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Based on document review and interviews, the hospital failed to meet the emergency needs of 7 of 18 patients (P2, P7, P22, P23, P24, P25 and P16) reviewed. The hospital did not provide care and services within safe an appropriate times. The hospital was found to be not in substantial compliance with the Condition of Participation of Emergency Services at 42 CFR 482.55

Although patients received a clinical assessment, this was conducted by a Registered Nurse (RN) or Social Worker (SW), and a medical screening examination or psychiatric screening evaluation by a qualified provider did not occur for several hours which could hinder timely and appropriate care of the emergency patient.

Findings include:

Refer to the deficiency issued at A-1103.

Based on interview and document review, the hospital failed to assess and render appropriate care and services within safe and appropriate times for 6 of 18 patients (P2, P7, P22, P24, P25, and P16) who presented to the emergency department (ED) and/or acute psychiatric services area (APSED). Patients may have received a clinical assessment by a registered nurse (RN) or social worker (SW), but there was no medical screening examination or psychiatric screening examination by a qualified provider for several hours, which could hinder timely and appropriate care of the emergency patient.

Findings include:

Medical record review revealed P2 arrived to the Acute Psychiatric Services Emergency Department (APSED) on 1/16/19, at 1:29 a.m. Emergency Medical Services (EMS) brought the patient by ambulance to the back door of the APSED due to an inability to care for himself, and possible methamphetamine use. Nursing staff initiated an APS Clinical Evaluation at 1:38 a.m. which included collateral information precipitating event, pertinent history, social history, mental status examination, impression and plan. There was no evidence of a medical screening examination or psychiatric screening examination by a qualified provider until 11:15 a.m., more than nine hours after P2's APSED arrival.

Medical record review revealed P7 arrived to the APSED on 1/18/19, at 10:23 p.m. EMS brought P7 by ambulance to the back door of the APSED due to intoxication. Nursing staff initiated a nursing note at 10:25 p.m. There is no evidence of a medical screening examination or psychiatric screening examination by a qualified provider until 3:31 a.m., about five hours after he presented to the APSED.

Medical record review revealed P22 arrived to the APSED on 1/3/19, at 12:34 p.m. P22 walked to APS from her medical clinic appointment due to bipolar disorder, non-medication compliance, and elevated mood. RN staff initiated an APS Clinician Evaluation note at 1:52 p.m., which included collateral information, precipitating event. pertinent history, social history, mental status examination, impression and plan. There was no evidence of a medical screening examination by a qualified provider until 8:01 p.m., more than 8 hours after she presented to the APSED.

Medical record review revealed P24 arrived to the APSED on 1/8/19, at 1:34 a.m. Law enforcement brought P24 to the lobby of the APSED due to suicidal ideation. RN staff initiated an APSED Clinical Evaluation at 2:28 a.m. which included collateral information, precipitating event, pertinent history, social history, mental status examination, impression and plan. There was no evidence of a medical screening examination or psychiatric screening examination by a qualified provider until 10:48 a.m., more than nine hours after P24 presented to the APSED.

Medical record review revealed P25 arrived to the APSED on 1/20/19, at 10:20 a.m. P25 was brought to the APS lobby by friends due to altered mental status, suicidal ideation and psychosis. RN staff initiated an APS Clinical Evaluation at 12:43 p.m., which included collateral information, precipitating event, pertinent history, social history, mental status examination, impression and plan. There was no evidence of a medical screening examination or psychiatric screening examination by a qualified provider until 11:25 a.m. on 1/21/19, more than 25 hours after P25 presented to the APS ED.

Medical record review revealed P16 presented to the ED, was medically cleared and discharged to the ASPED on 1/15/19, at 4:00 a.m.. While in the ASPED, a nurse practitioner (NP) ordered medication on 1/15/19, at 9:52 a.m. but there was no documentation of a psychiatric screening examination by a qualified provider until 1:37 p.m., over 10 1/2 hours after P16 presented to the APSED.

An interview was conducted on 1/31/19, at 11:25 a.m. with RN-K who verified the APSED takes patients with acute psychiatric or behavioral emergency conditions.

An interview was conducted on 1/31/19, at 2:45 p.m. with APS Manager E (RN)-E and Supervisor (RN)-F. They stated if patients come into APSED intoxicated, the provider does not see them until the blood alcohol level is zero, unless they seem to have a medical complaint. The RN or SW does the clinical assessment, but the qualified provider may not see and evaluate the patient for several hours, perhaps up to 24 hours. Recently the hospital changed protocol for patients who are intoxicated or have altered mental status in the APSED. The qualified provider is now to evaluate the patient within six hours of arrival. Although RN-E and RN-F thought most patients were seen in the APSED by a qualified provider within 6 hours, it is not always documented that way.

An interview was conducted with Administrative (RN)-G on 1/31/19, at 3:30 p.m. RN-G stated when patients come to the ED and state they are suicidal, the RN triage nurse assesses them. If they have not actually harmed themselves, the patient is not evaluated by an ED qualified provider, but will be seen in the APSED. There may or may not be any documentation that the patient presented to the ED. The only documentation may be in the APSED for these patients.

An interview was conducted on 1/31/19, at 1:50 p.m. with APS Medical Director (MD)-U. MD-U stated that patients present to the APSED via walk-in, ambulance, law enforcement or transfer from the regular ED. Patients present to the APSED without appointment for psychiatric emergency needs. The RNs are the first to see the patients. The RN may decide to send the patient to the regular ED if they believe the patient has a medical need. The patient may get a medical screening examination in the APS if the RN thinks the patient may need one. Each patient is to have a provider screening evaluation to determine medical versus psychiatric emergent medical condition, and make a notation in the medical record. This should be no more than 6 hours after the patient presents. Prior to 12/27/18, this documentation did not occur every time, but should now since 12/27/18.

An interview was conducted on 2/1/19, at 1:00 p.m. with Administrative RN-A who stated it is probably not in an RN's scope of practice for an RN to complete the patient's clinical evaluation which includes collateral information, precipitating event, pertinent history, social history, mental status examination, impression and plan.

The undated policy and procedure: Procedure: APS to ED: 1. The patient is assessed by APS RN/APS provider and has determined the patient needs for medical clearance. ED to APS: 2. ED Charge Communication RN will call APS charge RN to give preliminary information about the patient and inquire about bed status. The Clinician Assessment may be completed if the patient is intoxicated; however, the formal evaluation by the MD/APS provider will not be done until the patient's BAL: (blood alcohol level) =0.

The policy titled Assessment of Clients in APS, dated review 11/2/17, approved by the medical director, and provided by hospital staff was reviewed. Under Purpose: Patients are seen on a walk in basis and assessed each time they register for service in APS. The APS triage nurse does an initial assessment to determine medical stability as well as danger to self or others. The nurse enters the initial demographic information in EPIC and assigns an acuity level. The health screen is completed at this time as well. The patient is assigned to an APS nurse or social worker who reviews the medical record, previous APS contact, any other information that may arrive with the patient. Under the section Procedure: The patient is interviewed using the following protocol: 1. Assessment, 2. Treatment planning, 3. Obtain Consultation: Obtain consultation from other team members for complicated and difficult cases. Obtain psychiatric consultation for diagnostic clarification, medications, and hospitalization. 4. Crisis intervention. 5. Referrals.

The policy Emergency Medical Treatment and Active Labor Act (EMTALA), dated reviewed and revised 10/5/18, and provided by hospital staff was reviewed. Under Definitions: Dedicated Emergency Department means: For purposes of this policy, this includes HCMC Emergency Department, Urgent Care, Birth Center, Acute Psychiatric Unit and Special Care Unit. Medical Screening Exam (MSE) means: An examination performed by Qualified Medical Personnel for the purposes of determining with reasonable clinical confidence whether a person has an EMC. The scope of the examination depends on the specific circumstances and facts about each case but goes beyond a typical triage screening process.

Based on documentation review, observation and interview, the hospital failed to ensure compliance with the requirements of 42 CFR 489.24 as evidenced by the deficient practice cited at 489.24(a). In addition, the hospital was found to be out of compliance with 489.20(q).

The hospital failed to ensure all patients who entered the emergency department knew their rights under section 1867 of the Social Security Act and received an appropriate medical screening examination by a qualified provider.

Based on observations and interview, the hospital failed to post conspicuously in the emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination, signs specifying the rights on individuals under section 1867 of the Social Security Act with respect to examination and treatment in the emergency room.

Findings include:

A tour of the emergency department (ED) was conducted with registered nurse (RN)-C and RN-D on 2/1/19, at 9:30 a.m. The hospital ED had a main entrance and an ambulance entrance. There were no signs posted in the inside ED waiting areas, individual ED rooms, or the ambulance entrance specifying the rights of individuals under section 1867 of the Social Security Act with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA). There was an EMTALA sign just inside the entrance into the ED triage area across from the ED lobby waiting area.

This lack of EMTALA signage was verfied with RN-C on 2/1/19, during the ED tour.

The policy titled Emergency Medical Treatment and Active Labor Act, dated revised 10/5/2015 and provided by hospital staff, revealed under the section IV. Signs: A. Signs that provide notice of the provisions of EMTALA shall be posted in all dedicated Emergency Departments of the HCMC main Campus. The Director of Facilities and the Public Relations Director shall review the sign placement and content every three years. B. The signs shall conform to regulations and be written in clear terms in languages that are understandable by the populations served.


27956

Based on interview and document review, the hospital failed to provide a medical screening examination conducted by a person who is determined to be quantified for 6 of 31 patients (P2, P7, P22, P24, P25, and P16) reviewed. Although patients received a clinical assessment, this review was conducted by registered nurses (RN) or social workers (SW), and a medical screening examination or psychiatric screening evaluation by a qualified provider did not occur for several hours. Findings include:

Medical record review revealed P2 arrived to the Acute Psychiatric Services (APS) Emergency Department (ED) on 1/16/19 at 1:29 a.m. Emergency Medical Services (EMS) brought him by ambulance to the back door of the APS due to an inability to care for himself and possible methamphetamine use. Nursing staff initiated an APS Clinical Evaluation at 1:38 a.m.which included collateral information, precipitating event, pertinent history, social history, mental status examination, impression and plan. There was no evidence of a medical screening examination or psychiatric screening examination by a medical provider until 11:15 a.m., more than nine hours after his arrival.

Medical record review revealed P7 arrived to the APSED on 1/18/19, at 10:23 p.m. EMS brought him by ambulance to the back door of the APS due to intoxication. Nursing staff initiated a nursing note at 10:25 p.m. There was no evidence of a medical screening examination or psychiatric screening examination by a medical provider until 3:31 a.m., about five hours after his arrival.

Medical record review revealed P22 arrived to the APSED on 1/3/19, at 12:34 p.m. P22 walked to APS from her medical clinic due to bipolar disorder, non-medication compliant, and elevated mood. RN staff initiated an APS Clinician Evaluation note at 1:52 p.m., which included collateral information, precipitating event, pertinent history, social history, mental status examination, impression and plan. There was no evidence of a medical screening examination or psychiatric screening examination by a medical provider until 6:40 p.m., more than six hours after her arrival.

Medical record review revealed P23 arrived to the APSED on 1/4/19, at 11:33 am. EMS brought her by ambulance to the back door of the APS on a transportation hold due to hallucinations, delusional thoughts, and possible methamphetamine use. Nursing staff initiated an APS Clinical Evaluation at 2:41 p.m. which included collateral information, precipitating event, pertinent history, social history, mental status examination, impression and plan. There was no evidence of a medical screening examination or psychiatric screening examination by a medical provider until 8:01 p.m.., more than eight hours after her arrival.

Medical record review revealed P24 arrived to the APSED on 1/8/19, at 1:34 am. Law Enforcement brought him to the lobby of APS due to suicidal Ideation. RN staff initiated an APS Clinical Evaluation at 2:28 a.m. which included collateral information, precipitating event, pertinent history, social history, mental status examination, impression and plan. There was no evidence of a medical screening examination or psychiatric screening examination by a medical provider until 10:48 a.m., more than nine hours after his arrival.

Medical record review revealed P25 arrived to the APSED on 1/20/19, at 10:20 am. P25 was brought to the APS lobby by friends due to altered mental status, suicidal ideation, and psychosis. RN staff initiated an APS Clinical Evaluation at 12:43 p.m. which included collateral information, precipitating event, pertinent history, social history, mental status examination, impression and plan. There was no evidence of a medical screening examination or psychiatric screening examination by a medical provider until 11:25 a.m. on 1/21/19, more than twenty-five hours after her arrival.

Medical record review revealed P16 presented to the ED, was medically cleared and discharged to the ASPED on 1/15/19, at 4:00 a.m. While in the ASPED, a nurse practitioner (NP) ordered medication on 1/15/19, at 9:52 a.m. but there was no documentation of a psychiatric screening examination by a qualified provider until 1:37 p.m., over 10 1/2 hours after P16 presented to the APSED.

During an interview on 1/31/19, at 2:45 p.m., with APS Manager E (RN)-E and Supervisor (RN)-F, they stated if patients come in to APS intoxicated, the provider does not see them until the blood alcohol level is zero unless they seem to have a medical complaint. The RN or the SW does the clinical assessment, but the medical provider may not see and assess the patient for several hours, perhaps up to 24 hours. Recently the hospital changed protocol for patients who are intoxicated or have altered mental status in APS and they are now supposed to be seen by a medical provider within six hours of arrival. Although RN-E and RN-F thought most patients were seen in the APS by a medical provider within 6 hours, it was not always documented that way.

During an interview with Administrative (RN)-G on 1/31/19, at 3:30 p.m., she stated that when patients come to the ED and they state they are suicidal, the RN triage nurse assesses them. If they have not actually harmed themselves, they are not seen by an ED medical provider, but they are brought by an RN over to APS. These patients are not seen by a medical provider in the ED, but will be seen in APS. There may or may not be any documentation of their presentation to the ED, but the only documentation may be in APS for these patients.

During an interview with APS Medical Director (MD)-U on 1/31/19, at 1:50 p.m., he stated that patients come in to the APS via walk-in, ambulance, law enforcement, or transfer from the regular ED. Patients come into the APS without appointments for psychiatric emergency needs. The RN's are the first to see the patients, and they may decide to send them to the regular ED if they believe the patient has a medical need. The patient may get a medical screening examination in APS if the RN thinks they need one.

During an interview on 2/1/19 at 1:00 p.m., Administrative RN-A stated it is probably not in an RN's scope of practice for them to complete the patient's clinical evaluation which includes collateral information, precipitating event, pertinent history, social history, mental status examination, impression and plan.

The policy titled Assessment of Clients in APS, dated reviewed 11/2/17, approved by the medical director, and provided by hospital staff was reviewed. Under Purpose: Patients are seen on a walk in basis and assessed each time they register for service in APS. The APS triage nurse does an initial assessment to determine medical stability as well as danger to self or others. The nurse enters the initial demographic information in EPIC and assigns an acuity level. The health screen is completed at this time as well. The patient is assigned to an APS nurse or social worker who reviews the medical record, previous APS contacts, and any other information that may arrive with the patient. Under the section Procedure: The patient is interviewed using the following protocol: 1. Assessment, 2. Treatment planning, 3. Obtain Consultation: Obtain consultation from other team members for complicated and difficult cases. Obtain psychiatric consultation for diagnostic clarification, medications, and hospitalization. 4. Crisis intervention. 5. Referrals.

The policy titled: Emergency Department Scope of Service and dated revised 5/17/18, and provided by hospital staff was reviewed. Under the section IV. Scope of assessment and patient care. A. 1. All persons presenting to the emergency department seeking care receive an initial assessment of their condition by a registered nurse (RN). Upon completion of the assessment, the person will be assigned a patient acuity level and seen in the Emergency Department or referred to an appropriate patient care service area.

The policy titled Referrals between the ED and APS, dated reviewed 10/23/17, and provided by hospital staff was reviewed. Under the section titled Purpose: If/when a patient in the ED is in need of psychiatric assessment/evaluation, he/she will be referred to APS. Referral may include, but is not limited to: suicidal ideation with or without intent or plan; homicidal ideation with or without intent or plan; violent ideation with or without intent or plan; signs and symptoms of anxiety, depression, psychosis or mania;family issues or other losses. If/when a patient in APS is in need to medical attention, he/she will be referred to the ED for medical evaluation and clearance. Referral may include; suspected/reported overdose, difficulty breathing or shortness of breath; reported chest pain; reported/possible head injury; suspected frostbite hypothermia; severe bleeding/lacerations identified as needing sutures; unable to stand or walk; alcohol withdrawal signs and symptoms, DT's, or hallucinations and/or maximum Valium received per protocol, confusion, disorganization, and disorientation related to general medical condition; injury related to a fall while in APS; or critical high glucose.

Under the section Procedure: ED to APS: 2. ED Charge/Communication RN will call APS charge RN to give preliminary information about the patient and inquire about bed status. The Clinician Assessment may be completed if the patient is intoxicated; however the formal evaluation by the MD/APS provider will not be done until the patient's BAL=0. (BAL means blood alcohol level.)

APS to ED: 1. The patient is assessed by APS RN/APS provider and has determined the patient needs for medical clearance.

The policy Emergency Medical Treatment and Active Labor Act (EMTALA), dated reviewed/revised 10/5/15, and provided by hospital staff was reviewed. Under Definitions: Dedicated Emergency Department means: For purposes of this policy, this includes the HCMC Emergency Department, Urgent Care, Birth Center, Acute Psychiatric Unit, and Special Care Unit. Medical Screening Exam (MSE) means: An examination performed by Qualified Medical Personnel for the purposes of determining with reasonable clinical confidence whether a person has an EMC. The scope of the examination depends on the specific Circumstances and facts about each case but goes beyond a typical triage screening process.

The document titled Bylaws of the Medical Staff Hennepin County Medical Center Preamble, dated approved January 24, 2018, revealed: Practitioner shall mean any person permitted by law and authorized by the Governing Body to provide patient care services within the scope of that person's license and consistent with individually granted Clinical Privileges.