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Based on interview and record review the facility failed to follow their internal policies regarding provision of a medical screening examination (MSE) for one (Patient #27) of 26 records reviewed, eight of which were patients with closed head trauma/injuries, that presented to the emergency department (ED) requesting treatment or presenting on hospital property requesting medical care or a reasonable person would think needed emergency care.

The facility also failed to provide comprehensive, specific guidance in their MSE policy regarding psychiatric patient consults and method of transfer for those considered at risk for suicide for one (Patient #21) of 26 records reviewed, five of which were patients with psychiatric issues, that presented to the ED requesting treatment. The ED had an average daily census of 80. The facility census was 66.

These failure have the potential to affect all patients presenting to the ED or persons on hospital property requesting emergency medical care. Failure to provide an MSE or psychiatric evaluation/transport could delay further treatment/examination or result in patient deterioration/injury.

Findings included:

1. Review of the facility's policy titled, "EMTALA (Emergency Medical Treatment and Active Labor Act), Anti-Dumping Compliance of Emergency Department and Hospital Patient Transfers to Another Facility," undated, showed the following:
- An appropriate MSE will be provided by qualified personnel when an individual presents to the ED and requests examination or treatment for a medical condition.
- A screening is provided to determine if an emergency medical condition (EMC) exists and is within the scope of the hospital's capabilities.
- If any individual comes to the hospital (locations other than the ED) and the hospital determines that he/she has an EMC, the hospital must provide further examination and treatment required to stabilize the EMC.
- An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity (including psychiatric disturbances) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy.
- The ED must utilize routinely available ancillary services to conduct the MSE.
- An appropriate mode of transfer is selected along with personnel and equipment to provide any needed treatment for the condition or foreseeable complication.

2. Review of the facility's policy titled, "Medical Screening Exams-Emergency Department," undated, showed MSE's should include necessary testing to rule out an EMC, a physical examination of affected systems and potential affected systems.

3. Review of the facility's internal investigation, dated 02/24/14, regarding Patient #27, showed the following:
- Hospital A's operator called Staff I, Security, on 02/20/14 because a man (Patient #27) was found lying in their parking lot. Staff I responded to the scene and had the Call Center call 911.
- The County Ambulance District ambulance (SCCAD) responded and called Hospital A's ED and spoke with Staff K, ED Physician.
- Staff K authorized a transfer to Hospital B without conducting an MSE.

4. Review of security department daily activity report documentation, dated 02/20/14, showed Staff I, Security, received a radio call from the hospital operator about a man falling (Patient #27) in lot two. Staff I found a man on the ground and had the Call Center call 911. The report revealed Patient #27 was incoherent.

5. During an interview on 03/25/14 at 9:40 AM, Staff H, ED triage RN, stated that anyone presenting to the hospital's campus was considered to be on property and bound by EMTALA regulations.

6. During an interview on 03/25/14 at 9:50 AM, Staff A, Chief Nursing Officer, stated "Patient #27 was found in the parking lot (not the parking lot just outside the ED, but around the corner). The ambulance crew (SCCAD) told the ED physician (Staff K) that the patient had a potential head injury and since we (Hospital A) did not have neurology capabilities, the patient was sent to Hospital B, without an MSE."

7. During interviews on 03/25/14 at 10:57 AM, and on 03/26/14 at 10:36 AM, Staff B, Risk Manager, stated that Staff K admitted failure to do an MSE on Patient #27.

8. During an interview on 03/25/14 at 12:54 PM, Staff D, ED Manager, stated that Physician K told Staff B a patient fell in the parking lot. Physician K stated that he would have been happy to see Patient #27, but he felt he had to follow SCCAD's protocol related to head injury and blood thinners (if patient on blood thinners, take to trauma center). Since no history could be obtained from the patient, SCCAD wanted to take Patient #27 to Hospital B.

9. During an interview on 03/25/14 at 1:53 PM, Staff I, Security, stated that at about 5:30 PM on 02/20/14, he received a report of a man falling in the parking lot. Staff I responded to the scene and found a man on the ground. Staff I called the hospital operator to notify 911. No information could be gleamed (just gibberish) from Patient #27. The SCCAD crew arrived at the parking lot.

10. During an interview on 03/28/14 at 10:25 AM, Staff Q, SCCAD medic, stated the following:
- He arrived at Hospital A's parking lot, responding to a 911 call, at approximately 5:50 PM.
- He found Patient #27 lying on the pavement, behind a vehicle, and "we" (the ambulance crew) did not know how long he (the patient) had been lying there.
- The patient was very combative, asked repetitive questions, could not answer questions appropriately, had no identification, medication/allergy information, or history.
- Staff Q spoke with the ED physician, Staff K.
- Staff Q told Staff K the patient's vital signs and assessment, explained combativeness and situation, and asked for guidance, knowing the patient was in the ED parking lot.
- Staff Q told Staff K that he realized they were on his ED property and needed his (Staff K's) guidance, but personally felt the patient should go to a trauma center (Hospital B).
- Staff K told Staff Q to do what he thought was best, so the patient was taken to Hospital B for evaluation. (Staff K failed to follow the facility's policy regarding MSE).

11. During an interview on 03/26/14 at 8:37 AM, Staff K, ED Physician, stated that SCCAD crew, Staff Q, told him that a gentlemen in the parking lot appeared to have fallen, was not oriented and could give no history. So, not knowing about blood thinner potential with head injury, Staff Q wanted to take the patient to Hospital B. Staff Q said, "We realize we are on your property." Staff K asked about vital signs, but did not recall anything about other injuries. Hospital B was approximately ten miles away from Hospital A. Staff K confirmed this ED had the capacity and capability to treat the patient at the time of the call.

12. Review of the facility's policy titled, "Evaluation and Disposition of Psychiatric Patients in the Emergency Department," undated, showed all patients presenting in a state of emotional instability will be examined by a physician and every effort will be made to assist the patient in securing appropriate medical and psychological assistance. If the patient does not have a private psychiatrist and needs further care, referral may be made through Hospital C (a psychiatric hospital).

13. Review of Patient #21's ED record showed the following:
- The patient presented on 12/12/13 at 11:59 AM related to depression.
- Triage notes showed the patient said she was "severely depressed, worsened past 1 week, has had a lot of stress, feels hopeless, told mom she was feeling suicidal, went to work last night, still hopeless."
- The patient's history included depression, hopelessness and tearfulness for the past month. She was becoming increasingly depressed and tearful and had thoughts of overdosing on her medication yesterday (12/11/13). She was not sleeping well (a typical symptom of depression).
-The MSE, performed by Staff M, Physician Assistant, showed the patient was tearful and depressed.
- Nursing assessment showed the patient had alterations in her mood, behavior, sleeping patterns, and anxiety. The patient had insomnia and excessive worry. The patient had increased depression over the last year (showed an ongoing issue).
- The patient's discharge instructions showed the patient was seen because of thoughts of hurting herself.
- The patient was discharged at 3:04 PM, to travel by private vehicle to Hospital C for evaluation.
- There was no evidence Patient #21 ever arrived at Hospital C.
- There was no evidence a psychiatric consult/screen was conducted, prior to the patient's discharge.
- The patient could not be monitored for safety while transported via private vehicle.

14. During an interview on 03/25/14 at 3:47 PM, Staff J, ED Charge Nurse, stated that psychiatric patients were seen by the ED physician and the ED physician can consult with a Psychiatrist or Case Manager if desired. This hospital ED could utilize Behavioral Health Resources (BHR-intake staff consists of social workers) for back-up on admissions assistance. Hospital C, a psychiatric hospital, was on-call and available for consult by telephone. Patients could also be sent to Hospital C's emergency intake area for assessment.

15. During an interview on 03/26/14 at 8:37 AM, Staff K, ED Physician, stated that the ED physicians could use Hospital C for psychiatric evaluation/consult. If Hospital C was not utilized, the ED physicians do the psychiatric screening. If a patient was sent to Hospital C for evaluation by private vehicle, Hospital A never verified arrival of the patient. Staff K typically used the patient's history of suicide attempts, plan and method to implement plan as a guide of actual suicidal ideations and whether he would admit or ask for a consult.

16. During an interview on 03/26/14 at 10:20 AM, Staff D, ED Manager, stated that they utilized BHR, Social Workers and Case Managers for consult on psychiatric patients. The ED physician assesses and determines safety and admission or transfer. Staff D stated Patient #21 should have been sent via ambulance to Hospital C.

17. During an interview on 03/26/14 at 11:00 AM, Staff G, ED Medical Director, stated that transportation method of a psychiatric patient depended on the reliability of the family member transporting, and a contract for safety. It was the clinical judgment of the ED physician.

18. During an interview on 03/31/14 at 2:07 PM, Staff M, Physician Assistant at Hospital A, stated the following:
- She assessed Patient #21 and called Hospital C's intake personnel (not psychiatrists or psychologists, but nurses and social workers) for consult. Hospital C told her that it sounded like this patient could be a candidate for outpatient treatment, but the patient needed to be evaluated in their intake area.
- The policies and procedures for psychiatric consult and transport in Hospital A's ED were not real clear.
- It was unclear (within Hospital A) as to which service to use and/or when (BHR or Hospital C) on psychiatric patients at risk for suicide.
- Staff M stated that she acted consistently with hospital protocol/training; however, Hospital A was unable to produce a specific policy/procedure for how to evaluate/screen, transport, and/or refer suicidal patients to BHR or Hospital C.

Based on observation, interview, peer review and record review the facility failed to conduct as appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) was present for two (Patients #27, and #21) of 26 patients reviewed that presented to the ED for medical care or presented on hospital property requesting emergency care or a reasonable person believed the person needed emergency care.

The ED had an average daily census of 80.

These failure have the potential to affect all patients presenting to the ED or persons on hospital property requesting emergency medical care. Failure to provide an MSE or psychiatric evaluation/transport could delay further treatment/examination or result in patient deterioration/injury.

Findings included:

1. Review of the facility's policy titled, "EMTALA (Emergency Medical Treatment and Active Labor Act), Anti-Dumping Compliance of Emergency Department and Hospital Patient Transfers to Another Facility," undated, showed the following:
- An appropriate MSE will be provided by qualified personnel when an individual presents to the ED, (and locations other than the ED on hospital property) and requests examination or treatment for a medical condition.
- A screening is provided to determine if an emergency medical condition (EMC) exists and is within the scope of the hospital's capabilities.
- The ED must utilize routinely available ancillary services to conduct the MSE.

2. Review of the facility's policy titled, "Medical Screening Exams-Emergency Department," undated, showed MSE's should include necessary testing to rule out an EMC, a physical examination of affected systems and potential affected systems.

3. Review of the facility's internal investigation, dated 02/24/14, regarding Patient #27, showed the following:
- Hospital A's operator called Staff I, Security, on 02/20/14 because a man (Patient #27) was found lying in their parking lot. Staff I responded to the scene and had the operator call 911.
- The County Ambulance District ambulance (SCCAD) responded, assessed the patient, and called Hospital A's ED and spoke with Staff K, ED Physician. Staff K authorized a transfer to Hospital B without conducting an MSE.

4. Review of security department daily activity report documentation, dated 02/20/14, showed Staff I, received a radio call from the hospital operator about a man falling (Patient #27) in lot two. Staff I found a man on the ground and had the Call Center call 911. The report revealed Patient #27 was incoherent.

5. During an interview on 03/25/14 at 9:40 AM, Staff H, ED triage RN, stated that anyone presenting to the hospital's campus was considered to be on property and bound by EMTALA regulations.

6. During an interview and concurrent observation on 03/25/14 at 9:50 AM, Staff A, Chief Nursing Officer, stated that "Patient #27 was found in the parking lot (not the parking lot just outside the ED, but around the corner). Observation of the parking lot, just outside the ED entrance, showed Patient #27 would not have been visualized from the ED entrance. SCCAD told the ED physician (Staff K) that the patient had a potential head injury and since we (Hospital A) did not have neurology capabilities, the patient was sent to Hospital B, without an MSE."

7. During interviews on 03/25/14 at 10:57 AM, and on 03/26/14 at 10:36 AM, Staff B, Risk Manager, stated that Staff K admitted failure to do an MSE.

8. During an interview on 03/25/14 at 12:54 PM, Staff D, ED Manager, stated Physician K stated he would have been happy to see Patient #27, but he felt he had to follow SCCAD's protocol related to head injury and blood thinners (if patient on blood thinners, take to trauma center). Since no history could be obtained from the patient, SCCAD wanted to take Patient #27 to Hospital B.

9. During an interview on 03/25/14 at 1:53 PM, Staff I, Security, stated that at about 5:30 PM on 02/20/14, he received a report of a man falling in the parking lot. Staff I responded to the scene and found a man on the ground. Staff I called the hospital operator to notify 911. No information could be gleamed (just gibberish) from Patient #27. The SCCAD crew arrived at the parking lot.

10. During an interview on 03/28/14 at 10:25 AM, Staff Q, SCCAD medic, stated the following:
- He arrived at Hospital A's parking lot, responding to a 911 call, at approximately 5:50 PM.
- He found Patient #27 lying on the pavement, behind a vehicle, and "we" (the ambulance crew) did not know how long the patient had been lying there, or if he had been hit by the vehicle.
- The patient was very combative, asked repetitive questions, could not answer questions appropriately, had no identification, medication/allergy information, or history.
-The patient was extremely intoxicated and resisted the backboard.
- Staff Q called the ED nurse and asked to speak to the ED physician, Staff K.
- Staff Q told Staff K the patient's vital signs and assessment, explained combativeness and situation, and asked for guidance, knowing the patient was in the ED parking lot.
-Staff K asked him, "What do you think?" twice while conversing.
- Staff Q told Staff K that he realized they were on his ED property and needed his (Staff K's) guidance, but personally felt the patient should go to a trauma center (Hospital B).
- Staff K told Staff Q to do what he thought was best, so the patient was taken to Hospital B for evaluation.

11. During an interview on 03/26/14 at 8:37 AM, Staff K, ED Physician, stated that Staff Q, told him that a gentlemen in the parking lot appeared to have fallen, was not oriented and could give no history. So, not knowing about blood thinner potential with head injury, SCCAD crew wanted to take the patient to Hospital B. Staff Q told him, "We realize we are on your property." Staff K asked about vital signs, but did not recall anything about other injuries. Hospital B was approximately ten miles away from Hospital A. Staff K confirmed this ED had the capacity and capability to treat the patient at the time of the call. Staff K authorized transfer of Patient #27 without doing an MSE.

12. Patient # 27 went to Hospital B, received an MSE, was stabilized and released.

Review of the physician peer review for Patient # 21, dated 4/25/14, revealed the:
-ED was contacted by EMS (emergency medical personal-ambulance) regarding a patient found on property reportedly with altered mental status, concern for intoxication and potential head injury.
- The patient left the property without being evaluated by either an emergency department physician or nurse.
-An MSE was not performed delaying the medical screening evaluation for an inappropriate amount of time.
-Based on the EMS report it appeared the patient had an EMC.
-The ED had available space and resources needed to evaluate and stabilize the patient prior to transport.
-The receiving hospital was not contacted by the ED prior to transport.

13. Review of the facility's policy titled, "Evaluation and Disposition of Psychiatric Patients in the Emergency Department," undated, showed all patients presenting in a state of emotional instability will be examined by a physician and every effort will be made to assist the patient in securing appropriate medical and psychological assistance. If the patient does not have a private psychiatrist and needs further care, referral may be made through Hospital C (a psychiatric hospital).

14. Review of Patient #21's ED record showed the following:
- The patient presented on 12/12/13 at 11:59 AM related to depression.
- Triage notes showed the patient said she was "Severely depressed, worsened past 1 week, has had a lot of stress, feels hopeless, told mom she was feeling suicidal, went to work last night, still hopeless. "
- The patient's history included depression, hopelessness and tearfulness for the past month. She was becoming increasingly depressed and tearful and had thoughts of overdosing on her medication yesterday (12/11/13). She was not sleeping well (a typical symptom of depression).
-The MSE, performed by Staff M, Physician Assistant, showed the patient was tearful and depressed.
- Nursing assessment showed the patient had alterations in her mood, behavior, sleeping patterns, and anxiety. The patient had insomnia and excessive worry. The patient had increased depression over the last year (showed an ongoing issue).
- The patient's discharge instructions showed the patient was seen because of thoughts of hurting herself.
- The patient was discharged at 3:04 PM, to travel by private vehicle to Hospital C for evaluation.
- There was no evidence a psychiatric consult/screen was conducted, prior to the patient's discharge.
- There was no evidence Patient #21 ever arrived at Hospital C.

15. During an interview on 03/25/14 at 3:47 PM, Staff J, ED Charge Nurse, stated that psychiatric patients were seen by the ED physician and the ED physician can consult with a Psychiatrist or Case Manager if desired. This hospital ED could utilize Behavioral Health Resources (BHR-intake staff consists of social workers) for back-up on admissions assistance. Hospital C, a psychiatric hospital was on-call and available for consult by telephone. Patients could also be sent to Hospital C's emergency intake area for assessment.

16. During an interview on 03/26/14 at 8:37 AM, Staff K, ED Physician, stated that the ED physicians could use Hospital C for psychiatric evaluation/consult. If Hospital C was not utilized, the ED physicians do the psychiatric screening. If a patient was sent to Hospital C for evaluation by private vehicle, Hospital A never verified arrival of the patient. Staff K typically used the patient's history of suicide attempts, plan and method to implement plan as a guide of actual suicidal ideations and whether he would admit or ask for a consult.

17. During an interview on 03/26/14 at 10:20 AM, Staff D, ED Manager, stated that they utilized BHR, Social Workers and Case Managers for consult on psychiatric patients. The ED physician assesses and determines safety and admission or transfer.

18. During an interview on 03/31/14 at 2:07 PM, Staff M, Physician Assistant at Hospital A, stated the following:
- She assessed Patient #21 and called Hospital C's intake personnel (not psychiatrists or psychologists, but nurses and social workers) for consult. Hospital C told her that it sounded like this patient could be a candidate for outpatient treatment, but the patient needed to be evaluated in their intake area.
- The policies and procedures for psychiatric consult and transport in Hospital A's ED were not real clear.
- It was unclear (within Hospital A) as to which service to use and/or when (BHR or Hospital C) on psychiatric patients at risk for suicide.
- Staff M stated that she acted consistently with hospital protocol/training; however, Hospital A was unable to produce a specific policy/procedure for how to evaluate/screen, transport, and/or refer suicidal patients to BHR or Hospital C.

19. Review of the physician peer review for Patient #21, dated 4/17/14, revealed the patient:
- Presented with suicidal ideation and depression that were not properly addressed and evaluated.
- Did not receive an appropriate MSE and could not determine presence or absence of an EMC.
- Was not seen by a psychiatrist or mental health professional.
-Did not receive a proper mental health screen.
-Transferred by private vehicle without proper monitoring which greatly increased the risks.
-Unknown if arrived at Hospital C.
-No evidence Hospital C was notified of the transfer, a physician certified the benefits outweighed the risks of the transfer or that medical records were sent to Hospital C (requirements of an appropriate transfer).
-The transfer wan inappropriate and should have been done via supervision.