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Based on review of medical records, Medical Staff Bylaws, policy and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate ongoing medical screening examination for one (P) (P#1) of 20 patients reviewed when P#1 was discharged without receiving the behavioral health screening as ordered by the provider.

Findings include:

Cross refer to A-2406 as it relates to the facility's failure to provide an appropriate medical screening exam.

Based on review of police report, medical records, Medical Staff Bylaws, policy and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate and ongoing medical screening examination including behavioral health services to determine whether an emergency medical condition existed for one (P) (P#1) of 20 patients reviewed when P#1 was discharged without receiving the behavioral health screening ordered by PA DD. Specifically, P#1 was discharged without receiving the behavioral health screening as ordered by the emergency room provider.

Findings include:

A review of a police department report dated 10/26/25 revealed that at approximately 10:25 p.m., the police officer responded to a call regarding a suicide attempt. The police officer located P#1 at a bridge (no time documented) and collaborated with the emergency medical services to transport the patient to facility A.

A review of the 10/26/25 ambulance trip report, revealed that P#1 was picked up on 10/26/25 and assessed at 10:08 p.m. (Central Standard Time). P#1's chief complaint was suicidal ideation. Further review documented that P#1 was transported to facility A.

A review of the facility's (Facility A) Emergency Department Log revealed that Patient #1 presented to the Emergency Department (ED) via ambulance and was registered as a patient on 10/26/25 at 11:25 p.m.

A review of the 'ED Note Physician' by Physician Assistant (PA) DD dated 10/26/25 at 11:27 p.m. revealed that P#1 stated she was tired of life and wanted to talk to a counselor. The note further documented that P#1 denied suicidal and homicidal ideations, visual and auditory hallucinations and was not on any medication. The note documented that P#1 had a history of suicidal ideations and had been hospitalized in the facility's off-site mental health center in the past.

A review of facility A's ED note by (Clinical Coordinator) CC II on 10/26/25 at 11:27 p.m. revealed that P#1 1 stated that she wanted to speak to a counselor but denied suicidal and homicidal ideation. CC II documented P#1 as a level two acuity (needed to be seen urgently).

A review of the PA DD's orders on 10/26/25 at 11:32 p.m. revealed that he ordered a consultation with a Behavioral Health Intake Coordinator for P#1, and close observation.

Continued review of the record revealed that P#1 was discharged from Facility A on 10/27/25 at 1:41 a.m. with a diagnosis of depression with instructions to follow up with a primary care provider in two to four days.

A review of the 'Behavioral Health Forms' dated 10/27/25 at 1:02 a.m. revealed that P#1 left before an assessment could be performed.

A review of P#1's ED record from Facility A failed to reveal a behavioral health assessment.

A review of P#1's medical record from Facility B revealed that she arrived to the ED on 10/27/25 at 3:56 p.m. with a complaint of 'suicidal'.

A review of facility B's Behavioral Health Assessment note on 10/27/25 at 8:52 p.m. revealed that P#1 was assessed using telehealth (remote healthcare services). P#1 was assessed and endorsed suicidal ideation. Continued review revealed that P#1 was determined to be a high suicide risk per the C-SSRS.

P#1 was discharged from Facility B via transport to Facility C on 10/27/25 at 10:27 a.m.

A review of a behavioral health facility (C) revealed that P#1 was admitted on 10/28/25 at 4:22 p.m. with major depressive disorder documented by the medical doctor (MD).

A review of facility C's discharge noted on 11/6/25 at 11:59 a.m. documented by the registered nurse (RN) that P#1 was discharged per physician's orders and left on 11/6/25 at 11:40 a.m.

A review of the facility's Medical Staff By-laws revealed in article II that the purpose of the medical staff was to provide a mechanism that ensured all patients admitted to or treated in any of the facilities or services of the facility received a uniform level of appropriate quality care, treatment and services commensurate with community resources during the length of stay with the organization.

Review of "Appendix "B"-Rules and Regulations," revealed that rules and regulations were adopted in connection with the Medical Staff Bylaws and made apart thereof.

Article V
1. Any individual who is presented to the Emergency Department (ED) should have been provided with a medical screening exam (MSE) to determine whether the individual experienced an emergency medical condition (EMC). An EMC was defined as active labor or as a condition that manifested such symptoms that the absence of immediate medical attention was likely to cause serious dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual or unborn child.

A review of the facility policy titled, "EMTALA - Medical Screening and Treatment of Emergency Medical Conditions", number LL.026, effective 11/16/23 revealed that any individual who came to the facility or premises and requested examination or treatment was provided an appropriate medical screening examination performed by a physician or qualified medical personnel to determine whether an emergency medical condition existed. An emergency medical condition was a medical condition that manifested itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical condition could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part. The medical screening examination (MSE) was the process required to reach with reasonable clinical confidence, the point at which can be determined whether an emergency medical condition existed, or a woman was in labor. Such screening must be done within the facility's capability and available personnel, including on-call physicians. The MSE must be performed by a physician or other qualified medical personnel. The medical screening examination was an ongoing process, and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient was either stabilized or appropriately transferred.

During an interview with Clinical Coordinator (CC) AA on 12/8/25 at 10:50 a.m. in the Behavioral Health Unit (BHU) annex, she revealed that patients are taken to the BHU annex to wait for placement to a mental health facility. CC AA reported that patients who had suicidal ideations as recent as one week ago, would not be discharged home.

A phone interview was conducted with physician's assistant (PA) DD on 12/9/25 at 9:34 a.m. PA DD revealed that he worked in the emergency room (ER) at night. PA DD further revealed that he evaluated patients who came in for mental health concerns and decided whether they should be 1013 (mental health involuntary hold on individuals who are a danger to themselves or others). PA DD reported that he initiated a standing order set for patients who presented with mental health issues which included a psychiatric evaluation. PA DD further reported that once the order was initiated, the patient should have had a psychiatric evaluation prior to discharge. PA DD stated that he did not take a patient's trip reports from emergency medical services (EMS) but talked to the charge nurse to see why the patient presented to the ED. PA DD acknowledged that if a patient came in after a suicide attempt, he would not discharge them to go home.

A phone interview was conducted with Therapeutic Care Provider (TCP) EE on 12/9/25 at 1:10 p.m. TCP EE reported that she worked the night shift in the ER and at the facility's behavioral health center off site. TCP EE further reported that she conducted behavioral health intake assessments on patients when they first presented in the ED. TCP EE further reported that if she assessed a patient who presented with suicidal ideations, she would have them admitted to the facility.

A phone interview was conducted with Clinical Coordinator (CC) II on 12/9/25 at 9:43 p.m. CC II stated that her duties included triaging patients in the ED and getting them to where they need to go. CC II further reported that any patient who presented to the ED with suicidal ideation automatically received an acuity level two and should have had a behavioral health consultation. CC II further stated that any patient that came in with a suicidal ideation was automatically put on a 1013 and evaluated by a psychiatrist. CC II stated that patients who presented with suicidal ideations automatically had orders for blood and urine tests, and a consultation for behavioral health.