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Based on observation, interview and record review, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CF R 489.24, Special responsibilities of Medicare hospitals in emergency cases. The facility failed to provide an appropriate medical screen exam for 1 of 25 Emergency Department patients reveiwed (Patient ID #1).

Refer to tag A 2406 for additional information.

Based on record review and interview, the facility failed to ensure all patients who presented to the the emergency department (ED) received an appropriate and accurate medical screening examination (MSE) (Patient ID #1). The facility failed to assess allegations that were made to facility staff during the patient's ED stay of child abuse and an unsafe living environment and act upon those allegations. Specifically, social work and Childrens Protective Services were not consulted, the psychiatric consultant was not made aware of these allegations, and ED physician documentation did not demonstrate any further investigation of these allegations or consideration of the possibility that discharging patient into care of mother, accused of abuse, might be unsafe.

Findings Included:
Record review of facility's "Texas EMTALA - Medical Screening Examination and Stabilization Policy," effective 01/23, stated " ... 7 . Stabilizing Treatment Within Hospital Capability "The determination of whether an individual is stable is not based on the clinical outcome of the individual's medical condition. An individual has been provided sufficient stabilizing treatment when the physician treating the individual in the DED has determined, within reasonable clinical confidence, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or with respect to an EMC of a woman in labor, that the woman has delivered the child and placenta; or in the case of an individual with a psychiatric or behavioral condition, that the individual is protected and prevented from injuring himself/ herself or others. For those individuals who are administered chemical or physical restraints for purposes of transfer from one facility to another, stabilization may occur for a period of time and remove the immediate EMC, but the underlying medical condition may persist and, if not treated for longevity, the individual may experience exacerbation of the EMC. Therefore, the treating physician should use great care when determining if the EMC is in fact stable after administering chemical or physical restraints.
a. Stable. The physician or QMP providing the medical screening and treating the emergency has determined within reasonable clinical confidence, that the EMC that caused the individual to seek care in the DED has been resolved although the underlying medical condition may persist. Once the individual is stable, EMTALA no longer applies. (The individual may still be transferred; however, the "appropriate transfer" requirement under EMTALA does not apply.)
b. Stabilizing Treatment Within Hospital Capability and Transfer. Once the hospital has provided an appropriate MSE and stabilizing treatment within its capability, an appropriate transfer may be effected by following the appropriate transfer provisions. (See Transfer Policy.) If there is a disagreement between the physician providing emergency care and an off-site physician (e.g., a physician at the receiving facility or the individual's primary care physician if not physically present at the first facility) about whether the individual has been provided sufficient stabilized treatment to effect a transfer, the medical judgment of the transferring physician takes precedence over that of the off-site physician.
Refer to the hospital's Transfer Policy for additional directions regarding transfers of those individuals who are not medically stable. If a hospital has exhausted all its capabilities and is unable to stabilize an individual, an appropriate transfer should be implemented by the transferring physician.
c. Stabilizing Treatment and Individuals Whose EMCs Are Resolved. An individual is considered stable and ready for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his or her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions. The EMC that caused the individual to present to the DED must be resolved, but the underlying medical condition may persist. Hospitals are expected within reason to assist/provide discharged individuals the necessary information to secure follow-up care to prevent relapse or worsening of the medical condition upon release from the hospital. "

Record Review of Patient ID #1 Medical Record for date of service 4/4/2024 was performed with Pediatric Emergency Department Nursing Director Staff ID #64 on 5/21/24 at 1:00 pm. The following was noted in the facility's electronic medical record.

Atascocita EMS Run Record was reviewed. Patient ID #1 was brought by Atascocita ambulance to HCA Healthcare Hospital Kingwood on 4/4/2024 at 7:47 pm with "Benadryl Overdose." Poison control had been called by EMS per their record. The record stated the patient had "taken 10 Benadryl pills with intent to harm herself." The mother was present at the time EMS arrived to the scene.

Detailed nursing assessment including a suicide risk scale had a calculated suicide risk level: "high risk" as performed by RN Staff ID #80. A suicide safe environment was initiated with a 1:1 sitter and Q 15 min log completed for duration of her ED stay.

Staff RN # 78 documented "Rapid initial assessment: Subjective Assessment - Pt arrived via EMS on EDO unaccompanied by a parent for intentional ingestion of 10 25 mg Benadryl at 18:30. Pt endorses SI x 1 yr with previous plan and attempt to suffocate herself with a pillow last year. Pt states 'I knew I was in trouble anyways and felt overwhelmed.' After an argument with her mother prior to arrival, denies HI. Per EMS, pt with PMH of autism but no previous psych admits. Objective Assessment Patient arrived awake and mildly sleepy but GCS 15, ambulatory without difficulty, skin cool and mottled with brisk cap refill, afebrile, tachycardic, 100% on room air, abdomen soft and nondistended, PERRL, denies pain."

Unit Secretary Staff ID #77 documented on 4/4/24 at 9:21 pm that patient friend (redacted name) and her mother visited. Friends mom expressed concern for patient's safety stated that "mom and grandmother verbally abuse patient and stepdad slammed her hand in a door multiple times about 2 weeks ago. She also stated that mom used patients phone for drug deals regularly. Friends mother is the one that called 911."

4/5/2024 01:33 am Staff RN #78 documented "Teledoc in room for psych eval."

4/5/2024 02:15 am Psychiatric Consultant Physician Assistant Staff ID # 79 documented "Telehealth Psychiatric Consult" stated "11 year old woman brought to the ED by her mother after suicide attempt by intentional medication overdose (10 Benadryl tablets). She endorses passive suicidal ideation and states that she no longer has a plan to overdose on medication. The patient states now that she realizes that "taking medication" was the wrong thing to do. She states she was feeling overwhelmed when watching her younger siblings. The patient's mother states that patient has a history of autism." The consult note goes on to state "Overall Risk Level Suicide- Low Risk". Her assessment and plan stated " ...patient is agreeable to an outpatient psychiatric appointment upon discharge-tentative 4/8/24. Safety plan and outpatient resources have been discussed with the patient and the patient's mother voiced understanding of the safety plan."

On 4/5/2024 at 06:05 am Staff RN # 78 charts "Mom out of the room at this time to take her belongings to the car as MD states he is about to DC the patient. RN in the room, Patient is awake and alert, GCS 15. Ambulatory without difficulty. Skin warm and dry. No signs of distress. Patient reports she does feel safe at home and denies any concerns of abuse or neglect. RN discussed with (Physician Staff ID # 76) and she stated that patient denied any concerns on arrival. Advised RN that unit secretary mentioned that friends mother mentioned concerns to her and MD acknowledged. Pt denies any of these concerns."

4/5/2024 at 06:06 am. Physician Staff ID # 76 makes the decision for discharge.

4/5/2024 at 6:24 am. Patient ID #1 is discharged home with her mother.

Interview with Pediatric ED Physician Staff ID #71 on 5/21/2024 at 09:15 am. He stated that patients who present to the Pediatric ED with behavioral health complaints are evaluated thoroughly medically. He stated this would include a history and physical, bloodwork including toxicology labs and EKG. He stated that the facility obtains psychiatric evaluations utilizing the call schedule, which is published. He stated during the daytime hours, the psychiatric consultant providers may come in person. He stated after-hours, these can be performed using telehealth/video conference technology. He stated that he was unsure of the facility social work hours and commented that after-hours consults could be delayed as there was someone on call.

Interview with Pediatric ED Nursing Director Staff ID # 64 on 5/21/24 at 10:00 am. She confirmed the facility has a social worker in-house who covers the emergency department from 8a-6pm daily. She stated after 6pm, that the case manager/social worker "takes call" for consults/issues.

Interview with Pediatric ED Nursing Director Staff ID # 64 on 5/21/2024 at 1:30 pm. She performed electronic review of medical record and confirmed that Patient ID #1 had been brought by ambulance for evaluation after Benadryl ingestion with intent to harm herself. She confirmed that the there had been documentation by Unit Secretary Staff ID #77 on 4/4/24 at 9:21 pm which stated the patient's home was "unsafe" and alleged physical abuse by an adult in the home as well as drug use/abuse by adult caregivers. She confirmed that the medical record revealed this information was relayed to Staff RN #78 and Staff MD #76. She confirmed she could not locate physician documentation addressing these allegations. She confirmed there was no evidence that social work consult had been ordered or performed. She confirmed she would have expected a social work consult to be performed and/or Childrens Protective Services (CPS) to be notified for safe discharge planning.

Telephone Interview with Behavioral Health Team Provider Staff ID #79 on 5/21/24 at 2:00pm. She confirmed that she was the provider who performed the mental health assessment on Patient ID #1. She stated that she provided mental health team call from 8pm to 8am when on call. She stated consults are received in 2 fashions, both electronic, through "Patient Keeper and Meditech." She confirmed that nursing and/or providers do not establish personal contact for consultations, usually. She stated that they "have the ability to iMessage," through an electronic platform. She did not recall receiving additional information about Patient ID #1 to facilitate the consult. She denied visualizing the patient's electronic medical record for facilitation of the consultation. She confirmed the behavioral health consultation was performed with Patient ID #1's mother at the bedside. She confirmed that she documented patient's mother brought her for care after Benadryl overdose based on what the mother told her. However, she stated that the historical information relayed was not confirmed by any other method. She stated that assessments are typically performed afterhours utilizing telehealth which included video ipad technology with a camera to allow visualization of the patient. She confirmed that she had no knowledge of the allegation of abuse, allegation of unsafe home environment or drug use/abuse in the home and stated it could have impacted her recommendations regarding patient's ability to discharge home with a safety plan and follow-up as an outpatient. She stated that a message was sent to the Psych Plus office by her regarding Patient ID #1's need to schedule follow-up appointment in their clinic. She was unable to confirm is there was a process established to follow-up with high risk patients, who fail to follow-up or miss appointments. Provider #79 stated that she had never been contacted or collaborated with a facility social worker regarding their social work assessment or safe discharge planning, at any point while taking psychiatric call for the facility.