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Based on video and photograph review, medical record review and interviews, the facility failed to provide a medical screening exam for one (1) patient (#20) of 20 ED records reviewed.

The findings include:

Patient #20 was brought to Facility B's Psychiatric facility on 8/7/2025 by local law enforcement. The patient had been evaluated at the VA clinic (Facility D) by a provider related to Suicidal Ideations (SI) with a plan and a certificate of need (CON) was written for the patient. Facility A and Facility B were located on the same campus with an adjoining hallway. The staff at Facility B spoke with the transporting officer. The facility did not have an open bed and there were discussions with the officer related to taking Patient #20 to Facility A's ED for evaluation. The patient was taken to Facility's C's ED (2.7 miles from Facility A and B). The patient was not evaluated at Facility A. The patient was not listed on Facility A's ED Central Logs and there was no medical record for the patient. At Facility C, the patient received a medical screening examination and was found to have an ongoing Emergency Medical Condition. The patient required transfer to a inpatient psychiatric facility (Facility E).

Cross Refer to A-2406.

Based on review of facility policy, review of the Emergency Department (ED) Central Logs and interview, the facility failed to ensure an accurate and complete ED Central Log for one (1) patient (#20) of 20 ED records reviewed.

The findings include:

Review of Facility A's policy "EMTALA [Emergency Medical Treatment and Labor Act] ...Central Log Policy" last revised 12/2024, showed "...the hospital will maintain a Central Log containing information on each individual who comes to the hospital campus requesting assistance or whose appearance or behavior would case a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination should be performed, whether he or she refused treatment, whether he or she was refused treatment, or...transferred, admitted, and treated, stabilized and transferred or discharged..."

Patient #20 was brought to Facility B by local police on 8/7/2025 related to suicidal ideations (SI) under a Certificate of Need (CON). Facility A was on the same campus as Facility B and had a dedicated Emergency Department (DED).

Review of the ED Central Logs for 8/7/2025 showed Patient #20 was not listed on the ED Central Logs.

During an interview on 8/18/2025 at 4:00 PM, the Director of Quality Management for Facility A, confirmed Patient #20 was not listed on the facility's ED Central Logs.

During an interview on 8/19/2025 at 11:15 AM, with Facility A's Nurse Manager, the manager confirmed Patient #20 was not listed on the ED Central Logs.

Cross Refer to 2406.

Based on review of facility policy, review of video footage and photographs, medical record review and interviews, the facility failed to provide a medical screening examination for one (1) patient (#20) of 20 Emergency Department (ED) records reviewed.

The findings include:

Review of Facility A's policy "EMTALA [Emergency Medical Treatment and Labor Act] ...Medical Screening Examination and Stabilization, last revised 12/2024 showed "...an EMTALA obligation is triggered when an individual comes to a DED and the individual or a representative acting on the individuals behalf request an examination or treatment for a medical condition...a prudent layperson observer would conclude from the individuals appearance or behavior that the individual needs an examination or treatment of a medical condition...(j) Off-Campus Provider Based Emergency Department: an off campus provider based emergency department is a department of the hospital, located no more than 35 miles from the main hospital, that meets all the provider based requirement, holds the same Medicare provider number as the main hospital and either is (1) licensed by the state as an Emergency Department (ii) is advertised as providing care for the emergency medical condition on an urgent basis without appointment or (iii) provides at least one-third of all its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring previously scheduled appointments..."

Review of video footage and photographs dated 8/7/2025 for Facility B showed the following:
4:04 PM (25 seconds): The police cruiser arrived at the parking lot of Facility B.
4:04 PM (59 seconds): The police officer assisted a patient out of the police cruiser.
4:05 PM (17-34 seconds): Patient (#20) and officer walked into Facility B's waiting room. The officer went to the entrance desk and the patient was sitting in a chair in the waiting room. The officer was speaking with the receptionist and had an envelope in his hand.
4:08 PM (26 seconds): An employee at Facility B was talking to the police officer.
4:22 PM (11 seconds): Facility B's staff member was talking to the police officer.
4:22 PM (38 seconds): The patient and officer walked out of the entrance doors of Facility B.
4:23 PM (2 seconds): The officer assisted the patient into the police cruiser.
4:23 PM (32 seconds): The police cruiser pulled away from the entrance of Facility B.

Medical record review of a Certificate of Need (CON) dated 8/7/2025 at 2:15 PM, showed a
certificate of need (CON) was signed by a provider at Facility D for Patient #20, diagnosed with Major Depressive Disorder with an active plan to shoot himself and Post Traumatic Stress Disorder (PTSD).

Medical record review showed there was no ED record for patient #20 at Facility A.

Medical record review showed Patient #20 was admitted to Facility C's ED on 8/7/2025 at 4:46 PM. The patient was brought into the ED by local police related to Suicidal Ideations (SI) with a plan. The patient scored a 'high risk' on the Columbia Suicide Risk Rating Scale. Patient #20 had been evaluated at Facility D and placed under a CON related to a plan to shoot himself. On 8/7/2025, at 5:57 PM, the patient was medically cleared for psychiatric inpatient admission. The patient received Seroquel (antipsychotic) 100 milligrams (mg) orally, Zofran (medication used for nausea) 4 mg sublingual and Ambien (medication used for sleep) 10 mg orally while in the ED.

Medical record review of an ED Provider Note from Facility C dated 8/8/2025 at 3:08 AM, showed "...Patient at acute risk of harm to himself if he is not treated with inpatient psychiatric care. Patient has a plan to shoot himself with a gun and needs inpatient psychiatric care for this. He has a history of ptsd (post-traumatic stress disorder) and depression..." Patient 20's diagnosis included Depression with SI. Multiple referrals for inpatient psychiatric placement were made. Continued review showed the patient was accepted at Facility E on 8/8/2025 at 7:51 AM, and was transported by Emergency Medical Services (EMS).

During an interview on 8/18/2025 at 4:00 PM, the Director of Quality Management for Facility A confirmed Facility A and Facility B were on the same campus. Patient #20 had been evaluated at Facility D where he presented with SI and a plan. A CON had been written for the patient and Facility D asked for the patient to be taken to Facility A's ED for evaluation. Local police brought the patient to Facility B. Facility B staff spoke with the officer and told them they did not have an open bed and asked the officer to take the patient to Facility A's ED for evaluation. The officer took the patient to Facility C and bypassed Facility A. The Director of Quality Management confirmed the patient did not receive a medical screening examination and the patient was on Facility A's property.

During an interview on 8/19/2025 at 11:15 AM, the ED Manager at Facility A, the manager confirmed the patient was not evaluated at Facility A and there was no medical record for Patient #20.

During an interview on 8/19/2025 at 11:52 AM, the Director of Inpatient and Respond at Facility B, stated Patient #20 arrived with local police transporting. The patient had been evaluated at Facility D and placed under a CON. She had spoken with the officer and reviewed the paperwork. There were questions about if the patient should be taken to Facility A. She had spoken with the Chief Nursing Officer (CNO) and the Administrator on Call about the patient. They (Facility B) had evaluated the bed status and found they did not have an open bed for the patient. She spoke with the officer and told the officer to take the patient to (Facility A's) ED for evaluation, stabilization, and disposition. The officer was in agreement. She was not aware of any communication between the facilities about the patient. She confirmed the patient was on the campus of Facility A and Facility B and the patient did not receive a medical screening examination.