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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 Active Labor Act (EMTALA) requirements.

FINDINGS

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

Tag 2406: (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. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital's obligation under this section ends, as specified in paragraph (d)(2) of this section. 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 an emergency medical or psychiatric condition existed for two of three patients reviewed who presented with psychiatric complaints and were discharged.

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 an emergency medical or psychiatric condition existed for two of three patients reviewed who presented with psychiatric complaints and were discharged. (Patient #3 and #8).

Findings include:

Facility policies:

The Suicide Precautions Policy read, The purpose of this policy is to provide guidance to assist with the identification of patients in non-Behavioral Health (BH) settings who are at risk for suicide, ensuring a safe environment for the provision of care.

Columbia Suicide Severity Rating Scale(C-SSRS): Initial screening tool utilized by the nurse. It will provide an auto calculated level of no risk, low, moderate or high risk.

Suicide Detailed Risk Assessment (suicide DRA): Subsequent assessment completed by the Provider/Practitioner. The suicide DRA must be completed for any patient with a positive C-SSRS screen.

Overall Risk Level (ORL): Determined by the provider/practitioner's clinical judgement and suicide DRA. The provider/practitioner will assign a level of no risk, low, moderate, or high risk. This will take precedence over the C-SSRS, if the risk level differs.

It is the policy of the facility to create an environment of care that will foster the assessment, identification, and management of patients who are at increased risk for suicide or self-harming behaviors. Patients who are at an increased risk for suicide or self-harming behaviors require intensive support, close observation, and frequent reassessment for their emotional and physical well-being. The scope of this plan begins at triage, prior to admission to the hospital, and continues until the patient is discharged.

Minimum requirement: Patients in non-psychiatric areas (e.g., Emergency Room (ER) and non-BH inpatient units), ages 12 years and older, who are being evaluated or treated for BH conditions as their primary reason for care should be screened using the C-SSRS. The Provider/Practitioner will be notified of positive screens (i.e., at risk patients). The at-risk patient's (low, moderate, or high) environment will be made safe by implementing the checklist and observation precautions. The at-risk patient will be monitored and reassessed, with accompanying documentation daily, when a change in condition occurs, and prior to discharge. An ORL and a personal safety plan must be documented prior to discharge. Suicide prevention information and resource phone numbers will be included in the discharge planning instructions.

The EMTALA - Medical Screening Examination and Stabilization policy read, the purpose of this policy is to establish guidelines for providing appropriate medical screening examinations (MSE) and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA, 42 U.S.C. § 1395dd, and all Federal regulations and interpretive guidelines promulgated thereunder. An EMTALA obligation is triggered when an individual comes to a dedicated emergency department the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition; or a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition.

Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital.

An on-going process. The individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC, and if he or she does, until he or she is stabilized or appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer.

Individuals with psychiatric or behavioral symptoms: The medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicates danger to self or others.

Psychiatric QMP: The ED physician shall consult the QMP providing the behavioral assessment for psychiatric purposes but shall remain the primary decision-maker with regard to transfer and discharge of the individual presented to the ED with psychiatric or behavioral emergencies.

The Health One Crisis Assessment Team - Assessment and Referral Request policy read, assessments will be provided to hospitals and emergency departments who request assistance with the assessment of psychiatric emergencies.

1. The facility failed to perform a medical screening exam (MSE) to assess for a psychiatric emergency.

A. Medical record review

i. On 6/19/24 at 9:04 a.m., Patient #3 presented to the ED, brought in by the police on an emergency mental health hold (M1 hold), with the chief complaint of suicidal ideation, homicidal ideation, and hallucinations. Patient #3 stated he was being tormented by a poltergeist which was flying around and raping people, including himself. Patient #3 stated he had chronic thoughts of wanting to hurt himself but did not wish to discuss it as he was not going to act on these thoughts. A medical screening evaluation was performed at 9:07 a.m., which read, Psychiatric: depressed mood and guarded affect, no suicidal ideations, no homicidal ideations, chronic auditory hallucination, but does not appear to respond to internal stimuli at this time. The provider who evaluated the patient wrote that the M1 hold was discontinued. Patient #3 was discharged at 10:23 a.m.

There was no evidence a psychiatric exam was conducted to determine if Patient #3 was safe for discharge.

ii. On 6/1/24 at 7:43 p.m., Patient #8 presented to the ED, brought in by the police with the chief complaint of suicidal ideation. Patient #8 had attempted to run into traffic and had exhibited combative behavior with the police. The patient's behavior prior to arrival was described as violent, necessitating sedation and physical restraints for safety.

At 10:28 p.m., a suicide risk assessment was completed by the registered nurse (RN). The patient revealed the patient has a high risk for suicide.

On 6/2/24 at 1:52 a.m., Patient #8 was discharged into police custody. The provider note read the police would place the patient on suicide watch and an evaluation could be completed in jail.

There was no evidence a psychiatric exam was conducted in the ED to determine if Patient #8 had an emergency psychiatric condition.

The review of Patient #3 and #8's medical records were in contrast to the EMTALA policy which read, the MSE must be appropriate to the individual's presenting signs and symptoms. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer.

B. Interviews

i. On 8/14 24 at 7:32 a.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated behavior health consults were completed for patients who were suicidal, on a M1 hold, or if a patient requested one. RN #1 stated a risk assessment was to be performed to ensure patient safety and if not performed there was a risk the patient could harm themselves or others.

ii. On 8/14/24 at 8:04 a.m., an interview was conducted with RN #2. RN #2 stated health crisis assessment team (HCAT) consults were ordered and performed after a patient was medically cleared for patients who were suicidal, homicidal, or on a M1 hold. RN #2 stated the suicide risk evaluation was performed if a patient stated they were suicidal. RN #2 stated there was a risk of patients harming themselves if the assessment was not performed..

iii. On 8/14/24 at 9:47 a.m., an interview was conducted with RN #3. RN #3 stated the provider determined if a HCAT was needed, and were usually ordered for patients who had suicidal ideations. RN #3 stated if a suicide assessment was not completed for a suicidal patient, the patient may have harmed themselves or others.

iv. On 8/14/24 at 9:31 a.m., an interview was conducted with medical doctor (MD) #4. MD #4 stated suicidal ideation was considered an emergent medical condition. MD #4 stated nursing staff performed a self-harm assessment for patients admitted to the ED. The results of the self-harm assessment were discussed with the physician. Physician #4 stated a behavioral health evaluation was performed to ensure patients did not hurt themselves or others and help the clinician decide if outpatient or inpatient therapy is warranted. MD #4 stated there was a risk if patients were not assessed, the severity of an illness might not have been discovered and the patient could have harmed themselves or others.