/28/15 at 10:10 AM, Staff Q, APRN, stated the following:
- Patient #7 was brought to the facility by the police. The police completed an affidavit that included her agitated behaviors and that she ran out in traffic.
- Upon arrival the patient was agitated, very upset and argumentative with her grandmother. The patient had a history of verbal and physical aggression towards her grandmother for about the last six months and the grandmother was concerned that she was taken off her medication.
- She completed the MSE and determined that the patient was not suicidal or homicidal.
- The MHNL met with the patient and was aware that admission at a psychiatric facility was sought but there were problems locating a bed.
- She did not know if the MHNL had discussed the patient with the on-call psychiatrist, and did not know that Staff N, on-call psychiatrist, recommended transfer to an acute care facility.
- A medical professional had the right to determine if transfer to acute care was necessary and it clearly was not necessary.
- She discussed discharge plans with the grandmother; the grandmother felt comfortable taking her home and would take the patient to the facility the next day. The grandmother knew she could bring her back if there were any problems.
- The grandmother was the guardian and had the right to make decisions for further care.

During an interview on 05/28/15 at 9:15 AM, Staff N, Psychiatrist, reviewed the medical record for Patient #7 and stated that:
- He was the on-call psychiatrist on 05/08/15.
- He recalled that he received information from the MHNL about Patient #7, discussion about an affidavit, and the need for her to be transferred to a children's facility.
- He was not notified that in addition to an affidavit the record contained an Application for Imminent Harm completed by a deputy sheriff, and if known he would not have discharged the patient.
- If a pediatric patient was deemed harmful they were transferred to an acute care psychiatric facility.
- The record documented that the patient was deemed safe for discharge, and he stated that he did not deem her safe for discharge.
- He did not know that the patient was discharged home and she should have been transferred.
- If there were problems with securing a bed he should have been notified and he would have arranged for her to go to the facility's pediatric unit to await transfer.
- No one contacted him about this.

Record review of Patient #7's Psychiatric Emergency Services Assessment, documented by Staff L, MHNL, showed the following:
- The MHNL initiated the assessment on 05/08/15 at 6:01 PM
- Prior to admission, the patient displayed extreme mood changes, threatened to break her grandmother's neck and ran out after a car.
- Behaviors in the ED included anxiety/panic.
- She was deemed safe to go home and the grandmother would transport the patient to (specifically named psychiatric facility) in the morning.
- Staff N, on call Psychiatrist, was consulted.
- There was no reference to the Deputy Sheriff's application or affidavit in the document.

During a telephone interview on 05/28/15 at 4:50 PM, Staff L, MHNL, stated the following:
- Patient #7 had poor insight and behavior problems.
- She contacted Staff N, the on-call psychiatrist, about information contained in the patient's affidavit and application for imminent harm.
- Her grandmother, the patient's guardian, wanted her to go to a specifically named acute care facility.
- Staff Q, APRN, tried to secure a bed but they did not have one until the next morning.
- The grandmother did not want to stay overnight and wait until the next morning for transfer.
- Her observation's of the patient's behavior in the ED was calm and without problems.
- She was not concerned about the patient's behavior as documented in the affidavit because since she had calmed while in the ED.
- The APRN thought it was okay to discharge the patient since the grandmother agreed and was supportive of the plan to go home overnight and the grandmother would take her to the psychiatric facility the next day.
- She contacted Staff N, on-call Psychiatrist, a second time about the delay in securing a bed, her calm behavior in the ED, and he agreed to let her go home with grandmother overnight.
- She did not document the two separate calls to the on-call psychiatrist in the medical record.

During an interview on 05/27/15 a 10:20 AM Staff P, Mental Health Unit (MHU) Team Leader, stated the following:
- She oversaw the inpatient MHU and the PES in the ED.
- Physicians and APRNs perform the medical part of the MSE and alerted the MHNL, as indicated when a patient presents with psychiatric issues.
- The MHNL conducts the mental health screening evaluation in the PES.
- MHNL are nurses from the MHU that have passed specialized psychiatric competencies (education and training), and they were considered to be a QMP.
- After the MHNL completed the screening she contacted the on-call psychiatrist and all information was relayed to the doctor including presence of an affidavit, 96 hour hold applications, or any court orders.
- A face-to-face evaluation by the psychiatrist was conducted if it was requested by the MNHL or if the patient requested.
-The ED physician or APRN could also request a face-to-face if they were concerned about the psychiatrist's decision, needed clarification of the decision, when changes occurred in the patient status, or when the patient's behavior changed after the last contact and decision by the psychiatrist.
- Her expectation was for the MHNL to communicate to the psychiatrist how the patient arrived and with whom, and if there was an affidavit and if there was any 96 hour hold paperwork in place.
- The presence or absence of an affidavit was documented in the mental health section of the medical record. The MHNL had the ability to document this information in the EMR.
- When a decision was made that a minor needed inpatient admission, and there were no beds available at the time for transfer, the facility would admit the patient to the Pediatric Unit and provide a sitter (one-to-one supervision) until a bed became available.