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Based on interview, and record review, the facility failed to meet the regulatory requirements under Emergency Medical Treatment and labor Act (EMTALA) as evidenced by:

1. The facility failed to maintain a central log of individuals who presented to the Emergency Department (ED) seeking care when 1 of 22 sampled patients' (Patient 1) information was not entered into the central log when Patient 1 presented to the ED seeking care on 5/1/2025. ( Refer to A-2405); and

2. The facility failed to ensure a triage (process of prioritizing patients in need of medical attention) and a Medical Screening Exam (MSE- an exam to determine if an emergency medical condition exists) for 1 of 22 sampled patients (Patient 1) who presented to the Emergency Department (ED) when Charge Nurse 1 (CN1) encouraged Patient 1's representative to take Patient 1 to another local ED (Refer to A-2406).

Based on interview and record review, the facility failed to maintain a central log of individuals who presented to the Emergency Department (ED) seeking care when 1 of 22 sampled patients' (Patient 1) information was not entered into the central log when Patient 1 presented to the ED seeking care on 5/1/2025.

This failure resulted in Patient 1 presenting to the ED for care and not being entered into the required log for tracking and quality assurance.


Findings:

In an interview with a Licensed Clinical Social Worker (LCSW) on 7/8/2025 at 2:13 p.m., the LCSW, who works for the County Mental Health Services, indicated he received a call from the community health clinic Director of Behavioral Health Care (DBHC) regarding a patient (Patient 1) who exhibited signs and symptoms of a mental health crisis. An agreement was made to meet at the Hospital parking lot for the LCSW to further assess Patient 1. The LCSW stated Patient 1 was was assessed as being gravely disabled and placed on a 5150 hold ( allows for the involuntary hold of an individual who is experiencing a mental health crisis and is deemed a danger to themselves or others) by the LCSW. The LCSW stated both he, the DBHC, and Patient 1 presented to the Hospital ED on 5/1/2025 at approximately 12:00 p.m.

During an interview on 7/8/2025 at 3:45 p.m. with the Chief Nursing Officer (CNO), a policy for ED log was requested and a policy was not provided.

During an interview on 7/9/2025 at 8:30 a.m., with the Emergency Department Manager (EDM), EDM indicated logging ED patients was done by registration staff as patients come into the ED. The EDM stated, "It does happen that patients come in, but they leave before we could get their name. We can't control them leaving before we get their details."

During a concurrent record review and interview with the CNO and the EDM on 7/9/2025 at 9:40 a.m., the ED log for 5/1/2025 from the time, "2:51 a.m. - 23:37 [11:37 p.m.]" did not include an entry for Patient 1. The CNO and EDM confirmed Patient 1 was never placed on the log despite spending approximately 23 minutes in the ED lobby, while Patient 1's representative spoke with the ED charge nurse before being encouraged or advised to seek care at another hospital ED.

Based on interview and record review, the facility failed to triage (process of prioritizing patients in need of medical attention) and provide a Medical Screening Exam (MSE- an exam to determine if an emergency medical condition exists) for 1 of 22 sampled patients (Patient 1) who presented to the Emergency Department (ED) when Charge Nurse 1 (CN1) encouraged Patient 1's representative to take Patient 1 to another local ED.

These failures resulted in the delay of treatment and stabilization of a possible emergency medical condition when Patient 1, who was having a potential mental health crisis and was gravely disabled, was encouraged to leave the ED prior to triage or receiving a MSE and seek care and treatment at another local ED.

Findings:

In an interview with a Licensed Clinical Social Worker (LCSW) on 7/8/2025 at 2:13 p.m., the LCSW, who works for the County Mental Health Services, indicated he received a call from the community health clinic Director of Behavioral Health Care (DBHC) regarding a patient (Patient 1) who exhibited signs and symptoms of a mental health crisis. An agreement was made to meet at the Hospital parking lot for the LCSW to further assess Patient 1.

A review of a document dated 5/1/25 and identified by LCSW as the 5150 he wrote on 5/1/25 (allows a qualified professional to place someone on an involuntary 72-hour mental health hold), the document indicated Patient 1 presented, "as nonreality based. [Patient 1] was clearly responding to internal stimuli, [Patient 1] had tangential thought process (a type of disorganized thinking). Writer attempted to discuss why [Patient 1] and writer were talking with [Patient 1]. [Patient 1] explained that she was going to get her medications taken care of, then stated JP isn't sure if I should tell you ...[Patient 1] proceed to exit the vehicle and have a conversation with herself about why she shouldn't have exited the vehicle. Writer and [Patient 1] discussed her nutritional situation to which [Patient 1] made non-sensical statements. Writer ask (sic) where you get food, [Patient 1] made good eye contact and stated from the grocery store. Writer asked about the last time [Patient 1] had eaten. [Patient 1] proceeded to have another conversation with herself about not giving that information to writer. Writer ask (sic) if you were to go home right now how would you keep yourself safe? [Patient 1] replied I don't know". The document continued, "Writer discussed options with Behavioral Health Team, Writer completed 5150 hold due to [Patient 1] not being grounded in reality, inability to acquire and consume nutrition and inability to make a plan for safety or future plan."

In a continued review of the document dated 5/1/25 and identified by LCSW as the 5150, the document revealed, "Writer presented 5150 hold to (Hospital) ED. Charge nurse explained that they were low on available beds and would prefer to not take [Patient 1]. Charge nurse requested [Patient 1] be taken to [another local hospital] ED. Writer met with community clinic MH (Mental Health) at other hospital [hospital name] ED due to they were transporting. Writer presented [Patient 1] and 5150 at other hospital ED and [Patient 1] was admitted."

A review of a document provided by the Chief Nursing Officer (CNO), dated 5/3/2025, and described by the CNO as a written statement from CN 1, indicated, "I was working on Thursday May 1, and a coworker told me there was another 5150 hold in the waiting room and the case worker wanted to talk with someone. I went out to speak with them and they told me about the patient. I told them we had 4 holds currently and that most of the other beds had patients in them. I mentioned that with a fifth hold we would be down to having two functional ED beds if we wanted to stay in ratio [law mandating number of patients assigned to the care one nurse]. I explained it would be quite some time to get his patient a bed due to this ... I stated that we would of course take the patient, but if he didn't want to wait he could do as he pleases. He decided to head to the other facility. Kind regards, CN [name]."

During a telephone interview with CN 1 on 7/9/25 at 10 a.m., CN 1 confirmed he wrote the statement at the request of the CNO.

During a concurrent interview and review of the ED lobby monitoring video, on 7/9/2025, at 10:50 a.m., with the ED Manager (EDM) and CNO, the ED lobby camera footage, dated 5/1/25, at 12 p.m., revealed Patient 1 and DBHC entered the ED lobby and sat down at approximately 12:03 p.m. Shortly after LCSW entered and rang the doorbell into the ED, at which time, CN 1 came to the door and spoke to DBHC and LCSW. Patient 1, DBHC, and LCSW left the ED lobby at approximately 12:23 p.m. CNO and EDM confirmed Patient 1 was in the ED lobby for approximately 23 minutes and left without triage or medical screening exam.

During a telephone interview on 7/9/25 at 2:13p.m., with LCSW, LCSW stated he presented to the Hospital ED with Patient 1 and was greeted by CN 1 who stated there was one bed open in the ED and the need was to keep it open for emergencies in the community. LCSW stated CN 1 further stated, "We would prefer you take her to [name of other local ED]. LCSW stated Patient 1 was not triaged nor was a medical screening exam completed. LCSW stated CN 1 nor any other ED staff requested Patient1's name or any other identifiable information. LCSW believes they were in the ED about 20 minutes.

During a telephone interview with DBHC on 7/14/25 at 11:57 a.m., DBHC stated, on 5/1/25 he presented to the ED with Patient 1 and LCSW. DBHC stated CN 1 "refused" to accept the 5150 document and indicated Patient 1 needed to be taken to another local hospital ED as the Hospital only had one bed available and it had to be held for a "community emergency". DBHC stated he remembered CN 1 saying, "We don't want to take this patient". DBHC stated he, LCSW, and Patient 1 left the ED lobby after approximately 15-20 minutes. DBHC stated at no time was Patient 1 triaged nor offered a MSE.

Review of a policy titled, "Triage", dated 1/22, indicated, "Triage is the initial assessment and screening of patients who present to the Emergency Department (ED) for intervention...An ED Registered Nurse who has a minimum of six months ED experience and completed the Triage competency, will triage all patients who present for care in the ED...Following triage, a medical screening examination (MSE) is performed on all patients; this will be done by the ED physician or ED provider...MSE's are performed based on the triage level assigned by the triage RN...The documentation by the triage nurse will include name, chief complaint, vital sign, priority and any treatment initiated at that time ..."

Review of a policy titled, "EMTALA [Emergency Medical Treatment and Labor Act] Compliance", dated 10/18, indicated, "The Hospital's EMTALA obligation is triggered when an individual comes by him or herself or with another person or by ambulance to the Emergency Department; and a request is made by the individual, or on the individual's behalf or a prudent layperson observer would conclude from the individual's behavior or appearance, a need for examination or treatment of an emergency medical condition (EMC). In such a case, the Hospital has incurred an obligation to provide an appropriate medical screen exam (MSE) for the individual and stabilizing treatment within their capacity and capability, or an appropriate transfer ...The Hospital is obligated to provide the services necessary to determine if an EMC is present and provide stabilizing treatment."