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Based on review of hospital policies, interviews and closed patient medical records, the hospital failed to provide an appropriate medical screening exam to determine the presence of an emergency for one (#6) patient; and failed to provide stabilizing treatment within the capability and capacity of the Emergency Department (ED) for one (#5) patient that presented with an emergency, out of a total of 20 patients selected for review from April through September, 2012.

Findings included:

1. Review of hospital policy, "EMTALA: Medical Screening Examination and Stabilization Policy" dated 07/13/12, defined a patient as stable when the physician treating the emergency has determined that the EMC (emergency medical condition) that caused the individual to seek care in the ED is resolved.

Review of hospital policy titled, "Mental Health" revised 01/07, showed that ED staff should contact the Behavioral Health Call Center (BHCC), operated under the guidance and supervision of the Health System's psychiatric hospital, for all patients who present to the ED demonstrating symptoms of a mental illness or substance abuse. The policy specified the BHCC will provide guidance and assistance to determine the appropriate level of care required, and receive intake information for the purpose of transfer, placement and follow up care.

Review of Patient #5's closed medical record showed he presented to the ED on Sunday 7/1/12 at 12:06 PM stating he "cut [his] groin on Friday. "Documentation in the medical record indicated patient #5 signed the ED consent to treat form at 1:10 PM. ED registered nurse (RN) I documented her assessment of the patient on Monday 7/2/12 at 4:22 PM, over 24 hours after patient # 5 initially presented to the ED. RN I's "late entry" documentation indicated she assessed patient # 5 on 7/1/12 at 12:45 PM and that his behavior was "appropriate." "Upon physical examination of pt's testicles, this nurse observed two very swollen testicles, purplish in color with a tight yellow band secured at the base of the penis." ED physician J examined patient # 5 and documented (untimed entry) that the patient "wanted castration for years, (has) never seen a Urologist." Further documentation revealed the patient had a history of Bipolar disorder (severe mood disorder), prior suicide attempts, that he denied current thoughts of suicide or homicide, and had a history of a gunshot wound to his abdomen resulting in the loss of his right kidney. ED physician J documented he had a "long" discussion with the patient and his family member. "He does not want me to remove tourniquet", I advised follow up with his primary care physician and a psychiatric evaluation." "Discussed risks of self-castration including infection, bleeding and death. " ED physician J documented he contacted the on call urologist who recommended a psychiatric evaluation. ED physician J prescribed an oral antibiotic, a tetanus shot and application of a numbing gel-like medication (viscous Lidocaine) to the skin around the testicles, and provided discharge instructions for Epididymo-orchitis (a painful condition usually caused by either infection or swelling of both the testicles). Documentation in the medical record indicated Patient #5 departed the ED at 2:21 PM. The medical record did not contain evidence that patient # 5's emergency medical condition was stabilized prior to discharge.

Review of a second closed medical record showed Patient #5 returned to the ED on 7/1/12 at 6:20 PM, approximately 4 ? hours after discharge complaining of severe pain and profuse bleeding. ED physician L examined the patient and documented his scrotum and testicles were gone and the patient was bleeding from a large open wound. The on-call trauma surgeon was notified and the patient was taken to the operating room for repair of his traumatic laceration. At 7:45 PM, RN I documented Patient #5 stated "I told you I would take care of it honey, I had to do something because the ER (emergency room) doc just sent me home without doing anything." "I took my pocket knife at home and sharpened it really good and I just cut them off." Further documentation revealed that after surgery, the patient was taken to the intensive care unit for recovery and one-on-one psychiatric monitoring. An affidavit to support involuntary commitment was completed by a psychiatric nurse evaluator who specified that Patient #5 said "men think if you're going to castrate me, you might as well kill me." "Patient then states, 'I' m the same way, if I lose it I'd rather be dead." "States he's been suicidal most of his life." "Has had 2 suicide attempts including 1 gunshot to abdomen." Documentation in the medical record indicated Patient #5 was transferred by ambulance to a hospital with inpatient psychiatric care on Thursday 7/5/12 at 11:30 AM.

During an interview on 10/04/12 at 2:43 PM, Urologist H confirmed that he was the urologist on-call to the ED on 07/01/12 and that he spoke with ED physician J about Patient #5's condition. Urologist H stated, "Obviously this guy was suffering from a psychiatric condition." "I advised him (ED physician J) to cut the ligature and immediately transfer to a psychiatric hospital." "I told him I was not interested in performing surgery (castration) on a patient who was psychiatrically unstable (at the time of the first ED visit)."

During an interview on 10/03/12 at 8:22 PM, ED physician L (on duty when patient # 5 returned to the ED at 6:20 PM on 7/1/12) stated that Patient #5 had an emergency medical condition when he was discharged from the ED at 2:21 PM with his testicles still tied.

Refer to tag A 2407 for further details.

2. Review of hospital policy, "EMTALA: Medical Screening Examination and Stabilization Policy" dated 07/15/08, showed a medical screening exam (MSE);
-Is an ongoing process and must continue until the individual is stabilized or appropriately transferred;
-Is appropriate to the individual's presenting signs and symptoms, that determines whether or not the individual has an emergency medical condition (EMC);
-For individuals with psychiatric symptoms, the MSE should include both medical and psychiatric or behavioral components to determine that there is no EMC (e.g., alcohol or substance abuse, etc.); and that
-The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicates a danger to self or others; and
-For an individual with psychiatric conditions, the individual is considered to be stable for discharge when he or she is no longer considered to be a threat to self or others.

Review of a closed medical record showed patient # 6 presented with law enforcement to the emergency department on 07/03/12 at 2:08 PM because she had threatened suicide. The medical record contained two affidavits signed by patient # 6's friends stating she had beat her head on the curb, threatened to commit suicide by jumping off a bridge and had jumped in front of a truck in an attempt to take her life. The ED nurse documented patient # 6 had bruises over her arms and legs. The ED physician examined patient # 6 and documented that she was depressed, angry, hostile, agitated, and tearful, had suicidal thoughts, and that she had a history of prior suicide attempts and psychiatric problems including bipolar disorder (a serious mood disorder). Further documentation by the ED physician indicated patient # 6 was physically abusive toward staff and police were notified and "asked them to take patient to jail." Documentation indicated patient # 6 departed the ED at 2:49 PM. The medical record did not contain evidence that patient # 6 received a psychiatric evaluation or that she was no longer suicidal prior to discharge.

Refer to tag A 2406 for further details.









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Based on record review and staff interview, the hospital failed to provide a medical screening examination sufficient to determine the presence of an emergency medical condition for one (#6) of 20 patients who presented to the hospital Emergency Department (ED) seeking care, out of a sample selected from April through September, 2012.

Findings included:

1. Review of hospital policy titled, "Mental Health" revised 01/07, showed that ED staff should contact the Behavioral Health Call Center (BHCC), operated under the guidance and supervision of the Health System's psychiatric hospital for all patients who present to the ED demonstrating symptoms of a mental illness. The policy specified the BHCC will provide guidance and assistance to determine the appropriate level of care required, and receive intake information for the purpose of transfer, placement and follow up care.

Review of documentation provided by the hospital's Chief Nursing Officer dated 10/3/12 specified that staff at Belton Regional Medical Center contact the mental health assessor team through the call center (the BHCC) if a patient needs psychiatric care or assessment, and "we transfer if patient needs psychiatric care."

Review of a closed medical record showed patient # 6 presented with law enforcement to the emergency department on 07/03/12 at 2:08 PM because she had threatened suicide. The medical record contained two affidavits signed by patient # 6's friends stating she had beat her head on the curb, threatened to commit suicide by jumping off a bridge and had jumped in front of a truck in an attempt to take her life. The ED nurse documented patient # 6 had bruises over her arms and legs. The ED physician examined patient # 6 and documented that she was depressed, angry, hostile, agitated, and tearful, had suicidal thoughts, and that she had a history of prior suicide attempts and psychiatric problems including bipolar disorder (a serious mood disorder). Further documentation by the ED physician indicated patient # 6 was physically abusive toward staff and police were notified and "asked them to take patient to jail." Documentation indicated patient # 6 departed the ED at 2:49 PM. The medical record did not contain evidence that staff contacted the BHCC to arrange a psychiatric evaluation or transfer, or that patient # 6 was no longer suicidal prior to discharge.

Review of a second closed medical record revealed law enforcement transported patient # 6 to another hospital ED on 7/3/12 at 3:25 PM for a psychiatric examination.

During an interview on 10/03/12 at 10:26 AM, ED physician P stated that patient # 6 was well known to him and that she became abusive and uncooperative after his examination. ED physician P stated the police said they would put patient # 6 on a suicide watch. He stated that if the patient had been anyone else, he would have requested a psychiatric evaluation but because he knew her; he did not feel it was necessary. ED physician P stated that he did not feel the affidavits were credible because they (patient # 6 ' s friends) were both "drugged up." He stated there was no way a psychiatric evaluation could be done in patient # 6's condition.

Based on record review and interviews, the hospital failed to provide stabilizing treatment within its capacity and capability for one (#5) of 20 patients who presented to the hospital Emergency Department (ED) seeking care for an emergency medical condition, out of a sample selected from April through September, 2012.

Findings included:

1. Review of hospital policy titled, "Assessment and Reassessment, Vital Sign Policy for Emergency Department Patients" revised 09/01/09, showed that it is the responsibility of the physician to determine stability for discharge. If the patient is deemed medically unstable, they may be admitted to the hospital until such time that an appropriate transfer for mental health evaluation and/or treatment may be achieved.

Review of hospital policy titled, "Mental Health" revised 01/07, showed that the Health System's Behavioral Health Call Center (BHCC) should be contacted for all patients who present to the ED demonstrating symptoms of a mental illness or substance abuse. The policy specified the BHCC will provide guidance and assistance to determine the appropriate level of care required, and receive intake information for the purpose of transfer, placement and follow up care.

2. Review of Patient #5's closed medical record showed he presented to the ED on Sunday 7/1/12 at 12:06 PM stating he "cut [his] groin on Friday." Documentation in the medical record indicated patient #5 signed the ED consent to treat form at 1:10 PM. ED registered nurse (RN) I documented her assessment of the patient on Monday 7/2/12 at 4:22 PM, over 24 hours after patient # 5 initially presented to the ED. RN I's "late entry" documentation indicated she assessed patient # 5 on 7/1/12 at 12:45 PM and that his behavior was "appropriate." "Upon physical examination of pt's testicles, this nurse observed two very swollen testicles, purplish in color with a tight yellow band secured at the base of the penis." ED physician J examined patient # 5 and documented (untimed entry) that the patient "wanted castration for years, (has) never seen a Urologist." Further documentation revealed the patient had a history of Bipolar disorder (severe mood disorder), prior suicide attempts, that he denied current thoughts of suicide or homicide, and had a history of a gunshot wound to his abdomen resulting in the loss of his right kidney. ED physician J documented he had a "long" discussion with the patient and his family member. "He does not want me to remove tourniquet", I advised follow up with his primary care physician and a psychiatric evaluation." "Discussed risks of self-castration including infection, bleeding and death." ED physician J documented he contacted the on call urologist who recommended a psychiatric evaluation. ED physician J prescribed an oral antibiotic, a tetanus shot and application of a numbing gel-like medication (viscous Lidocaine) to the skin around the testicles, and provided discharge instructions for Epididymo-orchitis (a painful condition usually caused by either infection or swelling of both the testicles). Documentation in the medical record indicated Patient #5 departed the ED at 2:21 PM.

Review of Patient #5's second closed medical record showed he returned to the ED on 7/1/12 at 6:20 PM, approximately 4 ? hours after discharge complaining of severe pain and profuse bleeding. ED physician L examined the patient and documented his scrotum and testicles were gone and the patient was bleeding from a large open wound. The on-call trauma surgeon was notified and the patient was taken to the operating room for repair of his traumatic laceration. At 7:45 PM, RN I documented Patient #5 stated "I told you I would take care of it honey, I had to do something because the ER (emergency room) doc just sent me home without doing anything." "I took my pocket knife at home and sharpened it really good and I just cut them off." Further documentation revealed that after surgery, the patient was taken to the intensive care unit for recovery and one-on-one psychiatric monitoring. An affidavit to support involuntary commitment was completed by a psychiatric nurse evaluator who specified that Patient #5 said "men think if you're going to castrate me, you might as well kill me." "Patient then states, 'I' m the same way, if I lose it I'd rather be dead." "States he's been suicidal most of his life." "Has had 2 suicide attempts including 1 gunshot to abdomen." Documentation in the medical record indicated Patient #5 was transferred by ambulance to a hospital with inpatient psychiatric care on Thursday 7/5/12 at 11:30 AM.

Review of the Hospital's on call list revealed a urologist was on call for the ED on Sunday 7/1/12. And through the Health System's BHCC, a mental health professional was available to perform a mental health examination when Patient #5 presented to the ED on 7/1/12 at 12:06 PM with a medical and psychiatric emergency.

During an interview on 10/03/12 at 6:00 PM, ED physician J stated that he examined Patient #5 while his family member was in the room and confirmed that the patient had a ligature around his scrotum (testicle sac), and that the patient's scrotum was swollen and dark blue in color. ED physician J stated that patient # 5 hemmed and hawed around about why he was there then said he wanted to be castrated and that he was uncomfortable when a riding a horse and motorcycle. "I asked to remove the tourniquet, but the patient refused." "I asked why not" and the patient responded "contrary to what his goal was, what his experience was with castrating cattle." ED physician J stated he knew the patient was Bipolar but did not assess whether the patient took or was compliant with medications, whether he was seeing a psychiatrist, whether the patient's prior gunshot wound was self-inflicted, and could not recall "what his prior attempt at suicide was" and did not know if the patient had attempted suicide more than once. ED physician J stated that "apart from his scrotum, he (patient # 5) was stable." When asked about psychiatric emergencies and the risk for self-harm, ED physician J confirmed that binding your testicles was a means of self-harm. "I had a concern, unusual thing that he (patient # 5) did for an unusual reason." ED physician J stated that patient # 5 refused a psychiatric evaluation but he did not document this in the medical record. ED physician J stated he documented that he discussed "the risk of infection, bleeding and death." ED physician J stated "I felt the patient had a right to make the decision he was making."

During an interview on 10/02/12 at 1:05 PM, Patient #5's family member stated that she took Patient #5 to the ED because he had banded his testicles which were swollen the size of grapefruits, oozing serous-sanguinous fluid (appears like diluted blood), and the skin at the base of the band was black. While Patient #5 checked in, the family member stated she parked the car and then went to his room in the ED. The ED physician came into the room, glanced at patient # 5's testicles and said, "You should see a psychiatrist and a urologist", and left the room without performing a physical exam. The family member stated that the ED physician came back into the room and stated that the urologist said, "I won't touch him, he needs a psychiatrist." The family member stated patient # 5 responded "I will just have to take care of it myself." The family member said the nurse came into the room and put lidocaine (numbing medication) on patient # 5's "tissue" (skin around the band), gave the patient a prescription for an antibiotic, and both the patient and family member left. The family member stated the patient's parent and a sibling both committed suicide and that the patient sees a psychiatrist monthly, but the ED physician did not offer the patient a psychiatric evaluation. The family member said the ED physician didn't ask patient # 5 if he felt suicidal and "didn't ask me either", he just said, "This is crazy! This isn't an emergency, this is an ED. We don't do that (castrate) here." The family member stated that as they were leaving the ED patient # 5 told the ED physician that he "would just take care of it himself," and that the ED physician said, "Stop. I don't want you to do that."

During an interview on 10/09/12 at 4:30 PM the ED Patient Care Technician (PCT) O stated that on 07/01/12, when Patient #5 came in the first time, ED physician J asked her to contact the urologist on-call. After the phone call (between ED physician J and Urologist H), ED physician J asked her to get the patient's family member so they could speak in private. PCT O stated she overheard ED physician J telling the family member that "he (Patient #5) would greatly benefit from a psychiatrist" and the family member nodded. The PCT O said that ED physician asked her to come and witness his conversation with Patient #5. PCT O said that ED physician J told patient # 5 "We don't treat this particular situation (castration) here in the ED setting. You need to follow-up with a psychiatrist and PCP (Primary Care Physician)." The patient seemed anxious and was walking around the room when he said to the ED physician, "So, if someone comes in profusely bleeding, then you have no option but to take care of him, right?" ED physician J said, "That's right, but we're not going to talk about that." The patient asked if there was anything the doctor could do for his pain, so ED physician J ordered viscous (gel-like) Lidocaine to be applied to the patient's scrotum (testicle sac). PCT O said that after she left the room with the ED physician, "I told (ED physician J) that sounded like a threat" and he said, "Yes, it did." ED physician J asked a nurse to apply the ordered medication to the patient's scrotum and PCT O was asked to witness the medication application. PCT O stated that during the medication application, Patient #5's testicles were inflamed, the size of a softball and "very purple."

During an interview on 10/02/12 at 3:30 PM, ED registered nurse (RN) I confirmed that she asked PCT O to witness while she applied viscous Lidocaine to Patient #5's testicles. RN I stated that the patient's testicles were swollen to the size of a grapefruit. RN I stated she asked ED physician J whether they were going to leave the patient's testicles banded and ED physician J said "He has the right to refuse treatment" but the patient did not sign a form indicating he was refusing against medical advice. RN I said that when patient # 5 returned to the ED later on 7/1/12 he was in a wheel chair and bloody from the waist down and that he told ED physician L he was in a mowing accident.

During an interview on 10/03/12 at 8:22 AM, ED physician L (on duty on 7/1/12 when patient # 5 returned to the ED) stated that "based on the information I was provided, I believe the guy (Patient #5) was suffering from an emergency medical condition when he was discharged with his testicles tied." ED physician L stated if he had examined patient # 5 when he first presented to the ED on 7/1/12, he would have been concerned about the patient's blood flow to his testicles, he would have attended to the patient's psychiatric needs, and would have refused to let the patient leave the ED, would have detained him if needed.

During an interview on 10/04/12 at 2:43 PM, Urologist H confirmed that he was the urologist on-call to the ED on 07/01/12 and that he spoke with ED physician J about Patient #5's condition. Urologist H stated, "Obviously this guy was suffering from a psychiatric condition." "I advised him (ED physician J) to cut the ligature and immediately transfer to a psychiatric hospital." " I told him I was not interested in performing surgery (castration) on a patient who was psychiatrically unstable (at the time of the first ED visit)."

During an interview on 10/04/12 at 3:53 PM, Surgeon M confirmed that he was the surgeon on-call on 07/01/12 and that the ED contacted him about a trauma case in the ED. After Surgeon M arrived at the ED, he took Patient #5, who had completely removed his testicles, to the operating room (OR) for surgical repair. Surgeon M admitted patient #5 to the Intensive Care Unit (ICU) for recovery and one-to-one observation (constant observation of the patient by a staff member) for the patient's safety. Surgeon M stated that "I can't speak for (ED physician J) but I would have considered that he talk to someone, at least a psychiatrist." "You can involuntarily commit someone if you think they are a harm to themselves ... "

During an interview on 10/04/12 at 4:43 PM, House Supervisor N stated he was on duty when Patient #5 presented to the ED and said, "He (Patient #5) was having psychiatric issues, I'm sure."

During an interview on 10/02/12 at 7:40 PM, Triage Nurse K stated that Patient #5 was one of the last patients for ED physician J, because he left the ED early that day. "If I would have known he (Patient #5) had banded his testicles I would have made him a triage level two (increased severity), and immediately gotten the doctor." Nurse K added that she would not have let the patient leave with his testicles banded, and felt Patient #5's condition warranted a psychiatric evaluation as he obviously had an "urgent psychiatric matter." Nurse K stated that the ED can call the health system's psychiatric call center. " The call center will send out a professional to complete a psychiatric evaluation." "The psychiatric professional usually responds to the ED within one hour or less to evaluate the patient."