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Based on observation and interviews, the facility failed to ensure appropriate signage was posted conspicuously in the Emergency Room Department addressing patient rights and rights to medical screening and treatment, relating to EMTALA.

The findings were as follows:

Observations
On 12/19/2023 at approximately 2 PM, a guided tour of the emergency department was conducted. There were no signs observed on the walls to detail or inform patients of the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor. Upon further observation, the signs were located on top of a cabinet behind the information desk which were not visible to anyone entering the waiting room or emergency department.

Interviews

On 12/19/2023 at approximately 2 PM, an interview with Staff # 2, VP of Risk Management and Staff #9, Emergency Department Director indicated the signs have not been posted in the Emergency Department for approximately 19 days, since 12/1/2023. Staff #2 and Staff #9 were not aware of why the postings were taken down but indicated the hospital recently underwent renovations and other permanent signs were being ordered. Staff #2 and Staff #9 indicated they were aware the postings should be up at all times.

Based on record review and interview, the facility failed to complete a medical screening examination, as evidenced by not providing an appropriate mental health screening examination within the capability of the hospital's emergency department for (Patient #1), who presented to the Emergency Department with a chief complaint of suicidal ideation and self-mutilation.

Findings included:

Record Review:

Based on Patient #1's medical record, on 11/04/2023, Patient #1 was presented to Hospital A by a police officer for a suicide attempt. Patient #1 was placed on an Emergency Detention Order (EDO) before being brought to the hospital by, a Sheriff's Deputy for the County, Deputy #1. Hospital A ascertained Patient #1 was above the legal limit with a blood alcohol level of 271 and could not undergo a mental health screening unless the blood alcohol level reached 80 or below 80. Hospital A informed Deputy #2,. another county Sheriff, that an officer had to remain with patient #1 until a mental health screening was completed. Deputy #2 signed Patient #1 out of AMA and transported Patient #1 to Hospital B. Hospital B admitted Patient #1 and provided psychiatric treatment for depression and suicidal ideation with Lexapro 5 mg, and the dose was adjusted accordingly and discharged Patient #1 on 11/10/2023 on a prescription medication for depression.

Interviews:

In an interview with Deputy #2 (Police Officer), Deputy #2 stated he presented to Hospital A to assist with patient #1's EDO and admission to the facility. Deputy #2 indicated that Hospital A refused to perform a mental health screening due to patient #1 being intoxicated. Deputy #2 stated that Patient #1 was transported to Hospital B, where they provided a mental health screening, and Patient #1 was admitted for further treatment.

On 12/19/2023 at 3:00 PM, in an interview with the Emergency Department Director, Staff #9, the Director stated that Hospital A cannot complete a mental health evaluation unless the patient is sober. The Director stated that the Registered Nurses and Medical Doctors in the emergency room do not complete behavioral health assessments as they are conducted by the local mental health authority or the hospital's behavioral health unit. The Director stated that patients can be admitted into the ICU for one-to-one observation while they sober up; however, the police officers will be elected to stay, which caused an issue in this instance.

On 12/19/2023 at 3:50 PM, Emergency Room Charge Nurse, Staff #6, stated she recalled providing care to patient #1, who presented with suicidal ideations and self-harmed in the presence of the police officer. Staff #6 indicated that the patient was triaged, and the police officer was told that the mental health screening could not be conducted until the patient was sober or below the legal alcohol limit. Staff #6 stated she is unsure where this hospital policy exists, but it is a known practice.

On 12/19/2023 at 4:05 PM, the Emergency Room Physician, MD #1, indicated that at this facility, the behavioral unit will not evaluate unless the blood alcohol content is below the legal limit. MD#1 stated he witnessed the police officer who did not want to wait and took patient #1 prior to the mental health screening being completed.

On 12/19/2023 at 5:20 PM, the Director of Behavioral Health, Staff #10, stated that a patient must be medically cleared before the assessor can be sent to meet with them in the emergency room. This is to ensure they can take care of them, whether admitted to the floor. Staff #10 was asked where this information could be found in the policy. Staff #10 stated she could not locate a policy that says this. Staff #10 confirmed that a behavioral health screening is not completed as part of the medical screening examination.

Policy Reviews:

The policy titled Suicide Mental Health Policy [last reviewed 8/2021], originated 10/2020, indicated a Columbia Suicide Severity Rating Scale is completed as part of pre-assessment on all patients. However, admission, treatment, and discharge recommendations are completed in consultation with a psychiatrist or provider.
The policy titled Patient Transfer reviewed 12/19/2023 reflected that the hospital would provide appropriate medical screening examinations within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department.

There were no policies found to address assessing patients who are under the influence of drugs and alcohol.

Record Review

Patient #1's medical records from Hospital A and Hospital B indicate that Patient #1 was transferred by Deputy #2 without Hospital A initiating any transfer process, no Memorandum of Transfer (MOT), and no Physician Certification. Patient #1's medical records indicate that Hospital A knew that Patient #1 was being taken to Hospital B for a psychiatric evaluation and treatment. However, they categorized the patient as leaving "against medical advice" and did not provide further follow-up with Hospital B.

The facility Policy titled "Patient Transfers" [Last Reviewed Date: 12/02/20] states:

Transferring a Patient with an Un-Stabilized Emergency Medical Condition
If a patient has an Emergency Medical Condition that hasn't been stabilized, no transfer can occur unless:
" The physician explains to the patient or patient representative that the expected medical benefits from treatment at another hospital are greater than the increased risks to the patient (and, in the case of labor, to the unborn child) and recommends the transfer.
" The physician's certification is documented on the Memorandum of Transfer form.

Physician's Responsibilities
The transferring physician must:
" Before transfer, secure a receiving physician and a receiving hospital suitable for the patient's medical needs, willing to take responsibility for the patient's treatment and care.
" Ensure that the transfer is conducted to minimize risks to the patient.

Hospital's Responsibilities
In arranging for the patient's transfer, the hospital must:
" Organize transportation.
" Provide the necessary medical records to the receiving hospital.
" Complete the required forms, including the Memorandum of Transfer and the Patient's Request/Refusal/Consent to Transfer.

Interviews

The surveyor interviewed Deputy#2 on 12/14/2023 at 4:00 PM. Deputy #2 stated that the patient was suicidal and was transported to Hospital B for a psychiatric evaluation after Hospital A refused to provide an assessment until Patient #1 was considered sober.

The Surveyor Interviewed Complainant, Director of Clinical Risk, Patient Safety at Hospital B on 12/18/2023 at 02:14 PM, stated, " There were no records that accompanied the patient. After the patient arrived at Hospital B, the patient signed an ROI (release of information) and allowed Hospital B to request records. After reviewing the records, Hospital B identified Patient #1 was previously at Hospital A for the same chief complaint. Hospital A acknowledged there was no transfer between Hospital A and Hospital B.

The Surveyor interviewed Staff#1, Charge Nurse, on 12/19/2023 at 3:52 PM, who stated that Deputy#2 did not want to wait and was asked if Patient#1 could be transferred to another facility to conduct the behavioral health screening to admit Patient#1. Staff#1 told the officer he could not leave with patient#1. She said if he insisted, Patient#1 needed to be signed out of AMA.

On 12/19/2024 at 4:05 PM, an interview was conducted with MD#1, who stated, "They could transfer her to another facility to do the psychiatric evaluation, but the officer did not want to wait."

On 12/19/2023 at 4:22 PM, an interview was conducted with Registered Nurse (RN) Staff#2, who stated that she vaguely remembers the incident. She does not recognize the patient's name, but there was a patient for whom the officer signed an AMA. She said the police officer wanted to take her to another facility.

On 12/19/2024 at 4:33 PM, an interview was conducted. Registered Nurse Staff#3 stated that the deputy kept asking how long it would take for the blood Alcohol content Level to go down, and he called his superior. He kept asking to take her to Hospital B, but they told him they could not take her, but she was under the police officer's custody. The police officer was directed to charge nurse. The charge nurse gave him AMA and said he could take her.