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Based on medical record (MR) review, document review and interview, the hospital did not comply with the requirements at 489.24 and 489.20, Specifically, 1) The hospital did not provide a medical screening exam (MSE) to a patient (Patient #2) who presented to the emergency department for evaluation to determine if an emergency medical condition (EMC) existed. 2) The hospital's Medical Staff Bylaws/Rules & Regulations and policy and procedure (P&P)regarding EMTALA (Emergency Medical Treatment And Labor Act) did not adequately identify qualified medical professionals who could perform a MSE. 3) The facility initiated a transfer for a patient (Patient #1) determined to have an EMC when the hospital had capacity and capability to treat and admit him. This could lead to untoward patient outcomes. Please reference findings at Tag 2406 and Tag 2407.

Based on document review, medical record (MR) review and interview, 1) in 1 of 21 MRs reviewed a patient (Patient #2) did not receive a medical screening exam (MSE) to determine if an emergency medical condition (EMC) existed. 2) The hospital's bylaws and Emergency Medical Treatment and Labor Act (EMTALA) policy and procedure (P&P) lacked description of the titles of a qualified medical practitioner (QMP) who could perform a MSE. This could lead to untoward patient outcomes.

Findings regarding (1) include:

-- Review of the hospital's P&P titled, "COBRA (Consolidated Omnibus Budget Reconciliation Act), EMTALA," revised 8/2019, indicated to provide upon request and within the hospital's capabilities to anyone who comes to the hospital a MSE to determine if an individual has an EMC.

-- Review of Patient #2's MR revealed, she was seen in emergency department (ED) on 5/26/19 and diagnosed with renal calculi (kidney stones). She was evaluated and treated with intravenous (admisistered into a vein) pain medication, discharged to home with instructions to return to the ED if worsening symptoms and increased pain.

The next day on 5/27/19 at 10:30 pm, Patient #2 presented to the ED with complaints of increasing back pain, nausea and vomiting. Nursing documented Patient #2 appeared ill and uncomfortable. Pain was documented as a 10 (on a scale of 0-10, 10 indicating the most severe pain) and was sharp and stabbing. At 11:18 pm, the patient was angry, agitated demanding to see the doctor. Begging staff to bring her pain medication. Patient #2 stated, "I need something for pain right now." The patient was sitting on the floor in the doorway. ED physician was made aware. At 11:27 pm, the patient was at the nurse's station yelling at staff and demanding pain medication. ED physician was aware. At 11:56 pm, Patient #2 was lying on the floor in the doorway of her room and refused to get up until she received pain medication. Nursing staff informed her she needed to be seen by the ED physician. The patient stood up and became verbally aggressive with staff calling the staff names and then slammed the door of her exam room. Patient #2 then proceeded to the nurse's station and continued to request pain medication. She was again told she needed to be seen by the physician first to have pain medication ordered. The patient was yelling and cursing, demanding pain medication "or else." She was asked to return to her room, then cursed at staff again. Patient #2 threw the desk phone and computer keyboard at a nurse and tried to knock over the computer. The patient was asked to leave by the ED physician and ED staff due to disruptive and violent behavior and being verbally and physically aggressive. Patient #2 left the ED. An ED physician documented at 11:43 pm, that the patient was belligerent and cursing. She came up to the desk and threw items on the floor. She was asked to go back to her room and she refused, patient eloped. Her preliminary diagnosis was unspecified renal colic (pain when urinary stones block part of the urinary tract). Patient left due to unknown reason.

On 5/28/19 at 12:09 am, patients disposition was documented as she eloped from treatment room before seeing a physician.

There was no documentation that a MSE was completed on Patient #2.

Findings regarding (2) include:

-- Review of hospital's P&P titled "COBRA, EMTALA," revealed that a MSE should be provided by a physician/APPs (advance practice providers) working within the scope of their appointment and privileges. The P&P did not identify categories of health professionals considered by the hospital to be APPs.

-- Review of the hospital's Medical Staff Bylaws (not dated), lacked documentation addressing what categories of providers (e.g., physician, nurse practitioner, physician's assistant) could perform a MSE.

-- During interview of Staff A (Chief Nursing Officer-Vice President Patient Care) on 8/29/19 at 12:30 pm, he/she acknowledged the above findings.

Based on document review, medical record (MR) review and interview, in 1 of 21 MRs (Patient #1) reviewed, the hospital initiated a transfer for a mental health patient with an emergency medical condition (EMC) when they had capacity and capability. This could lead to untoward patient outcomes.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled, "COBRA (Consolidated Omnibus Budget Reconciliation Act), EMTALA (Emergency Medical Treatment and Labor Act)," revised 8/2019, indicated any individual experiencing an EMC must be offered stabilizing treatment within the capability of the hospital prior to transfer or discharge. In cases of psychiatric disturbances, stabilization includes the additional elements of providing a secure environment and providing therapies and medications necessary to stabilize the patient's mental status and ensure his/her safety.

-- Review of the hospital's P&P titled, "Admission of Patients Who Have Relatives or Significant Others on the Mental Health Center," last revised 9/2018, indicated if a patient presenting for evaluation is an immediate family member (e.g., brother, sister, mother, father, grandparent or significant other) of a staff member or another patient on the Mental Health Center, arrangements are to be made to transfer that patient to another facility. Exceptions can be made at the discretion of the psychiatrist or director. If no other facility beds are available the decision to admit will be at the discretion of the psychiatrist.

-- Per MR review, on 7/16/19 at 11:03 am, Patient #1, an 18-year-old male, presented to the emergency department (ED) via police for visual hallucinations. He was triaged as a level 2 on the Emergency Severity Index (ESI) (1 being resuscitation and 5 non-urgent). A triage assessment was completed at 11:06 am. His medical screening exam (MSE) began at 12:56 pm. Patient #1 was medically cleared by the ED physician for a mental health evaluation at 4:45 pm. A mental health evaluation was started at 5:26 pm. At 6:00 pm the mental health evaluation, completed by psychosocial assessor (PSA) was reviewed with a psychiatrist. Documentation by PSA revealed the patient is in need of inpatient psychiatric care. "Patient's legal status will be Directory of Community Services: 9.37 (Mental Hygiene Law for involuntary admission), commitment papers are completed. The patient displays symptoms of severe psychiatric disorder resulting in disordered behavior and significant interference with his/her ability to maintain self-care. Hallucinations. The patient's care requires a multi-modal treatment plan under close supervision and coordination due to the complexity and severity of the patient's symptoms. The patient requires administration and monitoring of psychoactive medications by skilled medical providers due to side effects of the psychoactive medications or significant dosage adjustments." Patient #1 received Lorazepam (anti-anxiety medication) 2 mg (milligrams) orally with a follow up response at 7:31 pm of decreased anxiety.

Documentation further indicated Patient #1 could not be admitted to the hospital's mental health unit (MHU) because of a conflict of interest. Patient will be referred to other facilities and wait hospital acceptance. On 7/16/19 at 7:15 pm referrals were faxed to two other facilities to transfer Patient #1. One facility responded that they had no bed availability at this time but stated they will keep referral for morning in hopes of discharges. Also at 7:30 pm, Patient #1 and his mother were refusing to be discharged based on having a conflict of interest in MHU.

The following day on 7/17/19 at 8:51 am, Paroxetine (anti-depressant medication) 20 mg orally once was ordered and refused by Patient #1. At 11:56 am, staff documented that patient's chart is being reviewed at other facilities, but currently no beds at one of the facilities.

At 12:35 pm, staff documentation revealed patient met with two psychiatrist who agreed to discharge patient home with his mother. Patient denied suicidal ideation/intent (SI)/ homicidal ideation/intent (HI). Patient contracted for safety and will follow up with outpatient services.

At 12:44 pm, psychiatrist documented Patient #1 is pleasant and cooperative, denies SI/HI and/or delusions. The patient and family want to continue treatment as an outpatient, there are no legal grounds to hold him. At this point the patient will be discharged, encouraged to stop using any substances and continue his treatment as an outpatient.

At 1:08 pm, patient discharged to home with discharge instructions.

-- During interview of Staff B (Psychosocial Assessor) on 8/28/19 at 9:55 am, Patient #1 had been recommended for inpatient admission. When Staff B presented Patient #1's information packet to a MHU Registered Nurse (RN), he/she was told "no way is he coming here."

Staff B was informed that the patient had a relative working on the inpatient MHU that was not comfortable having the patient there. The mother and patient did not have a problem with the patient going to the MHU knowing the staff member was there. They were upset and concerned that a transfer could take time and they just wanted to get treatment started as soon as possible. The hospital had bed availability on the MHU. A transfer request for inpatient admission to other facilities was then initiated. One of the facilities contacted did not have a bed available but expected discharges in the morning. It was decided to have Patient #1 remain in the ED overnight. The next day the patient and his family members had two face to face evaluations with the psychiatrists and it was determined Patient #1 could be discharged home with outpatient services.

-- During interview of Staff C (Psychosocial Coordinator) on 8/28/19 at 10:15 am, the hospital's MHU had the ability to admit and treat Patient #1.

-- During interview of Staff D (Psychiatrist) on 8/28/19 at 2:00 pm, he/she recalled Patient #1 was having a problem with depression and possible substance use. Patient #1 had started an antidepressant and Staff D thought the antidepressant may have triggered manic/suicidal cycling. He/she felt the patient was unsafe and recommended hospitalization locally. Staff D indicated he/she received a call informing him/her the patient was related to a MHU Staff member and per the hospital's policy and procedure there was clearly a conflict of interest and Staff D didn't want to violate the hospital's policy and procedure. The patient's mother was initially upset about Patient #1 having to be transferred. The following day, Staff D met with the patient and his family (mother included). The patient was doing better. Staff D asked a second psychiatrist to evaluate the patient. It was determined the patient was not in crisis or suicidal and safe for discharge with outpatient referrals.

-- During interview of Staff E (Psychiatrist) on 8/28/19 at 12:50 pm. he/she is not familiar with the hospital's "Conflict of Interest" P&P, it's usually a case by case decision, the client is asked if they feel comfortable.

A patient was not admitted and treated in the hospital's MHU when the hospital had capacity and capability due to the hospital's P&P titled "Admission of Patients Who Have Relatives or Significant Others on the Mental Health Center,". The patient and his mother did not object to him being admitted to CHMC's MHU.

-- During interview of Staff A (Chief Nursing Officer-Vice President Patient Care) on 8/29/19 at 12:30 pm, he/she acknowledged the above findings.