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Based on record review and interviews, the facility failed to comply with 489.24 and provide a complete medical screening examination (MSE) in 2 of 20 sample records (Pt #'s 1 and 14) that were reviewed.

Refer to A2406 for additional information.

2406
Based on a review of facility policy, patient records, and interviews, the facility failed to perform and document an appropriate medical screening examination (MSE), to include a complete psychiatric evaluation by qualified medical personnel for patients experiencing a psychiatric emergency, to determine if the patient was stable or had an emergency medical condition in 2 of 20 (Patients #1 and 14). Patient # 1 had an order for a psychological assessment but left against medical advice. Patient # 14 arrived with suicidal ideation without a plan. Patient # 14 was discharged home with the behavioral team, patient, and parent agreeing to outpatient services.

Medical Record

Patient # 1

A review of the document titled "Patient Medical Chart" for Patient 1, revealed the patient arrived at the facility on 10/23/24 at 2:58 pm in police custody for psychiatric assessment. Patient #1 was triaged at 3:20 AM. The MSE was started at 3:06 AM. However, there is no evidence Patient #1 received a psychiatric evaluation for their psychiatric medical emergency condition. The patient record indicates the patient left against medical advice (AMA).

A review of the document titled, "Apprehension by Police Officer Without Warrant (APOWW)", revealed the under section 1 "I have a reason to believe and do believe that the above named person evidences a substantial risk of serious harm to himself/herself, or others based upon the following : (handwritten) Patient was involved in a disturbance with his family. We arrived to screaming in the house, Patient #1 had a blank stare, with huge pupils, (illegible) about bed and not responding to the officers. He was clearly in a mental health crisis. We went to APOWW him and he resisted officers.
Under section 4. My beliefs are based upon the following recent behavior, overt acts, attempts, statements, or threats observed by me or reliably reported to me : Parents advised has diagnosis bipolar and schizo affective disorder and is off his meds, screaming, and mentally (illegible) body in crisis."
The APOWW is signed by a peace officer and indicates Patient #1 was restrained and transported to Facility A on 10/23/2024 at 02:46 AM.

A review of the document titled Emergency Provider Report" by Staff # 1, DO Emergency Medicine, revealed the following:
"History of Present Illness
The patient is a 26-year-old male with a past medical history of schizoaffective disorder who
presents to the emergency department via police with an EDO[Emergency Detention Order] for psychiatric assessment.
Patient was reportedly causing a public disturbance which is why the police were called, they
reported that the patient was making hyperreligious statements and at 1 point the police had to
take him to the ground and put him in cuffs but no other details were provided. No report of the
patient making any statements about harming himself or others, and no reported SI or HI. On arrival
to the emergency department the patient is now refusing to answer any questions. It was reported
however the patient has been off of his medication though I do not know how long he has been off of
his medications."

A review of the document titled "Rapid Initial Assessment" by Staff # 3, RN on 10/23/2024 at 3:10 AM revealed the following:
Per mom and dad, Patient #1 has been off his medication for a couple of weeks and was becoming aggressive towards them.

A review of the document titled "Emergency Notes" by Staff # 2, RN on 10/23/2024:
4:32 AM: "Requested security to escort Pt out."
04:33 AM: "Pt left @ this time with MPD[McKinney Police Department] & Security. Given drivers license."

Patient # 14

A review of the document titled "Emergency Provider Report" by Staff # 6, on 10/23/2025 at 11:17 AM revealed the following:
History of Present Illness
"This is a patient with no significant past medical history no allergies no surgeries on no
medications. Patient suffered physical abuse as a child from her father. She saw a psychiatrist
afterwards and there was concern for possible bipolar disorder then. She is presenting for acute
suicidal ideation without a plan. Patient has been having increased amounts of arguments with her
mother and states that she is unable to control her anger and emotions. Has a history of self-harm
but no loss of arms. Denies any HI. Denies any AVH. Does consume marijuana occasionally." ...
Vital signs on 10/23/25 at 11:18 AM: Temperature-36.5C, Pulse-85, Respirations-18, Blood Pressure-114/70, SPO2-100% on room air.
... "Lab Statement: Laboratory studies reviewed and considered in the medical decision-making"
Clinical Impression was noted as a mood disorder. Patient # 14 was discharged home on 10/23/2024 at 1:10 PM.
Discharge Instructions include referrals to a Behavioral Health Intensive outpatient program and to a Behavioral Health Partial Hospital Program.

A review of the document titled "Detailed Assessment" by Staff # 7, RN on 10/23/2024 revealed the following:
11:18 AM: Anxiety, Depression, and Post-traumatic stress disorder was noted.
1:22 PM: Patient # 14 was discharged in stable/stabilized condition and was expected to maintain stabilization. Patient # 14 departed with her mother and walked to the car.

The facility failed to ensure Patient # 14 received a full medical screening exam that included a psych exam for Patient # 14, who presented to the facility with acute suicidal ideation without a plan. Patient # 14 has past medical diagnoses of: anxiety, depression, and Post Traumatic Stress Disorder. During patient # 14 emergency room visit, no suicidal screening was completed. The facility failed to transfer a patient who had suicidal ideation with a past mental health history.

Policy
A review of the facility policy titled "PC.PP.112, Texas EMTALA Medical Screening Examination and Stabilization Model Policy", effective date 12/2000, last revised 09/2024, revealed the facility did not follow its policy: page 10, Section 3e, iii.
"Individuals with psychiatric or behavioral symptoms: The medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicates danger to self or others."

Interviews:

An interview with Staff # 5, RN, ED Manager, on 01/14/2025 at approximately 11:08 AM revealed that when a patient arrives with the Police, the doctor will speak with the police officer. The nurse will assess for mental health issues, including suicide and homicide ideation. We will have the patient change into blue paper scrubs and grippy socks. We would not restrain the patient if the patient refused care and had no violent/aggressive behaviors. Behavior Health would provide a psychiatric evaluation of the patient next. If the patient were not talking, we would wait for Behavior Health to provide a recommendation. We are working to have Behavioral Health available for psychiatric evaluations 24 hours a day, but at this time, it is hard to cover the 1st and 2nd shifts.

An interview with Staff # 1, MD, Emergency Medicine, on 01/14/2025 at approximately 4:43 PM revealed the following: "The Police brought the patient in. I was told he was making religious statements. The patient allowed me to complete a physical examination. He never spoke a word; he only shook his head and made eye contact." Nursing and I wanted him to stay and have a psychological evaluation, but we needed to complete a blood test first to have him medically cleared, but the patient refused. "He would have benefited from having a Psych Eval, but he didn't pose a threat to himself or others, and we could not hold him against his will. With the information, I had nothing that rose to that level."

An interview with Staff # 2, RN, ED Charge Nurse, on 01/14/2025 at approximately 4:52 PM revealed the following:
"I was notified that the patient was not answering questions for his assessments," I spoke to Staff # 1, MD Emergency Medicine, and he said we could override the EDO and discharge the patient. It was explained to the patient that he could not get a ride home if he left AMA. I asked the patient to sign the discharge Against Medical Advice (AMA), but he declined and sat on his bed. The patient had to be escorted by Security out of the building; he didn't want to leave. The Police were also notified that a patient was leaving AMA.