HospitalInspections.org

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Based on medical record reviews, facility documentation reviews, and interviews, the facility failed to perform and document an appropriate medical screening examination (MSE) in 1 of 20 patient records reviewed (Patient #2).
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The findings included:
Medical Record Review
1. The facility staff failed to perform and document an appropriate MSE in 1 of 20 patient records reviewed (Patient #2). The MSE was documented as "Not Completed" by the mid-level practitioner and never documented by the emergency department (ED) physician as completed.
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2. Patient #2's medical record review revealed the following:
Patient #2 was brought into the emergency department (ED) on 05/14/2023 at 1514 by Staff #30 (Universal City Police Department's Mental Health Officer) under an Emergency Detention Order (EDO) with mental decompensation and suicidal ideation after assaulting her caretaker, hearing voices that were telling her to kill herself. Staff #21 (ED provider) completed a medical screening exam (MSE) on 05/14/2023 at 1514 but did not consult behavioral health or psychiatry for completion of the MSE. No stabilizing treatments or medication changes were made to address the auditory hallucinations (hearing voices telling her to kill herself) or suicidal ideation, just one set of vital signs obtained by nursing.
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There is no evidence that a medical screening exam by Behavioral Health or Psychiatry made by the ED physician for Patient #2 was initiated or completed. No suicide assessment/screening could be located. Staff #21 determined that Patient #2 was "at her baseline" and that "no SW/CM (social worker or case manager) are on-call today (Sunday)." The facility does have an affiliate that provides telepsychiatry consultation, but they were not consulted. The total time in the ED was 4 minutes. The facility failed to ensure a complete medical screening exam for a behavioral health patient per its policies.
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Policy Review
3. EMTALA - Provision of On-Call Coverage Policy (Last Revised: 08/2016, Effective date: 08/2016) states on page 4:
"...Physician Appearance Requirements. If a physician on the on-call list is called by the hospital to provide emergency screening or treatment and either fails or refuses to appear within a reasonable timeframe, the hospital and that physician may be in violation of EMTALA as provided for under section 1867(d)(1)(C) of the Social Security Act. If a physician is listed as on-call and requested to make an in-person appearance to evaluate and treat an individual, that physician must respond in person within a reasonable amount of time. For those physicians who do not respond within a reasonable amount of time, the Chain of Command Policy should be initiated..."
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4. Rules and Regulations of the Unified Medical Staff (Last Revised: 03/23/2023, Effective date: 03/23/2023) states on pages 8-9:
" ...3.9 Telemedicine
The Medical Board, following consultation with appropriate Services as needed, shall
define which clinical services are appropriately delivered through a telemedicine medium, according to commonly accepted
quality standards.14 The clinical services approved to be delivered through a telemedicine link are:
Diagnostic Radiology
Neurology
Intraoperative Monitoring
Psychiatry ..."
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Patient #2 did not receive a psychiatric medical screening at all and was discharged back to the group home she came from without stabilizing treatments provided. The facility failed to follow its "EMTALA - Provision of On-Call Coverage Policy" and "Rules and Regulations of the Unified Medical Staff" when the telepsychiatry consult was not requested.
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Interviews
5. On the morning of 08/22/2023, Staff #7 (Vice President of Quality) was asked why the documentation on Patient #2 did not receive a "completed" MSE.
Staff #7 replied that their mid-levels never complete the MSE and it is therefore documented as "incomplete".
Staff #7 was asked why the following ED physician was not documenting a completion time for the MSE.
Staff #7 replied that she was unaware that the facility needed to do that.
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Based on a review of patient records, facility documentation, and interviews, the facility failed to meet the following requirements of an appropriate transfer when 8 of 30 MOTs for patients who had acute emergency medical conditions were reviewed were found to be incomplete and 2 of 30 were not found in the patient records.

Findings included:

Documentation review
1. Memorandum of Transfer (MOTs) were chosen from the transfer log for March through May 2023 and a random sample of 10 records from each month for a total of 30 MOTs were reviewed with Staff #7 (Vice President of Quality).

During March 2023, there were a total of 50 MOTs. Of the 10 reviewed for March 2023, 4 had incomplete or missing physician's
certifications. There were 2 of 10 that were missing the "risks" portion; 1 was missing both "risks and benefits" portions; and 1
was not found in the patient record on the signed physician certifications.

Patient #22 - date of service: 03/04/2023, diagnosis: electrical shock left hand, the reason for transfer: a higher level of care; the
MOT had benefits listed, but no risks were found on the signed physician certification.

Patient #26 - date of service: 03/15/2023, diagnosis: brain tumor (glioblastoma), the reason for transfer: a higher level of care, the
MOT had benefits listed, no risks listed on the signed physician certification.

Patient #24 - date of service: 03/20/2023, diagnosis: toxic ingestion and suicidal ideation, the reason for transfer: specialty care,
the MOT had no risks or benefits listed on the signed physician certification.

Patient #28 - date of service: 03/29/2023, diagnosis: suicidal ideation, the MOT was missing.

During April 2023, there were a total of 48 MOTs. Of the 10 reviewed for April 2023, 3 had incomplete or missing physician's
certifications. There was 1 missing both "risks and benefits" portions; 1 was missing both "risks and benefits" and the "reason
for transfer" on the signed physician certifications. There was 1 missing MOT.

Patient #29 - date of service: 04/07/2023, diagnosis: suicidal ideation, the MOT was not found in the patient record.

Patient #30 - date of service: 04/12/2023, diagnosis: 40 weeks pregnant, the MOT had no risks, benefits, or reason for transfer
found on the signed physician certification.

Patient #23 - date of service: 04/20/2023, diagnosis: suicidal ideation, the reason for transfer: specialty care, the MOT had benefits
listed, but no risks were found on the signed physician certification.

During the month of May 2023, there were a total of 52 MOTs. Of the 10 reviewed for May 2023, 4 had incomplete or missing
physician's certifications. There were 2 missing the "benefits" portion; 1 was missing both "risks and benefits" and the "reason
for transfer" portion on the signed physician certification; and 1 was not found in the patient record.

Patient #25 - date of service: 05/11/2023, diagnosis: left eye pain, the reason for transfer: a higher level of care, the MOT had no
benefits or risks listed on the signed physician certification.

Patient #27 - date of service: 05/12/2023, diagnosis: suicidal ideation, the MOT was missing.

Patient #21 - date of service: 05/18/2023, diagnosis: lip laceration, the MOT had no risks, benefits, or reason for transfer listed on
the signed physician certification.

2. Texas EMTALA - Transfer Policy (Last Revised: 05/2017, Effective date: 10/2018) states on page 3:
" ...1. Transfer of Individuals Who Have Not Been Stabilized
ii. A physician has signed a certification that, based upon the information available at .... The certification must contain a
written summary of the risks and benefits upon which it is based.
Note: The date and time of the physician or QMP certification should match the date and time of the transfer ...."

page 9:
" ...h. Send Memorandum of Transfer. A Memorandum of Transfer must be completed for every patient who is transferred to
another separately licensed hospital. The Memorandum of Transfer and the patient's medical record must be sent with the patient
at the time of the transfer. A copy of the Memorandum of Transfer shall be retained by the transferring hospital and incorporated
into the patient's medical record. A copy of the MOT must be filed separately from the patient's medical record and in a manner
which will facilitate its inspection by the department. All MOT forms filed separately must be retained for five years ..."

Interviews
3. On the afternoon of 08/23/2023, Staff #7 was interviewed throughout viewing the MOTs and was asked to provide copies of the incomplete MOTs.
Staff #7 acknowledged the missing information and provided the copies.