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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in §489.24, related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.

FINDINGS:

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

Tag A2405 - Emergency Room Log

Based on interview and record review, the facility failed to maintain a centralized log that contained accurate information for patients who presented to the facility for emergency services. Specifically, patients who presented to the facility's behavioral health intake office for emergency services were not included on the central log for 6 of 6 patients who were admitted to the facility after presentation to the behavioral health intake office (Patients B, C, D, E, F and G).

Tag A2406 - Medical Screening Exam

Based on interviews and record review, the facility failed to ensure patients presenting for emergency services, or requesting an examination, received an appropriate medical screening examination (MSE) by a qualified individual for 8 of 8 patients who presented to the behavioral health intake office and were discharged from the facility (Patients A, H, I, J, K, L, M and N).

Based on interview and record review, the facility failed to maintain a centralized log that contained accurate information for patients who presented to the facility for emergency services. Specifically, patients who presented to the facility's behavioral health intake office for emergency services were not included on the central log for 6 of 6 focus sample patients who were admitted to the facility after presentation to the behavioral health intake office (Patients B, C, D, E, F and G).

Findings:

POLICY

According to the EMTALA (Emergency Medical Treatment & Active Labor Act) and Transfer Policy, the hospital will maintain an Emergency Medical Care Log, which includes patient information. The Emergency Medical Care Log is an electronic record of all individuals who come to a department seeking emergency care. It shall contain specific patient information including: patient name, medical record number, chief complaint, and disposition.

1. The facility failed to maintain a complete and accurate central log of patients who presented to the facility.

a) During an interview with Behavioral Health Evaluator (BHE) #1, on 08/10/16 at 2:24 p.m., s/he stated the facility's Behavioral Health Intake Office was an area where patients could get a free assessment for mental health needs. BHE #1 stated they did not take hospital direct admissions from the behavioral health intake office. BHE #1 stated all patients listed on the Walk-ins to Behavioral Intake & Assessment 2016 (Walk-in) form provided to the surveyors were patients who presented for emergency services. The BHEs would conduct the screening to determine if the patient needed to be admitted for inpatient services or was able to receive services on an outpatient basis.

b) Review of the Walk-in form showed 21 patients presented at the behavioral health intake office for emergency services from 03/01/16 through 07/18/16. As example, the following patients did not appear on the central log.

Patient B presented to the facility with depression on 07/18/16 and was admitted for inpatient services. Review of his/her Psych Behavioral Health Evaluation showed s/he walked into the behavioral health intake office with severe depression and was subsequently admitted.

There was no documentation on the central logs, titled ED Multi Visit and ED Admits, that Patient B had presented to the facility seeking emergency services on 07/18/16.

c) Patient C presented to the facility on 05/18/16 for mania. His/her Psych Behavioral Health Evaluation, stated Patient C walked in and was diagnosed with bipolar disorder with severe mania. The patient was admitted for inpatient mental health services.

There was no documentation on the emergency room logs that noted Patient C had presented to the facility seeking emergency services on 05/18/16.

d) Review of the Walk-in form showed Patient D presented to the facility for suicidal ideation on 04/21/16 and was admitted for inpatient services to the adolescent psychiatric unit for major depression.

According to the Psych Behavioral Health Evaluation, dated 04/21/16, Patient D was admitted due to "Suicidal Ideations" for further observation and stabilization of symptoms.

There was no documentation on the emergency room logs to show Patient D presented to the facility for emergency services.

e) Similar findings were noted for Patient E (on 04/19/16), Patient F (04/07/16), and Patient G (04/06/16). Specifically, the patients presented to the facility seeking emergency assistance; however, there was no documentation on the central log to show the individuals came to the facility for emergency services, whether they refused treatment, were refused treatment, or whether they were transferred, admitted and treated, stabilized and transferred or discharged.

f) During an interview, on 08/11/16 at 8:23 a.m., the Chief Nursing Officer (CNO #2) stated the facility "discovered this week" that patients presenting to the Behavioral Health Intake Office weren't being considered as presenting for emergency services and therefore EMTALA requirements were not followed. CNO #2 stated s/he thought if the patient had an emergency they would have been sent to the emergency department.

Based on interviews and record review, the facility failed to ensure patients presenting for emergency services, or requesting an examination, received an appropriate medical screening examination (MSE) by a qualified individual for 8 of 8 focus sample patients who presented to the behavioral health intake office and were discharged from the facility (Patients A, H, I, J, K, L, M and N).

This failure created a situation in which patients who had an identified medical concern were allowed to leave the facility without an appropriate medical screening exam to determine whether and emergency medical condition existed.

FINDINGS:

POLICY

According to the EMTALA (Emergency Medical Treatment & Active Labor Act) and Transfer Policy, any person who comes to the hospital facility requesting assistance for a potential emergency medical condition/emergency services will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exist.

The Medical Screening must be performed by Physicians and Obstetrical RN's (Registered Nurses) as defined in the policy. These professionals will function within the scope of their license and certification with approval by the Board

According to the Rules & Regulations, when a patient presents for emergent care, an initial medical screening examination must occur and may be provided by any privileged physician practitioner, (generally an emergency room physician) or in the event of an obstetrical patient, a labor and delivery RN may provide the initial medical screening as the Qualified Medical Person (QMP).

1. The facility failed to ensure patients received an appropriate MSE by a physician or other QMP for their presenting signs and symptoms.

a) During an interview with Behavioral Health Evaluator (BHE) #1, on 08/10/16 at 2:24 p.m., s/he stated the facility's Behavioral Health Intake Office was an area where patients could get a free assessment for mental health needs. BHE #1 stated they did not take hospital direct admissions from the behavioral health intake office. BHE #1 stated all patients listed on the Walk-ins to Behavioral Intake & Assessment 2016 (Walk-in) form, provided to the surveyors, were patients who presented for emergency services. The BHEs would conduct the screening to determine if the patient needed to be admitted for inpatient services or was able to receive services on an outpatient basis.

b) Review of the Walk-ins form revealed the following patients presented for emergency services and did not receive a medical screening exam by a QMP. Examples included:

On 06/17/16, Patient H, walked into the behavioral health intake & assessment office and requested services. According to a behavioral health screening form the patient was to choose three problems that bother them the most at this time. Patient H marked anxious, worries too much, unable to concentrate, can't make decisions, pain, depressed, wanting to be alone a lot, hopeless, low self-esteem, cries easily, feels sad most of the time, weakness, eating more, poor sleep and bored/lack of interest.

The bottom of the form had an area for staff signature, physicians signature and for the facility to document if further action was indicated. The area was blank and left unsigned.

There was no documentation to show the patient had been evaluated by a physician or qualified medical person to determine if s/he had an emergent medical condition.

c) According to the Walk-in form, Patient I requested services on 03/08/16 for suicidal ideation. The intake and assessment form, completed by BHE #3, noted the patient's parent received a message stating the patient was making suicidal statements. BHE #3 documented the patient did not "meet inpatient mental health criteria at this time" and the patient was discharged home.

There was no documentation the patient was evaluated by a physician or other qualified medical person to determine if an emergent medical condition existed. Additionally, there was no documentation BHE #3 had been designated as a qualified medical person.

d) Review of the Walk-in form showed Patient J presented for emergent services on 03/15/16 for an arm cut.

Review of an undated and unsigned typewritten form revealed the patient was a 14 year old who "snapped" while at school. The patient grabbed a box cutter from his/her backpack and went into a stall in the girls bathroom, started to cry and cut his/herself with the razor. The typewritten note stated the lacerations did not require medical care at this time.

However, there was no documentation to show the note had been completed by a QMP as it was not dated and signed.

Review of the Diagnostic Impression section of the intake form, dated 03/15/16 and completed by BHE #3, showed BHE #3 consulted a psychiatrist and determined Patient J did not "meet inpatient mental health criteria at this time."

There was no documentation the patient received an appropriate medical screening exam by a QMP to determine if an emergent condition existed which required further treatment.

e) Review of the Walk-in form and intake assessment forms showed similar findings of patients who presented for emergency services and did not receive an appropriate medical screening by a qualified medical person to determine if an emergent medical condition existed for Patients A, K, L, M and N.

f) During an interview, on 08/11/16 at 8:23 a.m., the Chief Nursing Officer (CNO #2) stated the facility "discovered this week" that patients presenting to the Behavioral Health Intake Office weren't being considered as presenting for emergency services and therefore EMTALA requirements were not followed. CNO #2 stated s/he thought if the patient had an emergency they would have been sent to the emergency department.