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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag 2406: - Applicability of Provisions of this Section (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction. Based on interviews and document review, the facility failed to provide an appropriate medical screening examination (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to determine whether or not an emergent psychiatric condition existed for one of nine medical records reviewed of patients who presented to the facility and requested emergency psychiatric services but were not admitted.

Based on interviews and document review, the facility failed to provide an appropriate medical screening examination (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to determine whether or not an emergent psychiatric condition existed for one of nine medical records reviewed of patients who presented to the facility and requested emergency psychiatric services but were not admitted. (Patient #7)

Facility findings:

Facility policy:

The EMTALA policy read, it is the hospital policy that when an individual comes to the Emergency Department (ED): The hospital will provide an appropriate medical screening exam (MSE), within the capability of the hospital's dedicated emergency department, including ancillary services routinely available to the dedicated emergency department, to determine whether or not an emergency medical condition exists. The MSE is an ongoing process. The medical record must reflect ongoing assessment of the patient's condition. Monitoring must continue until the individual is stabilized, appropriately admitted or transferred. There should be evidence of this prior to discharge or transfer.

According to the policy's definitions:

Emergency medical condition: A medical condition manifesting 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 attention could reasonably be expected to result in either (1) placing the health of the individual (Or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, or (2) serious impairment to bodily functions or (3) serious dysfunction of any bodily organ or part.

Medical screening exam (MSE): The screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist. Initial triage is not considered a MSE. The MSE represents a spectrum ranging from a brief history and physical examination to complex processes that also involve performing ancillary studies and procedures.

1. The facility failed to ensure patients who presented to the facility for emergency psychiatric services received a MSE to determine if an emergency psychiatric condition existed for the patient.

a. Review of Patient #7's medical record, dated 6/15/23 at 1:10 a.m., revealed Patient #7 arrived at the ED with the chief complaint of danger to self or others. Medical record review revealed a Columbia-Suicide Severity Rating Scale (a suicide risk assessment tool that involves asking the patient a series of simple, plain-language questions) was performed on Patient #7 on 6/15/23 at 1:01 a.m., which determined Patient #7 was at a moderate suicide risk with the risk interventions recommended of continuous visual observation, remaining with the patient until monitoring was in place, notifying the provider and performing room safety checks.

At 1:35 a.m., Patient #7's medical record revealed he was discharged, 35 minutes after the patient was classified as a moderate risk for suicide, with the disposition of left without being seen (LWBS). Registered nurse (RN) #1 documented in Patient #7's medical record that the patient approached the triage desk and threw a water bottle at a staff member, refused to calm down or answer questions, continued to be violent towards staff, and was subsequently escorted off hospital property by security.

Further medical record review revealed no evidence that a provider evaluated Patient #7.

b. On 11/7/23 at 2:29 p.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated if a patient presented with a psychiatric complaint they were to be evaluated by a provider. RN #1 stated if a patient scored as a moderate risk on the Columbia scale the patient was at risk of harming themselves or others and should not have been asked to leave. RN #1 stated it was important for all patients to receive a medical screening exam because there could have been a medical problem that needed to be addressed.

c. On 11/8/23 at 7:59 a.m., an interview was conducted with medical provider (Physician) #2. Physician #2 stated all patients who presented to the emergency department were to receive a Columbia score per policy. Provider #2 stated if a patient were to throw a water bottle they would not be asked to leave. Provider #2 stated more questions would need to be asked to determine if the patient was a risk of self harm or of harm to others. Provider #2 stated everyone who presented to the ED was entitled to a medical screening even if they were disruptive. Provider #2 stated she was not aware of a specific risk if a medical screening was not performed.

d. On 11/8/23 at 8:51 a.m., an interview was conducted with ED physician (Physician) #3. Physician #3 stated all patients who presented to the ED should have been provided a medical screening exam. Physician #3 stated it was important for patients to be seen so a medical condition could be assessed to minimize negative outcomes. Physician #3 stated there was a risk of any medical condition going unidentified if a medical screening was not performed.

e. On 11/8/23 at 12:59 p.m., an interview was conducted with the director of emergency services (Director) #5. Director #5 stated it was important for patients to be seen by a provider for a medical screening evaluation because the evaluation could prevent a negative situation for the patient, including death.