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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. 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 condition (EMC) existed for one of two patients reviewed who discharged home after placement on an involuntary 72-hour emergency mental health hold (mental health hold). (Patient #3)

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 condition (EMC) existed for one of two patients reviewed who were discharged home after placement on an involuntary 72-hour emergency mental health hold (mental health hold). (Patient #3)

Findings include:

Facility policies:

The Safety Precautions: Suicide, Danger to Self, and Danger to Others in Non-Behavioral Health Settings for Adults, Children, and Adolescents read, patient safety is promoted through the screening and identification of patients at risk for self-harm, suicide or harm to others. All patients will be screened for Danger to Self upon the initial presentation to the facility using the Columbia-Suicide Severity Rating Scale (C-SSRS) to conduct a patient self-harm assessment.

All patients are screened for potential suicidal ideation and danger to self upon presentation to the facility using the C-SSRS-Screening Tool. Depending on the results of the C-SSRS-Screening Tool, the physician or allied health provider will be notified and determine the need for a Behavioral Health Consult/Assessment for the patient.

The Registered Nurse (RN) or a qualified designee will perform a suicide screening with the patient to determine the patient's Danger to Self, using the C-SSRS screening tool. The patient will also be assessed for a history of violence and/or current aggressive behavior as risk factors for Danger to Others (DTO).

Self-harm is defined as intentional and repetitive behavior that involves the infliction of harm to one ' s body with or without suicidal intent. Suicide is defined as the act of intentionally killing oneself.
A Suicide Risk Assessment is an assessment of the suicidal ideation (thoughts), intent (intention to act on suicidal thoughts), plan (specific way in which death would be accomplished), and access to means to commit suicide (is the method in which takings ones own life would be possible).

The Medical Staff Rules and Regulations read, any patient evaluated in the Emergency Department who is known or suspected to be suicidal or any patient who attempts suicide shall have a consultation/evaluation by a trained behavioral health professional from the Assessment Referral Team (ART).

The Qualified Medical Personnel Authorized to Perform Medical Screening Examinations policy read, psychiatric screenings and psychosocial assessments will be performed by psychologists and Crisis Counselors. The assessment/evaluation includes an assessment of suicide or homicide attempts or risk, assaultive/violent behavior and behavior which indicates a danger to self/other. When a Crisis Counselor or psychologist performs the psychiatric screening/examination, the physician is responsible for obtaining pertinent information regarding the need for the psychiatric screening/examination. The Crisis Counselor and/or psychologist will consult with the physician.

1. The facility failed to ensure patients with active mental health holds who expressed suicidal thoughts or gestures were provided an MSE to determine whether or not a psychiatric emergency existed before the mental health hold was terminated and the patient discharged from the facility.

A. Interviews and medical record review revealed the emergency department (ED) and Behavioral Health staff did not perform a suicide assessment or psychiatric evaluation for Patient #3. Specifically, a behavioral health assessment and suicide assessment were not performed for Patient #3 prior to his release from the involuntary mental health hold.

a. On 3/5/22 at 7:32 p.m., Patient #3 was brought into the ED after he was detained by police officers. Police officers detained Patient #3 after he spat on an officer and threw a brick into the window of a retail business store.

The registered nurse (RN) providing care for Patient #3 documented Patient #3 had verbalized suicidal statements to the police officers and was placed on a mental health hold. According to the Emergency Mental Illness Report and Application form (the mental health hold form), Patient #3 "appeared to be mentally ill".

i. The Triage notes read, Patient #3's chief complaint (the primary medical or psychiatric problem of the patient) included having suicidal thoughts. However, the RN who cared for Patient #3 documented a suicide assessment was not performed "due to the clinical condition" of Patient #3 when he presented to the ED.

This was in contrast to the Safety Precautions: Suicide, Danger to Self, and Danger to Others in Non-Behavioral Health Settings for Adults, Children, and Adolescents policy which stated, all patients who present to the ED will have a suicide assessment performed by an RN to determine the presence of active suicidal ideation.

ii. According to the Behavioral Health Report notes entered at 8:18 p.m., Patient #3 had a history of suicidal ideation (thoughts or ideas of killing oneself). Additionally, the note read Patient #3's mother disclosed to ED staff that Patient #3 was suicidal and "had told her he was feeling suicidal".

iii. On 3/6/22 at 3:50 p.m., the Behavioral Health Report note entered by Crisis Intake Therapist Coordinator (Coordinator) #3 read, "no ART (behavioral health Assessment Referral Team) consult was ordered due to the patient not having a primary mental illness". Patient #3 was then documented as discharged to his home at 5:34 p.m.

b. An interview was conducted with Coordinator #3 on 6/7/22 at 2:35 p.m. Coordinator #3 stated the behavioral health staff performed behavioral health evaluations for patients experiencing a psychiatric crisis. Coordinator #3 stated he provided documentation for Patient #3 on 3/5/22. Coordinator #3 stated he did not perform a suicide assessment or a behavioral health assessment of Patient #3 and was not aware Patient #3 was suicidal. Coordinator #3 stated he had not spoken to or seen Patient #3 while he was in the ED.

The facility was unable to provide evidence Patient #3 had a behavioral health evaluation performed by behavioral health staff to rule out if Patient #3 had active suicidal thoughts and did not have a psychiatric emergency medical condition (EMC).

This was in contrast to the Medical Staff Rules and Regulations facility policy which stated, Emergency Department patients with known or suspected suicidal ideation will receive a behavioral health consultation and a behavioral health evaluation will be performed by a staff member trained to perform behavioral health evaluations.

c. On 6/8/22 at 3:19 p.m., an interview was conducted with Registered Nurse (RN) #1. RN #1 stated all patients seen in the ED received a self-harm assessment. RN #1 stated suicidal ideation was considered an emergent medical condition and suicidal patients were required to be assessed by a trained behavioral health professional from the behavioral health team. Furthermore, RN #1 stated suicidal patients were at risk of inflicting self-harm and even death.

d. On 6/9/22 at 9:36 a.m., an interview was conducted with ED Physician (Physician) #2. Physician #2 stated there were processes and protocols in place at the facility for providing care to suicidal patients. Physician #2 stated suicidal patients were considered to have an emergent medical condition. Physician #2 stated nursing staff performed a self-harm assessment for all patients admitted to the ED. The results of the self-harm assessment were discussed with the physician.

Physician #2 then stated a behavioral health evaluation and a suicide assessment was expected to be performed for all suicidal patients who presented in the ED. Physician #2 stated a behavioral health evaluation was performed to ensure patients did not hurt themselves or others.