HospitalInspections.org

Based on review of the facility Medical Staff Bylaws and Rules and Regulations, Medical Record (MR), Policies and Procedures, staff and interviews, it was determined the facility failed to ensure:

1. Individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Department (ED) were identified in the facility medical staff Bylaws or Rules and Regulations.

2. A patient presenting to the ED with psychiatric diagnoses received an appropriate MSE by designated qualified medical personnel (QMP) approved by the hospital governing body.

This had the potential to affect all patients presenting to the ED and did affect Patient Identifier (PI) # 1.

Findings include: Refer to Tag A 2406 MEDICAL SCREENING EXAM CFR(s): 489.24(a).

Based on review of the facility Medical Staff Bylaws and Rules and Regulations, Medical Record (MR), Policies and Procedures, staff and interviews, it was determined the facility failed to ensure:

1. Individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Department (ED) were identified in the facility medical staff Bylaws or Rules and Regulations.

2. A patient presenting to the ED with psychiatric diagnoses received an appropriate MSE by designated qualified medical personnel (QMP) approved by the hospital governing body.

This had the potential to affect all patients presenting to the ED and did affect Patient Identifier (PI) # 1.


Findings include:

Facility Policy: Statement on "EMTALA" (Emergency Medical Treatment and Active Labor Act)
Policy Number: None
Reviewed Date: August 2022

MSE:
...The purpose of the MSE is to Determine the existence or absence of an Emergency Medical Condition (EMC). The scope of the MSE must be sufficient, based on individual circumstances, to accomplish this purpose. The MSE must be completed by a qualified medical provider. The DCH (____City Hospital) Board of Directors formally designates specifically who may complete this exam.

1. Review of the facility Medical Staff Bylaws dated June 15, 2021, and Rules and Regulations dated April 20, 2021, revealed no documentation of individuals identified who was approved by the governing body designated qualified to perform Medical Screening Examinations for the ED.

2. Patient #1's medical record was reviewed. Review of the emergency department (ED) intake assessment dated 7/27/23 at 5:52 P.M., with a chief complaint of Psychiatric Symptoms. Further review revealed that patient #1 was at a grocery store, and that emergency medical services was called, as the patient presented to the ED extremely delusional, thoughts focused on turning into a mermaid. Documentation by the ED Nurse, "Pt (patient) states she is depressed." The patient was triaged (the prioritization of injured or sick individuals based on their need for emergency treatment) as a level 2 -Emergent.

Review of the Emergency Department Note completed by the ED physician (EI #9) revealed that PI#1 was a 22-year-old who states, "it was hot outside, and she needed the inhaler." Patient denies suicidal ideation, homicidal ideation, visual hallucinations. Or auditory hallucination. The ED physician (EI#9) documented "Patient has delusions that she is a mermaid and had a penis but cut off." The physical examination conducted by the ED physician (EI#9) revealed in part, Psych (Psychiatric): "Appearance: Yes, grossly normal. Attitude: Yes, calm Speech: Yes, Normal speech, Mood and affect: Yes, normal affect and Yes Other affect and mood findings present (NORMAL MOOD)." Laboratory tests were ordered, and the patient's Urine drug screen was positive for multiple illicit drug substances. Further review revealed the ED physician (EI#9) consulted with a physician at Hospital B (the accepting Hospital), The physician at accepting hospital agreed to accept the patient for inpatient admission to their psychiatry (psych) unit. The patient was evaluated and cleared medically by the ED physician, (EI #9).

A Psychiatric Triage Assessment was completed on the patient by a Licensed Medical Social Worker (LMSW) (El# 10) at 7/27/23 at 5:51 P.M. Review of the Psychiatric Triage Assessment titled "Inquiry Form/Assessment" was completed by EI # 10. The LMSW (EI #10), who then conferred with the psychiatrist (EI #11) at DCH Regional Medical Center who recommended admission to a Psychiatric Intensive Care Unit. An Assault and Violence Assessment Tool was completed by the LMSW (EI #10) on 7/27/23 at 8:32 PM. The psychiatric medical screening examination was not performed by designated qualified medical personnel approved by the hospital's governing board.

An interview conducted on 8/16/23 at 12:00 PM with EI # 1, confirmed there was no documentation in the Hospital Bylaws or Rules and Regulations to identify individual(s) who were qualified to perform the MSE.