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Based on a review of the facility's central log, medical record, video footage review, staff interviews, and policy and procedures, it was determined that the facility failed to provide one patient P (#1) out of 20 sampled patients with an appropriate Medical Screening Examination (MSE) within the capability of hospital's emergency department , including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed. Specifically, P#1 was accompanied by Emergency Medical Services (EMS) to Emory Johns Creek Hospital (Facility #1) ED. EMS presented a previously physician signed 1013 to the Charge Nurse and requested P #1 be accepted for medical treatment. The Charge Nurse declined to honor the signed 1013 and P #1 did not get a MSE. EMS transported P#1 to Facility #2's ED.

Findings were:

Cross refer to A-2406, as it relates to the facility's failure to provide P#1 with an appropriate MSE.

Based on a review of the facility's central log, medical record, video footage review, staff interviews, and policy and procedures, it was determined that the facility failed to provide one patient P (#1) out of 20 sampled patients with an appropriate Medical Screening Examination (MSE) within the capability of hospital's emergency department , including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed. Specifically, P#1 was accompanied by Emergency Medical Services (EMS) to Emory Johns Creek Hospital (Facility #1) ED. EMS presented a previously physician signed 1013 to the Charge Nurse and requested P #1 be accepted for medical treatment. The Charge Nurse declined to honor the signed 1013 and P #1 did not get a MSE.EMS transported P#1 to Facility #2's ED.

Findings included:



1. Review of the Emergency Department video footage showed on 8/28/23 at 3:42 p.m., an ambulance arrived at the ED entrance and a male person that was identified as P #1 entered in the ED escorted with Paramedic identified as Paramedic II. Paramedic II went to talk to Charge Nurse DD. Registrar EE was seen putting the patient wristband on P #1 at 3:53 p.m. and Paramedic II was seen talking with nurse identified as RN DD. At 3:54 p.m. P #1 was seen outside the ED, across the entrance along with another male adult (identified later as P #1's family). Paramedic II was seen at the Nurse's station talking with Charge Nurse DD. At 3:57 p.m. Paramedic II walked outside the ED and was seen talking to someone in the ambulance (latter identified as Paramedic JJ). At 4:00 p.m. Paramedic II went across the ED entrance toward where P #1 was seen standing. Paramedic II went back and forth between Paramedic JJ in the ambulance and P #1 from 4:00 p.m. and 4:14 p.m. Paramedic II and P #1 got into the ambulance at 4:14 p.m. and the ambulance drove away at 4:15 p.m.


2. A review of the facility's Central Log from 3/1/23 through 8/30/23 revealed that Patient (P) #1 presented to the Emergency Department (ED) and was registered as a patient on 8/28/23 at 3:49 p.m. The registration status was marked as canceled on 8/28/23 at 4:23 pm.


3. Review of medical record obtained from Facility #2 revealed Patient #1 (P #1) was a 32-year-old male who presented to the Emergency Department at facility #2 on 8/28/23 at 5:41 p.m. Triage notes indicated P #1 came in with a Chief Complaint of Suicidal Ideation. History from the medical record indicated that P #1 went to see his private Psychiatrist (a doctor that treated mental health disease) who, after assessment, placed P #1 on a 1013, called 911 to transport patient #1 to the hospital for safety (a 1013 was indicated to be called on any individual who was deemed a danger to self and/or others; a provider had state issued authority to detain such individual against his/her will).During ED assessment P #1 admitted to months of suicidal ideation; P #1 revealed two months prior he took very large dose of cocaine in an attempt to hurt himself. Patient #1 confessed to chronic drug and alcohol use in recent months. Further review of the record revealed P #1 had the following past medical history and diagnoses: Anxiety (a feeling of rear, dread, and uneasiness), Asthma (a chronic lung condition that causes inflammation and narrowing of the airway, leading to breathing difficulties), and Bipolar 1 disorder (a mental health condition characterized by extreme mood swings, including periods of intense mania (elevated mood, increased energy) and periods of depression.)

Review of the physical examination revealed the patients vital and laboratory results were within normal limits. The ED provider notes stated that he agreed with the need to continue the 1013 and decided to resign it and maintain P #1 in the Emergency Department on a 1013 status with plan for inpatient management. The ED provider ordered Ativan 1mg tablet (a sedating medication used to treat seizure and other mental disorders) PRN plus nicotine patch.
The ED provider requested a Mental Health Assessment with a Behavior Health and under ED Disposition it was indicated that P #1 was medically cleared for inpatient management and was being transferred to a Psychiatric facility pending placement. The ED final diagnosis was: Suicidal Ideations. Further review of revealed the patient was appropriately transferred via ambulance to Facility #2 (Psychiatric) on 8/29/2023 at 11:49 a.m.
During the ED course P #1 received



In a phone interview with the complainant (HH) on 9/5/23 at 12:25 p.m., complainant HH identified himself as Chief Emergency Medical Services (EMS) for (Name of County). Chief HH explained that on 8/28/23 his crew received a call to pick up a mentally ill patient from a private clinic. Chief HH said when his crew got there, the doctor had signed a 1013 to transport the patient (Patient #1) to the hospital. Chief HH said the paper did not specify to what facility to transport the patient. Chief HH explained that he received a call from his crew who told him that they were at facility #1 but the ED staff said they were not going to see the patient because they were not a psychiatric receiving facility. Chief HH said the crew took P #1 to (facility #2). Chief HH said he had had conversation with the ED staff before concerning 1013 because it was not the first-time staff at facility #1 was reluctant about accepting patients on 1013.

In an interview with The Emergency Department (ED) Nursing Director (RN) AA on 9/5/23 at 12:50 p.m. in the Board Room, Director AA said she was in the Emergency Department when EMS brought P #1 in the ED. Director AA said the department received the call from EMS to inform the staff, they were coming with a patient on a signed 1013. Director AA said staff informed EMS crew they were not a 1013 receiving facility. Director AA said the crew told the staff they were going to call back and hung up. Director AA said the EMS crew never called back but just showed up in the ED with P #1. Director AA explained that the facility was not a 1013 receiving facility, however they still accepted and treated all patients, including patients with psychiatric needs. Director AA said they would not turn a patient away even once the patient was on their property. Director AA said it did not matter that the EMS crew did not call back because it was a courtesy for EMS to call the ED staff. Director AA explained that all ED staff were aware that once a person showed in the department and requested medical assistance, they had to make sure such person receive a medical examination. Director AA said when the crew arrived, EMT II entered the ED with P #1 for a brief period and P #1 went outside to smoke to never return in the ED.


In an interview with Chief Paramedic BB on 9/5/23 at 1:30 p.m. in the Board room, Paramedic BB said he worked as a Paramedic in the ED and he was in the ED when P #1 arrived. Paramedic BB said he was aware that a call came to the ED from the ambulance that a 1013 patient was coming from a doctor's office. Paramedic BB said he was aware that the facility contracted an outside group to assess mental health patients whenever they had Psychiatric patients in the ED. Paramedic BB said when the call came in, he was sitting next to the Charge Nurse DD who answered the call and that the Charge Nurse DD advised the ambulance crew to consider a 1013 receiving facility because they were not a 1013 receiving facility but would take the patient if he came there. Paramedic BB said about 15 minutes after the phone conversation, the ambulance crew arrived in the ED with P #1. Paramedic BB said he saw the patient #1 inside the ED while the ambulance crew talking to Charge Nurse DD. Paramedic BB said he was busy with other patients but at some point, he saw P #1 standing outside next to the parking lot. Paramedic BB said he also noticed P #1 was talking to an adult male outside. Paramedic BB said he went to a patient room and when he came out a few minutes later, the ambulance crew along with P #1 was gone. Paramedic BB said it was his understanding that all persons who presented to the ED requesting medical help should receive medical treatment. Paramedic BB said the whole event was "confusing" to him. Paramedic BB explained he wondered why the patient (P #1) left as they were supposed to see everyone.


In an interview with Charge Nurse CC on 9/5/23 at 1:45 p.m. in the Board Room, Charge Nurse CC said she was working in the ED when ambulance brought P #1 in the ED. Charge Nurse CC stated that day she was not working as Charge Nurse, but she was a staff RN on that day. Charge Nurse CC said she was coming out of a patient room, and she noticed the EMT crew talking with Charge Nurse DD. Charge Nurse CC said they advised the EMT crew that they were not a 1013 receiving facility. Charge Nurse CC explained they accept Psych patients and that they had three ED rooms dedicated to Psych patients. Charge Nurse CC said she believed it was their policy not to accept a 1013 that was already signed by an outside doctor. Charge Nurse CC said if a patient presented in the ED with a signed 1013, she would ask them to take the patient to 1013 receiving facility. Charge Nurse CC said she saw the patient and P #1 was going to be her patient. Charge Nurse CC said she was getting a room ready for P #1 when she saw the EMT crew and P #1 leaving. Charge Nurse CC said Paramedic II told her "We're leaving".


In a phone interview with Charge Nurse DD on 9/6/23 at 10:13 a.m., Charge Nurse DD acknowledged she was the Charge Nurse on the day P #1 presented in the ED. Charge Nurse DD explained she received a call and spoke with Paramedic II who reported that he was about to bring a 1013 patient to the ED. Charge Nurse DD said Paramedic II stated he was at a private doctor's office where he was picking up the patient. Charge Nurse DD acknowledged she told Paramedic II that they were not a 1013 receiving facility. Charge Nurse DD said Paramedic II said he was going to call back but never did only to show up with patient #1 a while later. Charge Nurse DD said she only saw P #1 once when the crew just arrived because P #1 went back outside to smoke. Charge Nurse DD said as Paramedic II was talking to her, Paramedic II asked where the patient (P #1) and Paramedic II went outside to locate P #1 and Paramedic II never returned in the ED. Charge Nurse DD reiterated that they were not a 1013 receiving facility.




In an interview with Patient Access/Registrar EE on 9/6/23 at 1:14 p.m. in the Board Room, Registrar EE said she remembered when P #1 came in the ED with Paramedic II. Registrar EE said she registered P #1 and that she remembered P #1 had Psychiatric complaint. Registrar EE said she verified P #1's name and date of birth and put the arm band. Registrar EE said she commented to the EMT that P #1 did not have a family member to sign consent for him. Registrar EE said when a Psych patient came, they usually had a person to sign consent on their behalf. Registrar EE said she went to relieve her partner in the back for a bathroom break and when she came back P #1 and the Paramedic were gone. Registrar EE said she did not know why they left. Registrar EE said they never turned patients away and that they accepted all types of patients. Registrar EE stated from what she heard, it appeared the facility was not a 1013 receiving facility, but she was not sure because she was not a nurse and only did registration.


During an interview with the ED Medical Director, MD FF on 9/6/23 at 3:43 p.m. in the Board Room, Director FF said they were not a 1013 receiving facility. Director FF said if a patient came in the ED regardless of the patient status, they accepted the patient anyway once on the property. Director FF said they had procedures they followed for all Psychiatric patients; they consulted/contracted with a local Psychiatric group to assess their Psych patients, and they followed their recommendations. Director FF explained that if a patient had already been assessed and placed on 1013, there was no need to transport such patient to their facility because the patient had already been deemed a danger to self; for the 1013 patient, ED Medical Director said they advised the ambulance to take the 1013 patient to a 1013 receiving facility.


In a phone interview with Emergency Medical Technician (EMT) II on 9/7/23 at 9:50 a.m., EMT II said he responded to a call from a doctor's office on 8/28/23 regarding a Psych patient. EMT II said when the crew arrived at the doctor's office, the doctor gave him a signed 1013 to take P #1 to the hospital. EMT II said P #1 was accompanied by his parent. EMT II said both P #1 and his parent were not very pleased with the doctor who did not tell them about the decision. EMT II said P #1 was very cooperative when he picked him up at the doctor's office. EMT explained that he decided to take P #1 to facility #1 because it was the closest place to take P #1. EMT II said the 1013 did not specify which facility to take the patient (P #1) to. EMT II said he called facility #1 and he spoke with the ED Charge Nurse DD. EMT II said Charge Nurse DD told him they were not a psychiatric receiving facility. EMT II said he did not call the facility back, but he showed up in the ED with P #1. EMT II said when he got in the ED, he told Charge Nurse DD about the 1013 and gave her the signed 1013. EMT II said Charge Nurse DD said that the doctor who signed the 1013 was not one of their providers and because of that they were not going to honor the 1013. EMT II said that P #1 was already upset about the whole situation was becoming even more upset. EMT II said P #1 told him he was going outside to smoke a cigarette. EMT II said P #1 was having a bad day and that he would not deny the patient the opportunity to go outside for a cigarette. EMT II said there was a lot of back and forth between him and Charge Nurse DD about the 1013. EMT II said Charge Nurse DD was very reluctant to accept the 1013; EMT II said the whole time he was "pleading" with Charge Nurse DD to accept P #1. EMT II said that Charge Nurse DD was so reluctant that he felt he was wasting precious time. EMT II said he stepped out discussed the situation with his partner. EMT II said he decided to take P #1 to facility #2 and informed his Supervisor HH about the situation. EMT II said the back and forth between him and Charge Nurse DD that he did not go back inside the ED, but EMT II said he told Nurse CC that he was leaving. EMT II said RN CC did not make any effort to encourage him to stay.


In a phone interview with EMT (Emergency Medical Technician) JJ on 9/7/23 at 10:19 a.m., EMT JJ said she did not go inside the ED, she remained in the ambulance because of parking issue. EMT JJ said EMT II was inside for quite a while in a back and forth with ED nurses. EMT JJ said EMT II came out to inform her that the facility did not want to honor the 1013 because they were not a designated psychiatric receiving facility for a 1013. EMT JJ said she called EMT Supervisor HH who directed them to take P #1 to facility #2.


Review of policy title "EMTALA - Medical Screening, Treatment and Related Issues" effective date: 10/20/2016. The Policy revealed in part, "hat any individual who came to the Emergency Department or Labor & Delivery requesting care should be offered an appropriate Medical Screening Examination (MSE) to determine if the individual had an Emergency Medical Condition. The policy delineated if an Emergency Medical Condition existed, the facility should provide treatment to stabilize the condition or an appropriate transfer in accordance with the facility policy on Transfers. ..
Procedure: It was stated an appropriate Medical Screening Examination should be provided to any individual who came to the Emergency Department (and/or on facility Property) and: (1) the individual or a representative acting on the individual's behalf requested an examination or treatment for a medical condition; or (2) it was apparent that the person needed an examination or treatment of a medical condition based on the individual's appearance or behavior. If an Emergency Medical Condition was determined to exist, the individual should be provided necessary stabilizing treatment, within the capacity and capability of the facility, or appropriately transferred ... The policy articulated that in the Emergency Department, a physician, physician's assistant or advanced practice nurse were deemed Qualified to initiate treatment of any Emergency Medical Condition ...Individuals with psychiatric symptoms: The policy revealed that the medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes was to determine if the psychiatric symptoms had a physiologic etiology. The psychiatric MSE included an assessment of suicidal or homicidal thoughts or gestures that indicates danger to self or others."


Review of policy title "Certificate Authorizing Transport to Emergency Receiving Facility (1013/2013)" effective 10/1/2022. The policy stated that Psychiatric patients brought to the Emergency Department who were determined to require an involuntary psychiatric evaluation at an ERF, must have a Medical Screening Examination (MSE) and meet criteria for Medical Clearance by a physician/APP. The policy explained that patients admitted to inpatient units should be deemed medically stable by a physician/APP prior to transport on 1013/2013.



The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to provide an appropriate medical screening examination within the capacity and capability of the hospital's ED f to include ancillary services routinely available to determine whether or not an emergency medical condition existed for patient #1 on 8/28/2023 who presented to the hospital's ED with a signed 1013 form from his psychiatrist indicating , it was apparent that the patient needed an examination or treatment based on his behavior. This patient had identified psychiatric emergency and required an appropriate medical screening examination prior to transferring Patient #1 to facility #2.