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Based on interview and record review with regard to Complaint # TX00430791, the hospital did not abide by the provider's agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements in that, Patient #1 was not provided a continuing medical screening examination on 08/21/22.

Cross Refer to Tag 2406

Findings included:

Based on record review and interview the facility failed to provide a medical screening to 1 of 25 patients
(Patient #1).

Review of medical record revealed the Patient #1 was brought to the facility's emergency department (ED) on 8/21/22 by a family member (mother). The patient arrived in the ED at 8:45 PM with a chief complaint of self-harm behavior in a suicide attempt. Per family member (mother) Patient #1 was combative and held a knife to his throat earlier. Patient #1 was sitting in the vehicle outside the ED and fled the scene prior to staff arrival. The police apprehended and accompanied Patient #1 back to the ED. Police reported Patient # 1 had intentionally hit his head on the concrete and multiple times in the backseat of the police car. Personnel #8 and Personnel # 9 spoke to Patient #1 through the window of the police car asking if he wanted to see the doctor for his injuries. Patient #1 kept repeating "I want to go home". Patient #1 refused treatment even though the family member (mother) requested treatment. Personnel #8 and Personnel #9 presented to Patient #1 and family member a Refusal of Exam and treatment form (EMTALA), which the mother signed.

At 9:21 PM, a nurse (Personnel # 9) noted "Mother brought patient to ER to be seen, asked for assistance in getting patient out of car because he was being combative and had held a knife to his neck prior to arrival. When we went out to see what the situation was about, patient left vehicle and proceeded to leave property. Mother called police for assistance. Police arrived back on campus with patient in back seat of police car. We spoke to patient through window asking if he wanted to be seen by doctor for injuries. Police officer stated patient hit his head on concrete intentionally multiple times and in the back of the police car, patient has a raised bump on forehead with scant amount of blood. Patient's mother at police vehicle and she asked him as well if he would let doctors look at him. He just keeps repeating that he wants to go home. Police plan on taking him to jail, processing and then have MHMR assess and possibly take to JPS. Nurse Practitioner was also at side of police car to assess and patient not consenting to being seen. Wound to neck and forehead seem to be superficial. Mother signed EMTALA form."

Patient # 1 wounds were not fully evaluated, including a wound to the patient's neck. Patient #1 was allowed to leave in policy custody without having received a Medical Screening Exam (MSE) and was not stabilized.

Record review indicated Patient #1 was placed under an Emergency Detention Warrant on 08/21/22 at 8:10 PM.

During an interview via phone call on 10/24/22 at 1:04 PM, Personnel #8 stated Patient #1 presented to the ED and appeared to be a harm to himself and needed to be transferred to a psychiatric facility. Personnel # 8 stated she did not document in Patient #1 medical record because she did not officially perform an assessment.