HospitalInspections.org

Based on Emergency Medical Treatment and Transfer Policy (EMTALA) policy review, Release Against Medical Advice policy review, Mental Health Services Telehealth policy review, medical record review, and medical staff interviews the facility failed to follow their policies for 1 (Patient 10A) of 20 sampled Emergency Department (ED) patients. This failed practice has the potential to cause negative outcomes for all patients who present to the ED seeking emergent care and treatment. According to facility provided data the ED saw an average of 194 patients and 20 transfers per month.

See citation A2406 and A2407, that also resulted in A2400 to not be met.

Based on facility policy review, medical record review, medical staff interviews and staff interviews the facility failed to ensure 1 (Patient 10A) of 20 Emergency Department (ED) sampled patients were provided a complete medical screening exam (MSE) psychiatric evaluation to determine whether the presence of an emergency medical condition (EMC) existed prior to patient disposition (final determination of the patients next level of care which includes discharge, admit or transfer). This failed practice has the potential to cause harm or death to all patients who present to the ED with an EMC. According to facility provided data the ED saw an average of 194 patients per month.

See citation A2400 and A2407, that also resulted in A2406 to not be met.

Findings include:

A. Review of the facility Emergency Medical Treatment and Labor Act (EMTALA) policy, effective 6/2024 revealed:

An EMC is defined as a condition manifesting itself by acute symptoms of sufficient severity (including psychiatric disturbances) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health in serious jeopardy. An MSE is defined as the process required to reach, with reasonable clinical confidence that can be determined whether a medical emergency does or does not exist.

Review of the facility Refusal of Service/Release Against Medical Advice (AMA) policy, effective 6/2023 revealed:

AMA is defined as the patient refuses to participate or consent to care/treatment as outlined by the physician and may choose to leave the facility against the advice of the physician. Patients are not physically prevented from leaving the facility unless they do not have the capacity to understand the medical risks of leaving the hospital, refusing care, and the risk creates a danger for the patient's safety. In instances where a patient wants to leave the facility AMA and a mental health professional has submitted an affidavit to the County Attorney's office for review, patients can be held until determination is made by the County Attorney on filing.

Review of the facility Mental Health Service -- Telehealth Services policy, effective 5/2023 revealed:

The ED will notify the Mental Health Emergency Department when services are requested for a patient. Documentation from the telehealth will be in the patient's electronic medical record.

B. Review of Patient 10A's medical record revealed, P10A presented to the critical access hospital ED on 2/26/2025 at 10:55AM via law enforcement, with a chief complaint of agitation and further evaluation for emergent protective custody (EPC - a temporary measure where law enforcement can take someone into involuntary custody if mentally ill and/or dangerous to either themselves or others) with a past medical history of Bipolar 1 (mental health condition with extreme mood swings).

Prior to P10A's arrival to the ED local law enforcement were summoned to P10A's residence, where P10A was barricaded into their room with reports of being held hostage but could not say who was holding them hostage.

P10A's medical screening exam revealed positive for agitation, nervous/anxious, tearful, inappropriate and hyperactive behavior, tangential (a communication disorder that a person strays away from the main topic of conversation) speech, negative for self-injury and suicidal ideas. P10A's medical screening exam lacked evidence of homicidal (harm to others) evaluation. P10A requested a shot for anxiety. P10A's medical record lacked evidence of any medication orders while at the facility's ED, confirmed by Registered Nurse (RN)-C. The electronic medical record revealed on 2/26/2025 at 11:09AM patient continues to be verbally aggressive.

On 2/26/2025 at 12:07 PM P10A left the facility AMA accompanied by law enforcement. The local law enforcement and state patrol did not EPC the patient. P10A's medical record lacked evidence of a psychiatric evaluation to rule out an EMC (harm to self or others) prior to disposition of AMA, confirmed by RN-C.

C. During an interview on 4/14/2025 at 10:41AM, RN-C revealed law enforcement stayed with P10A the entire ED visit on 2/26/2025 due to patient behaviors toward ED staff. RN-C did not recall when Physician-D became involved in P10As case, or if the Mental Health Telehealth was utilized during the 2/26/2025 ED visit. RN-C confirmed P10A's medical screening exam lacked evidence of homicidal (harm to others) or full psychiatric evaluation. RN-C confirmed that P10A's electronic medical record lacked evidence of a complete columbia suicide severity rating scale (C-SSRS) (scale that includes no risk, moderate risk or high risk for suicide).

During an interview on 4/14/2025 at 11:54AM, Physician-D revealed they did not recall contact with Physician Assistant-B on 2/26/2025. Physician-D confirmed they were not asked to see or speak to P10A on 2/26/2025. However, on 2/27/2025 Physician-D had a message requesting to see P10A as soon as possible. Upon evaluation Physician-D revealed P10A is their own guardian and refused voluntary inpatient psychiatric treatment initially. The local and state law enforcement determined P10A did not meet EPC criteria on 2/26/2025. Physician-D revealed on 2/5/2025 P10A was granted a 90 day suspension (in the process of commitment) from the mental health board in a different county. P10B was transferred to the county to reinvoke the mental health board commitment.

Based on policy review, medical record review, medical staff interviews and staff interviews the facility failed to ensure 1 (Patient 10A) of 20 Emergency Department (ED) sampled patients were provided stabilizing treatment prior to patient disposition (final determination of the patients next level of care which includes discharge, admit or transfer). This failed practice has the potential to cause harm or death to all patients who present to the ED with an emergency medical condition (EMC) requiring stabilizing treatment. According to facility provided data the ED saw an average of 194 patients, and 20 transfers per month.

See citation 2400 and A2406, that also resulted in A2407 to not be met.

Findings Include:

A. Review of the facility Emergency Medical Treatment and Labor Act (EMTALA) policy, effective 6/2024 revealed:

An EMC is defined as a condition manifesting itself by acute symptoms of sufficient severity (including psychiatric disturbances) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health in serious jeopardy. An MSE is defined as the process required to reach, with reasonable clinical confidence that can be determined whether a medical emergency does or does not exist. To stabilize is defined as to provide medical treatment of the EMC necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility. For psychiatric conditions, the patient is said to be stable when they are protected from injuring themselves or others. Transfer is defined as the movement of an individual outside of the medical center at the direction of any person employed by the medical center. If an EMC exists, the medical center employees and medical staff will provide further health assessment/examination and treatment to stabilize the medical condition. Before transfer, the medical center must provide treatment within its capability to minimize the risk to the individual.

Review of the facility Refusal of Service/Release Against Medical Advice (AMA) policy, effective 6/2023 revealed:

AMA is defined as the patient refuses to participate or consent to care/treatment as outlined by the physician and may choose to leave the facility against the advice of the physician.

Review of the facility Mental Health Service -- Telehealth Services policy, effective 5/2023 revealed:

The ED will notify the Mental Health Emergency Department when services are requested for a patient. Documentation from the telehealth will be in the patient's electronic medical record.

B. Review of Patient 10A's medical record revealed, P10A presented to the critical access hospital ED on 2/26/2025 at 10:55AM via law enforcement, with a chief complaint of agitation and further evaluation for emergent protective custody (EPC - a temporary measure where law enforcement can take someone into involuntary custody if mentally ill and/or dangerous to either themselves or others) with a past medical history of Bipolar 1 (mental health condition with extreme mood swings), presumed not to be taking prescribed medication.

Prior to P10A's arrival to the ED local law enforcement were summoned to P10A's residence, where P10A was barricaded into their room with reports of being held hostage but could not say who was holding them hostage.

P10A's medical screening exam revealed positive for agitation, nervous/anxious, tearful, inappropriate and hyperactive behavior, tangential (a communication disorder that a person strays away from the main topic of conversation) speech, negative for self-injury and suicidial ideas. P10A's medical screening exam lacked evidence of homicidal (harm to others) evaluation [per EMTALA policy to be considered stable]. P10A requested a shot for anxiety. P10A's medical record lacked evidence of any medication orders while at the facility's ED, confirmed by Registered Nurse (RN)-C. The electronic medical record revealed on 2/26/2025 at 11:09AM patient continues to be verbally aggressive.

P10A returned to the facility ED on 2/27/2025 at 11:44AM sent from the clinic for acute psychosis (a temporary mental state where someone loses touch with reality, often seeing or hearing things that are not there), agitation (restless) and paranoia (distrust or suspicion often the belief that others are out to harm them). P10B was transferred to a facility with inpatient mental health care on 2/27/2025 at 6:17PM.

C. During an interview on 4/14/2025 at 10:41AM, RN-C revealed law enforcement stayed with P10A the entire ED visit on 2/26/2025 due to patient behaviors toward ED staff. RN-C confirmed P10A did not received any medication while in the facility ED on 2/26/2025.

During an interview on 4/14/2025 at 11:54AM, Physician-D revealed P10B was labile (thoughts change frequently) during the 2/27/2025 psychiatric evaluation. Physician-D confirmed they were not asked to see or speak to P10A on 2/26/2025.