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Based on interviews and review of medical records, it was determined that the hospital failed to comply with CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases.

Findings include:

As detailed in Tag 2406, Tag 2407 and Tag 2409, it was determined that the hospital failed to provide an appropriate medical screening examination, stabilizing treatment and a safe and appropriate transfer to 1 of 25 patients whose emergency department (ED) medical records were reviewed and, therefore, failed to comply with CFR §489.24.

Reference Tag 2406, Tag 2407 and Tag 2409

Based on interviews and reviews of medical records, it was determined that the hospital failed to provide a medical screening examination of Patient #1, performed by a person who had been determined to be qualified to do so by the hospital bylaws or rules and regulations. The hospital's failure to do so placed Patient #1 at risk of having an undiagnosed emergency medical condition, diagnosed and treated by a person qualified to do so.

Findings include:


1.) Lack of Medical Screening Examination

On October 13, 2016 at 1:18 PM, the complainant stated that a receiving hospital (Hospital #2) had received a patient from the ED (Emergency Department) of a sending hospital (Hospital #1). The patient had been sent to the receiving hospital without any documentation that care had been provided to the patient, including the lack of a medical screening examination (MSE). The complainant stated that the nurse manager of the ED at Hospital #2 had more information.

On October 13, 2016, at 1:23 PM, the nurse manager of the ED for Hospital #2 stated that Hospital #1 had not done a MSE or involved a physician in the patient's care. S/he also stated that Hospital #1 had not called Hospital #2 regarding the impending transfer of Patient #1, and Hospital #2 had been notified that the patient was arriving when a call was received from the a local law enforcement detail.

On October 18, 2016, ED RN (Registered Nurse) #1 was interviewed. ED RN#1 was the nurse who assessed Patient #1 in the triage room at Hospital #1. The RN stated that Patient #1 had said to the nurse that s/he heard voices in her/his head that told her/him to kill anybody and everybody and s/he had a knife. The RN stated that s/he was very afraid and stepped out of the room and reported to the charge nurse that Patient #1 was homicidal and suicidal. The ED RN confirmed that s/he had not notified the ED physician about the patient.

On October 18, 2016 at 1:50 PM, the investigator interviewed the nurse who had been in charge of the ED at Hospital #1 the day that Patient #1 presented to the ED. The charge nurse stated that ED RN #1 had reported that Patient #1 had threatened her/him and "everybody in the building". The charge nurse stated that security and the police were called and the ED was "locked down", which meant that door were locked and people could not easily enter or leave the patient care area of the ED.

The charge nurse stated that the police came on the scene and "stood around" and one officer told the charge nurse that "the patient needed to be seen". The charge nurse stated that there were no locked rooms in the ED, which was confirmed by a tour of the ED on October 19, 2016 and other interviews. S/he stated that hospital security "stood by" and eventually the police transported the patient to another hospital.

On October 18, 2016 at 2:20 PM, the Chief Quality Officer (CQO) was interviewed. S/he stated that s/he had been the AOC (Administrator on Call) for the day Patient #1 had come to the ED. S/he stated that s/he heard about the situation and went to the ED where s/he called the CDMHPs (County Designated Mental Health Professionals). The CDMHPs reportedly directed the CQO to transport the patient to another hospital, although they did not personally evaluate the patient. The CQO stated that the patient was handcuffed and taken by the police to the police car. The CQO confirmed that neither a "Code Silver" (someone threatening with a weapon) or a "Code Gray" (show of force required) had been called to help with the patient. The CQO stated that s/he had completed the transfer form as much as s/he could, and faxed it to the receiving hospital after Patient #1 had left the ED.

When asked what would have prevented the ED physician from doing a MSE while the patient was handcuffed and secured in the police car, the CQO acknowledged that nothing would have, but s/he didn't see a physician "anywhere".

On October 27, 2016 at 8:00 AM, MD #1 was interviewed. MD #1 was the physician on duty in the ED the day that Patient #1 presented to the ED. The MD stated that s/he was "in the middle of [her/his] day, seeing patients in the back", and no one let her/him know about the situation until after the patient was gone. The MD stated that the ED does not have actual security, because the security staff "do not touch".

The MD stated that s/he could have done a MSE when the patient was secured in the police car, or in the triage area outside of the ED, because s/he had experience caring for mental health patients.

No medical record had been created for Patient #1, with the exception of an incomplete triage assessment.
A transfer form, completed by the CQO, documented that the patient was unstable. The reason listed for the transfer was the lack of a "locked/secure unit". The form documented that the local police department transported the patient, but did not document any communications with the receiving hospital.

The hospital policy "EMTALA - Medical Screening Exam" was reviewed and found to contain the following directions:
"...PURPOSE:
Patients presenting to [Hospital #1] Property or Premises requesting emergency services will receive an appropriate Medical Screening Examination...
POLICY:
1. Any individual who comes to [Hospital #1's]Property or Premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by individuals qualified to perform such examination...
2. The EMTALA obligations are triggered when there has been a request for medical care by an individual...if an EMC is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer..."

3. Emergency Medical Condition (EMC):
...c. With respect to an individual with psychiatric symptoms...
ii. That an individual is expressing suicidal or homicidal thoughts or gesture and are determined to be a danger to self or others..."

2.) Personnel Qualified to Perform a MSE
The investigator asked the CQO to provide evidence that the hospital, in bylaws and/or rules and regulations, had determined who was qualified to perform MSEs. Portions of the Medical Staff Rules and Regulations were reviewed with the CQO.

The "Rules and Regulations of the Medical Staff", Article II, EMERGENCY SCREENING, TREATMENT, AND TRANSFER, "was found to contain the following:
"2.2 EMERGENCY DEPARTMENT SCREENING"...
Any individual who presents to the Emergency Department of this Hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition...All patients shall be examined by qualified medical personnel, which shall be defined as a Physician trained in emergency medicine, or in the case of a woman in labor, a registered nurse trained in obstetric nursing...

The investigator interviewed the CQO to determine if the ED Medical Director, and ED MD #1, were qualified, as defined by the governing board's definitions, to practice in the ED. Review of the credentialing file of the ED Medical Director revealed that the Medical Director was board-certified in Emergency Medicine. Review of the credentialing file of ED MD #1, revealed that s/he was board-certified in Family Medicine. The CQO was unable to provide evidence or documentation that defined what "physician trained in emergency medicine" meant, and whether any board certification, specific education or specific experience was required.

The Chief Nursing Officer confirmed that mid-levels, defined as nurse practitioners and physician assistants, were employed in the ED; however, mid-levels were not identified in the Rules and Regulations as being qualified to perform MSEs.

During an interview, the CQO provided documentation that the governing board had determined that in "...the event that an obstetrics patient comes to the Labor and Delivery Unit in suspected labor, Registered Nurses or ARNPs on the Labor and Delivery unit that have been given specialized training shall be allowed to perform the appropriate medical screening necessary to evaluate patients for suspected labor..."

During the same interview, the CQO was unable to describe what the "specialized training" consisted or, or to provide documentation that described or defined what specialized training OB RNs were required to have to be allowed to perform MSEs.

Based on interviews, review of medical records and review of hospital documents, it was determined that Hospital #1 failed to provide stabilizing treatment to 1 of 3 patients (Patient #1) who presented to the Emergency Department (ED) with a potential emergent condition, and were eventually transferred to other hospitals. The hospital's failure to do so resulted in Patient #1 not being provided with stabilizing treatment in the ED before s/he was sent to another hospital, Hospital #2, via police car.

Findings include:

On October 18, 2016, ED RN (Registered Nurse) #1 was interviewed. ED RN#1 was the nurse who evaluated Patient #1 in the triage room at Hospital #1. The RN stated that Patient #1 had said to the nurse that s/he heard voices in her/his head that told her/him to kill anybody and everybody and s/he had a knife. The RN stated that s/he was very afraid and stepped out of the room and reported to the charge nurse that Patient #1 was homicidal and suicidal. The ED RN confirmed that s/he had not notified the ED physician about the patient.

On October 18, 2016 at 1:50 PM, the RN who was in charge that day was interviewed. The charge nurse stated that ED RN #1 had reported that Patient #1 had threatened her/him and "everybody in the building". The charge nurse stated that security and the police were called and the ED was "locked down".

The charge nurse stated that the police came on the scene and "stood around" and one officer told the charge nurse that "the patient needed to be seen". The charge nurse stated that there were no locked rooms in the ED, which was confirmed by a tour of the ED on October 19, 2016 and other interviews. S/he stated that hospital security "stood by" and eventually the local police department transported the patient to Hospital #2.

On October 27, 2016, the investigator interviewed MD #1 who was the ED physician on duty at Hospital #1, on the day Patient #1 presented. The MD stated that s/he had been "in the back" caring for other ED patients when Patient #1 had presented to the ED triage nurse. The MD stated that s/he had not been told about the patient until after the patient had been removed from the ED by the police.

The MD stated that s/he never saw the patient, but could have done a medical screening exam after the patient was secured, either in the triage room, waiting area or in the police car. The MD stated that s/he had experience dealing with mental health patients and had done so in the past.

Based on interviews, review of medical records and review of documents, it was determined that the hospital failed to assure the appropriate transfer of 1 of 3 patients(Patient #1) who had been in the Emergency Department (ED) and subsequently transferred to other hospitals. The hospital's failure to do so resulted in Patient #1, who required emergency psychiatric care, not receiving a safe and appropriate transfer to an accepting hospital. The hospital's failure to do so resulted in the patient being transferred with out informed consent, and in a potentially unsafe manner, which placed the patient at potential risk for a deterioration in health status.

Findings include:

Interviews:

On October 13, 2016, at 1:23 PM, the nurse manager of the ED at Hospital #2, which received Patient #1, stated that Hospital #1 had not performed a medical screening examination (MSE) or involved a physician in the patient's care. S/he also stated that Hospital #1 had not called Hospital #2 regarding the impending transfer of Patient #1, and the Hospital #2 had been notified that the patient was arriving when a call was received from the police department.

On October 18, 2016, Hospital #1 ED RN (Registered Nurse) #1 was interviewed. ED RN#1 was the nurse who evaluated Patient #1 in the triage room. The RN stated that Patient #1 told the nurse that s/he heard voices in her/his head that told her/him to kill anybody and everybody and s/he had a knife. The RN stated that s/he stepped out of the triage room and reported to the charge nurse that Patient #1 was homicidal and suicidal. The ED RN confirmed that s/he had not notified the ED physician about the patient.

On October 18, 2016 at 1:50 PM, the ED charge nurse for that day was interviewed. The charge nurse stated that ED RN #1reported that Patient #1 had threatened her/him and "everybody in the building". The charge nurse stated that security and the police were summoned and the ED was "locked down".

The charge nurse stated that the police came on the scene and "stood around" and one officer told the charge nurse that "the patient needed to be seen". The charge nurse stated that there were no locked rooms in the ED, which was confirmed by a tour of the ED on October 19, 2016 and interviews with other ED personnel. S/he stated that hospital security "stood by" and eventually the police transported the patient to Hospital #2.

On October 18, 2016 at 2:20 PM, the Chief Quality Officer (CQO) was interviewed. S/he stated that s/he had been the AOC (Administrator on Call) for the day in question. S/he stated that s/he heard about the situation and went to the ED where s/he called the CDMHPs (County Designated Mental Health Professionals). The CDMHPs reportedly directed the CQO to transport the patient to another hospital, although they did not personally evaluate the patient. The CQO stated that the patient was handcuffed and escorted to the police car. The CQO stated that s/he had completed the transfer form as much as s/he could, and faxed it to the receiving hospital after Patient #1 had left the ED.

During the same interview, the CQO was asked to provide the written guidance about which person in the ED had responsibility to assure that all paperwork, including medical records and transfer forms, were sent to the receiving hospital. The CQO was unable to describe the process, or to provide documentation that described the process. The "Patient Transfer Protocols" policy directs "the transferring hospital" to send copies of medical records, but did not specify who was responsible.

On October 27, 2016, the investigator interviewed MD #1 who was the physician on duty in the ED at Hospital #1 on the day Patient #1 presented to the ED. The MD stated that s/he had been "in the back" caring for patients when Patient #1 had presented to the ED triage nurse. The MD stated that s/he had not been told about the patient until after the patient had been removed from the ED by the police.

The MD stated that s/he never saw the patient, but could have done a medical screening exam after the patient was secured, either in the triage or waiting area or in the police car. The MD stated that s/he had experience dealing with mental health patients and had done so in the past.

Medical Record Review:
No medical record had been created for Patient #1, with the exception of an incomplete triage assessment.

A transfer form, completed by the CQO, documented that the patient was unstable. The reason listed for the transfer was the lack of a "locked/secure unit". The form documented that the police had transported the patient, but did not document any communications with the receiving hospital, Hospital #2. The CQO stated that s/he faxed the form to the receiving hospital after the patient had left the ED in the company of the police.