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Based on policy review, record review and interview, the hospital failed to implement facility policy and comply with the requirements at 42 CFR 489.24(a), as evidenced by failure to ensure an appropriate medical screening exam (MSE), including a mental health screening exam, was provided to one (Patient 1) of twelve patients reviewed, who presented to the emergency department (ED) with mental health or suicidal ideation concerns and 42 CFR 489.24(e)(1) the hospital's Emergency Department (ED) failed to ensure an appropriate transfer for one (Patient 1) of twelve sampled patients who presented to the ED with a psychiatric emergency medical condition.

Failure of the hospital to ensure an appropriate medical screening exam was provided had the potential to place the patient at risk for harm to self or others. Failure of the hospital to ensure an appropriate transfer had the potential to place the patient at risk for delays in obtaining stabilizing treatment.

Findings Include:

Review of the hospital's Emergency Department (ED) policy titled, "Emergency Medical Treatment and Labor Act Guidelines for Emergency Department Services," dated as reviewed July 2020, showed the facility defined an Emergency Medical Condition as, "A medical condition with sufficient severity (including severe pain, psychiatric disturbances, symptoms of substance abuse, pregnancy/active labor) such that the absence of immediate medical attention could place the individual's health at risk." The policy also showed that the facility defined a Medical Screening Exam as, "The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not."
According to the policy, a, "Medical Screening Exam (MSE) should include at a minimum the following:
-Physical exam of affected systems and potentially affected systems
-Notification and use of on-call staff to complete previously mentioned guidelines
-Notification and use of on-call physicians to diagnose and/or stabilize the patient as necessary
-Complete documentation of the medical screening exam."

The policy also showed, "Emergency medical conditions include: Psychiatric disturbances including severe depression, insomnia, suicide ideation or attempt, dissociative state, inability to comprehend danger or care for self."

Review of the hospital's ED policy titled, "Transfer of Patient to Another Facility," dated as reviewed July 2020, showed, "Purpose: Establish guidelines based on EMTALA standards to ensure that adequate care is given to each patient. If unable to continue with care, offer specialty care or higher level of care, patient shall be transferred to an appropriate facility. Policy: All patients shall be evaluated by the Emergency Department Provider regardless of condition, race, religious preference or ability to pay. If the provider determines, through the hospital policy, that the patient should be transferred to another facility for further care, EMTALA standards must be followed: The patient must: Have no life-threatening condition... Acceptance to the receiving facility must be made physician to physician, with documentation of the receiving facility's physician's name."

Review of the facility's Nursing Department policy titled, "Self-Harm, Assessment," dated as reviewed July 2020, showed the purpose of the policy was, "To prevent self-injury and ensure patient safety." The policy showed, "All patients admitted to the Emergency Department, as well as those patients with a primary psychiatric diagnosis or primary complaint of an emotional or behavioral disorder admitted to general units, shall be evaluated for self-harm potential as part of the initial nursing assessment. The registered nurse [RN] must complete the Initial Screening for Self-Harm as an initial part of the nursing assessment. Utilizing the screen results, the RN shall immediately place the patient on the appropriate level of suicide prevention. The patient's psychiatrist shall be notified, and an appropriate order shall be given."

A review of Patient 1's emergency department (ED) medical record showed the patient (a minor) presented to the ED with law enforcement on 04/29/2022 at 10:45 PM, with a chief medical complaint of suicidal ideation and to obtain, "medical clearance." The facility assessed Patient 1 as high risk for suicide. The facility conducted laboratory testing but failed to conduct a medical screening examination related to the patient's chief complaint of suicidal ideation. According to interviews with facility staff, an outpatient service, Facility #5 (the local community health center) completed a mental health evaluation for Patient 1 prior to presentation to the hospital. In addition, hospital staff stated they believed Facility #5 had already arranged for an inpatient hospital stay for the patient, and the only service they needed to provide for Patient 1 was, "medical clearance." However, the facility had no documented evidence Patient 1 had received a psychiatric evaluation and discharged the patient with a state social worker (SW). After discharge, the SW determined an inpatient hospital stay had not been arranged for Patient 1 and had to take the patient to the ED at Facility #4 (a regional hospital 41 miles away from Facility #1), where the patient stayed in the ED for two days before finding inpatient psychiatric placement. Further review of Patient 1's medical record showed no evidence that the CAH arranged an appropriate transfer (including determining the capabilities and capacity of a receiving hospital, the necessary appropriate transport personnel/equipment, physician certification and copies of the patient's medical records pertaining to the emergency) for the Patient. Refer to A2406 and A2409.

Based on interview, record review, and policy review, the hospital's Emergency Department (ED) failed to ensure an appropriate medical screening examination (MSE), including a mental health screening exam, was completed by a Qualified Mental Health Professional (QMHP) for one (Patient 1) of twelve sampled patients who presented to the ED with psychiatric concerns or suicidal ideation (SI). The hospital's failure to conduct an appropriate MSE led to an inappropriate discharge of a patient (with a psychiatric medical emergency) that resulted in delays in the patient receiving necessary stabilizing treatment to inpatient psychiatric services.

Findings Include:

Review of the critical access hospital's (CAH's) services showed that the ED staff had the capability for obtaining a mental health screening exam utilizing tele-psychiatry by contracted staff from Facility #5 (the local community mental health center). Other medical records reviewed during the investigation indicated the CAH utilizes Facility #5 to conduct mental health screening exams.

A review of Patient 1's ED medical record showed the patient (a minor) presented to the ED, accompanied by law enforcement on 04/29/22 at 10:45 PM. A review of the "Clinical Report - Nurses" form showed the patient's chief complaint was suicidal thoughts. The suicidal thoughts started the day before and the patient's plan was to hang him/herself. The patient stated the thoughts were from trauma in the past. The patient had anxiety and described feelings of depression. According to the medical record, the nurse completed a "Self-Harm Assessment" and Patient 1 answered "yes" to the following questions:
-Have you recently felt down, depressed, or hopeless?
-Do you have thoughts of harming or killing yourself?
-Do you have a plan for harming or killing yourself?
-Have you noticed less interest or pleasure in doing things?
-Are you here because you tried to hurt yourself?
-Have you ever tried to hurt yourself before today?"

A review of the ED "Clinical Report - Physicians/Mid-Levels" revealed Patient 1's "History of Present Illness Chief Complaint" was suicidal thoughts and "medical clearance." The patient had been depressed and had suicidal thoughts and had inflicted self-injury. The patient described the symptoms as "severe." The patient had been hospitalized twice for suicidal ideation, most recently in March 2022. The patient had unwanted memories of past trauma that triggered the patient to begin thinking he/she would be better off dead. The patient stated his/her plan was to hang him/herself but had not thought about the steps. The patient stated the day before, he/she had cut his/her forearms intentionally. According to the note, the patient had small skin lacerations to the right and left arms.

According to Patient 1's ED Suicidal Risk Assessment, the patient's suicide risk factors were being a youth and depression. The patient also had a diagnosis of major depression. According to the clinical suicide risk assessment, Patient 1 was "high risk" for suicide. Further review of Patient 1's ED record revealed the facility obtained laboratory tests, including a complete blood count; comprehensive metabolic panel; drug screen, TSH (thyroid-stimulating hormone); blood alcohol level; acetaminophen (Tylenol) level; salicylate (aspirin) level; and magnesium levels, as well as a COVID-19 test.

According to Patient 1's ED medical record, there was no evidence the facility conducted a medical screening examination appropriate to Patient 1's presenting signs and symptoms of suicidal ideation.

Continued review of Patient 1's medical record revealed on 04/30/2022 at 12:11 AM, discharge instructions were reviewed with the "intake worker," who verbalized understanding. The record showed the patient was discharged to Facility #2 (a foster care agency), accompanied by the intake worker. A review of the "General Instructions" showed Patient 1 was discharged with suicidal ideation, with no suicide attempt, and recurrent major depressive disorder. The instructions showed, "You have been given the following additional information: Depression Suicidal, 72-hour hold."

Review of the medical record showed the CAH failed to provide Patient #1 with an appropriate MSE. The CAH had the necessary policies and procedures, and a process in place for obtaining a psychiatric evaluation via tele-psychiatry to determine if a psychiatric emergency medical condition existed while the patient was present in the ED. However, the CAH failed to ensure Patient 1 had a psychiatric evaluation prior to discharging Patient 1 to the care of a state intake worker/social worker.

During an interview on 05/18/22 at 11:00 AM, the Nurse Manager, Staff F, stated the facility normally transferred children to Facility #3 (children's psychiatric hospital) after a mental health screening evaluation was completed. She stated a doctor-to-doctor call was made, transfer arrangements were made, including a patient room number at the receiving facility. Staff F stated with this case, it was unclear if Patient 1 would be going to Facility #2 (Foster Care Agency) or another facility. Staff F stated the patient was a ward of the state and discharged with the state SW. Staff F stated the line of communication was not good with the SW and, "Looking back we should have asked more questions."

Based on interview, record review, and policy review, the hospital's Emergency Department (ED) failed to ensure an appropriate transfer was completed for one (Patient 1) of twelve sampled patients who presented to the ED with a psychiatric emergency medical condition.

The hospital's failure to conduct an appropriate transfer of a patient with a psychiatric medical emergency led to an inappropriate discharge of a patient that resulted in delays in the patient receiving necessary stabilizing treatment to inpatient psychiatric services.

Findings Include:

A review of Patient 1's ED medical record showed the patient (a minor) presented to the ED, accompanied by law enforcement on 04/29/22 at 10:45 PM. A review of the "Clinical Report - Nurses" form showed the patient's chief complaint was suicidal thoughts. The suicidal thoughts started the day before and the patient's plan was to hang him/herself. The patient stated the thoughts were from trauma in the past. The patient had anxiety and described feelings of depression. According to the medical record, the nurse completed a "Self-Harm Assessment" and Patient 1 answered "yes" to the following questions:
-Have you recently felt down, depressed, or hopeless?
-Do you have thoughts of harming or killing yourself?
-Do you have a plan for harming or killing yourself?
-Have you noticed less interest or pleasure in doing things?
-Are you here because you tried to hurt yourself?
-Have you ever tried to hurt yourself before today?"

A review of the ED "Clinical Report - Physicians/Mid-Levels" revealed Patient 1's "History of Present Illness Chief Complaint" was suicidal thoughts and "medical clearance." The patient had been depressed and had suicidal thoughts and had inflicted self-injury. The patient described the symptoms as "severe." The patient had been hospitalized twice for suicidal ideation, most recently in March 2022. The patient had unwanted memories of past trauma that triggered the patient to begin thinking he/she would be better off dead. The patient stated his/her plan was to hang him/herself but had not thought about the steps. The patient stated the day before, he/she had cut his/her forearms intentionally. According to the note, the patient had small skin lacerations to the right and left arms.

According to Patient 1's ED Suicidal Risk Assessment, the patient's suicide risk factors were being a youth and depression. The patient also had a diagnosis of major depression. According to the clinical suicide risk assessment, Patient 1 was "high risk" for suicide. Further review of Patient 1's ED record revealed the facility obtained laboratory tests, including a complete blood count; comprehensive metabolic panel; drug screen, TSH (thyroid-stimulating hormone); blood alcohol level; acetaminophen (Tylenol) level; salicylate (aspirin) level; and magnesium levels, as well as a COVID-19 test.

Continued review of Patient 1's medical record revealed on 04/30/22 at 12:11 AM, discharge instructions were reviewed with the "intake worker," who verbalized understanding. The record showed the patient was discharged to Facility #2 (a foster care center), accompanied by the intake worker. A review of the "General Instructions" showed Patient 1 was discharged with suicidal ideation, with no suicide attempt, and recurrent major depressive disorder. The instructions showed, "You have been given the following additional information: Depression Suicidal, 72-hour hold."

Review of the medical record showed the CAH failed to provide Patient #1 with an appropriate discharge. The CAH failed to ensure Patient 1 had a psychiatric evaluation prior to discharging Patient 1 to the care of a state intake worker/social worker and prior to knowing where the patient was being discharged or having arranged inpatient psychiatric bed placement.

Review of a second medical record showed that Patient #1 presented to Facility #4 (a regional medical center 41 miles away from Facility #1) on 04/30/22 at 2:53 AM, approximately three hours after discharge from this hospital. Facility #4 staff examined Patient #1 and determined the Patient was actively suicidal and initiated arrangements for an appropriate transfer to a hospital with psychiatric capabilities for inpatient admission.

During an interview on 05/18/22 at 11:00 AM, the Nurse Manager, Staff F, stated the facility normally transferred children to Facility #3 (a children's psychiatric hospital) after a mental health evaluation was completed. She stated a doctor-to-doctor call was made transfer arrangements were made, including a patient room number at the receiving facility. Staff F stated with this case, it was unclear if Patient 1 would be going to Facility #2 (a foster care center) or another facility. Staff F stated the patient was a ward of the state and discharged with the state SW. Staff F stated the line of communication was not good with the SW and, "Looking back we should have asked more questions."

A telephone interview was conducted on 05/19/2022 at 7:45 AM with the state intake worker/social worker (SW), who was present in the ED on 04/30/2022 when Patient 1 was discharged. The SW stated she was notified that Patient 1 was picked up by law enforcement and could not return to the foster care home until the patient received mental health treatment. The SW arrived at the ED where Patient 1 was taken for medical clearance prior to inpatient psychiatric admission and relieved the deputy sheriff. The SW stated it was her understanding that arrangements for inpatient treatment had been completed; however, she told the ED nurse that she did not know where the patient was going. It was not until she was in her private vehicle with the patient after discharge that she realized inpatient arrangements for Patient 1 had not been made. The SW stated when she called Facility #2 (a foster care center) for direction regarding the inpatient facility, she was informed there were no beds available for inpatient admission. SW stated she was instructed to transport Patient 1 to Facility #4 (a regional medical center 41 miles away from Facility #1) until an inpatient psychiatric bed could be located. The SW indicated the hospital should not have discharged Patient 1 until a bed was available for inpatient psychiatric services.

During an interview on 05/18/2022 at 11:00 AM, the Nurse Manager, Staff F, stated the facility normally transferred children to Facility #3 (a children's psychiatric hospital) after a mental health evaluation was completed. She stated a doctor-to-doctor call was made, transfer arrangements were made, including a patient room number at the receiving facility. Staff F stated with this case, it was unclear if Patient 1 would be going to Facility #2 (a foster care center) or another facility. Staff F stated the patient was a ward of the state and discharged with the state SW. Staff F stated the line of communication was not good with the SW and, "Looking back we should have asked more questions."

A telephone interview was conducted on 05/18/2022 at 10:50 AM with Staff B, the physician assistant (PA) who assessed Patient 1 at the ED. Staff B stated the ED RN called at approximately 9:30 PM on 04/29/22 and told him the sheriff was bringing a patient in with suicidal ideation that had been at the sheriff's office since approximately 5:00 PM. Staff B stated he was notified that Facility #5 (the local community mental health center) had already completed a mental health screening for Patient 1 via Zoom at the sheriff's office and they just needed medical clearance for an inpatient psychiatric admission. Staff B stated laboratory tests were completed and, at approximately midnight, the SW from Facility #2 (a foster care center) arrived and the deputy sheriff released the patient to the SW for transfer. Staff B stated the patient was discharged to the care of the SW and the SW had no questions at the time of discharge. Staff B stated patient left with the SW with medical clearance in hand and, "As far as I knew, they were going to the psych hospital arranged by [Facility #5]." Staff B stated it was his understanding that all they needed was medical clearance. Staff B stated normally the ED conducted a tele-health conference with Facility #5 for mental health evaluations and held the patient until a psychiatric bed could be located; however, this situation was different because Facility #5 was already involved. Staff B stated looking back, he should have contacted Facility #5 directly.

The medical record did not contain evidence of the completed "mental health screening" referenced by PA staff B during the interview, or that the CAH arranged an appropriate transfer (including determining the capabilities and capacity of a receiving hospital, the necessary appropriate transport personnel/equipment, physician certification and copies of the patient's medical records pertaining to the emergency).