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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 Active Labor Act (EMTALA) requirements.

FINDINGS

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

A-2407- (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; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital's obligation under this section ends, as specified in paragraph (d)(2) of this section. Based on interviews and document review, the facility failed to provide an appropriate Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to utilize ancillary services available within the emergency department (ED) for two of eight patients who presented with signs and symptoms of alcohol use disorder (AUD) (Patients #4 and #12). Furthermore, the facility failed to ensure suicidal psychiatric patients were assessed and released to a facility capable of providing medical treatment for mental health and psychiatric conditions for two of two suicidal psychiatric patients reviewed (Patients #10 and #11).

Based on interviews and document review, the facility failed to provide an appropriate Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to utilize ancillary services available within the emergency department (ED) for two of eight patients who presented with signs and symptoms of alcohol use disorder (AUD) (Patients #4 and #12). Furthermore, the facility failed to ensure suicidal psychiatric patients were assessed and released to a facility capable of providing medical treatment for mental health and psychiatric conditions for two of two suicidal psychiatric patients reviewed (Patients #10 and #11).

Findings include:

Facility policies:

The Emergency Medical Treatment and Labor Act policy read, facilities with emergency departments, a qualified medical provider (QMP) shall perform an appropriate medical screening evaluation (MSE), within the capability of the facility for any individual who requests examination or treatment of a medical condition.

Medical screening examination is the process required to determine whether or not an emergency medical condition exists. Medical screenings and services must be provided within the hospital's capabilities.

Transfer: The transfer of a patient to another facility occurs when the receiving facility has the available space and the qualified personnel to treat the patient. Additionally, the receiving facility must agree to the transfer and provide the appropriate medical treatment needed for the patient.

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).

The Rules and Regulations Manual read, the facility does not provide psychiatric or substance abuse services. However, the Hospital does provide contract arrangements for consultative or transfer services to an appropriate psychiatric facility.

The Management of the Behavioral Health Patient policy read, patients presenting with psychiatric complaints will receive a medical screening examination to rule out current injury or illness. Once a life-threatening illness/injury has been addressed and stabilized, a mental health evaluation is completed with referral and recommended follow-up. Patients with psychiatric complaints are provided a medical screening examination to rule out current injury or illness. A Mental Health Evaluator or contracted Mental Health Evaluator will evaluate patients with the following behaviors: Anxiety/panic attack which impacts the patient's ability to function, depression, suicide attempt or suicidal ideation, homicidal ideation or violent behavior, psychotic symptoms, situational crises and impaired cognitive status. Impaired cognitive status includes the following: Delirium, dementia or substance use disorder and mental illness.

A mental health hold (M-1) will be completed for the following situations: Suicidal/homicidal patients. Any situation where a patient appears to be an imminent danger to him/herself or others. When the patient is medically stable, the patient must be transferred to a facility appropriate to the level of care needed. The inpatient mental health facilities which are appropriate include facilities A and B.

Emergency Commitment (EC) holds: Used for patients intoxicated or incapacitated by drugs and/or alcohol and are a danger to themselves due to being under the influence of a substance(s). The accepting facility is notified of the patient's condition, any medications that were administered to the patient, the means of transportation established for the patient, the estimated time the patient will arrive and a nurse to nurse report provided.

The Assessment and Care of the Suicidal Patient policy read, if a patient screens positive for suicide risk, a healthcare order for a behavioral health evaluation will be provided.

1. The facility failed to provide patients with alcohol use disorders (AUD) an appropriate MSE, treatment, and after-care services.

A. Facility documents and medical records were reviewed and revealed ancillary services (mental health services, behavioral health services, laboratory testing and substance abuse services) were not utilized to determine if an emergency medical condition (EMC) existed for AUD patients.

a. According to the Management of the Behavioral Health Patient policy, a Mental Health Evaluator or contracted Mental Health Evaluator will evaluate patients with situational crises and impaired cognitive status such as substance use disorders.

b. Medical record review revealed Patient #12 was transported by EMS to the ED on 10/11/21 at 2:39 p.m. EMS documented Patient #12 was found lying on a bus bench and appeared lifeless.

Patient #12 had appeared lethargic (fatigued and lacked mental and physical energy), intoxicated and smelled of alcohol when he arrived at the ED. Patient #12 had mild tachycardia (the presence of rapid beating of the heart) and was hypoxic (low oxygen levels in the blood).

i. At 2:50 p.m., the ED nurse caring for Patient #12 documented Patient #12 stated he wanted to kill himself. The ED Provider Notes for Patient #12 revealed a mental health evaluation was needed for suicidal ideation.

There was no evidence a behavioral health or mental health consultation order was entered for Patient #12. Furthermore, there was no evidence a mental health evaluator had seen and performed an evaluation to rule out a psychiatric EMC for Patient #12.

This was in contrast to the Emergency Medical Treatment and Labor Act policy which stated an appropriate MSE and treatment will be provided for psychiatric patients seen in the ED. Furthermore, the Assessment and Care of the Suicidal Patient policy stated, patients who screen positive for suicidal ideations will have a behavioral health evaluation and the healthcare provider overseeing the patients' care will place a mental health consultation order.

ii. On 3/30/22 at 4:01 p.m., an interview was conducted with Chief Medical Officer (CMO) #5. CMO #5 stated behavioral health evaluations and or mental health evaluations were ordered for patients at risk for self-harm and for patients with suicidal ideations.

iii. On 3/30/22 at 3:30 p.m., an interview was conducted with Behavioral Health Manager (Manager) #6. Manager #6 stated the physician needed to place an order for the patient to be seen by a Mental Health Evaluator. Manager #6 stated Mental Health Evaluators would perform evaluations to determine the patient's risk of self-harm.

Manager #6 stated substance abuse evaluations were also performed by Mental Health Evaluators. Manager #6 stated substance abuse evaluations were performed when the patient was sober (not affected by alcohol or drugs). Manager #6 stated the physician had complete discretion for the placement of a behavioral and mental health evaluation order.

c. Review of Patient #4's medical record revealed on 1/26/22 at 12:24 p.m., Patient #4 presented to the ED for alcohol withdrawal.

i. At 12:30 p.m., the ED Intake Provider Notes for Patient #4 read, Patient #4 had been treated twice for alcohol withdrawal 16 days prior on 1/10/22.

According to the medical record, Patient #4 had symptoms of alcohol withdrawal present when assessed by the ED physician. Patient #4 was nauseous and experienced emesis (vomiting) for an unknown number of days prior to being seen in ED.

Patient #4 reported he had last consumed alcohol on 1/25/22 and consumed excessive amounts of alcohol for greater than one week. Patient #4 had a prior history of alcohol withdrawal seizures and verbally confirmed he wanted assistance to stop drinking.

ii. At 1:49 p.m., a Minnesota Detoxification Scale (MINDS) assessment for the treatment of alcohol withdrawal was performed on Patient #4. The MINDS assessment indicated Patient #4 had alcohol withdrawal symptoms present.

On 3/30/22 at 11:05 a.m., an interview was conducted with LSW #2. LSW #2 stated the MINDS assessment was a protocol used for patients experiencing symptoms of alcohol withdrawal. LSW #2 stated the MINDS assessment was used to assess and diagnose the severity level of alcohol withdrawal. LSW #2 stated AUD patients were at risk for seizures, nausea, tremors, anxiety, hallucinations, headaches and even death when alcohol withdrawal symptoms were not treated.

iii. At 2:04 p.m., Patient #4 was administered 2 mg of lorazepam (a medication used to decrease symptoms related to alcohol withdrawal) and 43 minutes later at 2:47 p.m., Patient #4 was administered one 30 mg tablet of clorazepate (a medication used to relieve the symptoms of alcohol withdrawal). Both the lorazepam and the clorazepate were prescribed for Patient #4 for Alcohol Withdrawal Syndrome.

iv. At 4:09 p.m., Patient #4 was discharged from the ED. The face sheet for Patient #4 read Patient #4 was discharged home for self-care.

There was no evidence in Patient #4's medical record of a behavioral health consultation for chemical dependency and there was no evidence Patient #4 was provided assistance or resources for his AUD and alcohol detox services.

This was in contrast to the Management of the Behavioral Health Patient policy, which stated patients with substance use disorder were evaluated by a Mental Health Evaluator or contracted Mental Health Evaluator. A mental health evaluation will be completed and the recommended follow-up and referrals provided.

B. Interviews with staff revealed AUD patients seen in the ED were not provided consistent medical examinations, treatment, patient care, and after-care. Specifically, utilization of ancillary services routinely available to patients seen in the ED were not provided.

a. On 3/30/22 an interview was conducted with Chief Medical Officer (CMO) #5. CMO #5 stated there was not a standard of care established at the facility for the treatment of AUD patients. CMO #5 stated when an AUD patient arrived at the ED the patient would be physically assessed. CMO #5 stated unless an AUD patient had additional medical concerns no diagnostic labs or ancillary services would be performed for the patient.

CMO #5 stated alcohol intoxication and alcohol dependency were psychosocial concerns (the combination of a patient's psychological development with the patient's social environment). CMO #5 stated substance abuse was defined as the chronic use of alcohol. CMO #5 stated the ED Provider had complete discretion as to what treatment and services an AUD patient received.

b. On 3/30/22 at 11:42 a.m., an interview was conducted with Provider #1. Provider #1 stated medical treatment provided to AUD patients was based on the clinical assessment (the collection of information from a patient and drawing of conclusions to determine medical concerns) of the patient. Provider #1 stated AUD patients were treated per the discretion of the ED Provider. Provider #1 stated unless alcohol withdrawal symptoms or additional medical conditions were present, intoxicated patients were considered stable and did not require additional diagnostic or ancillary services.

c. On 3/30/22 at 1:02 p.m., an interview was conducted with LSW #3. LSW #3 stated the facility was able to coordinate patient treatment for patients who identified that they wanted to be sober and wanted to initiate a sobriety plan. LSW #3 stated ED patient consultations for behavioral health services, substance abuse and psychiatric services had to be placed by the ED Provider. LSW #3 stated behavioral health consultations, mental health evaluations and substance abuse/use evaluations were only performed when the ED Provider requested the consultation. LSW #3 stated consultations were entered at the discretion of the ED Provider.

LSW #3 stated patients with AUD and SUD experienced decreased inhibitions and were unaware of the level of harm they self-inflicted. LSW #3 stated AUD and SUD patients were at an increased risk for injury and/or harm to self and others.

d. On 3/30/22 at 10:29 a.m., an interview was conducted with Registered Nurse (RN) #4. RN #4 stated patients who request chemical dependency services would be seen by a behavioral health specialist. RN #4 stated the patient was not supposed to be intoxicated when the patient was seen by the behavioral health specialist.

RN #3 stated intoxicated patients seen in the ED would have diagnostic labs performed. RN #3 stated a breathalyzer test was a standard diagnostic test performed for intoxicated patients. RN #3 stated a blood alcohol level could also be performed for intoxicated patients. RN #3 stated both diagnostic tests would have to be ordered by the ED provider. RN #3 stated the ED Provider decided when and what diagnostic labs to order.

2. The facility failed to ensure suicidal psychiatric patients were assessed and released from the ED to a mental health facility capable of providing the necessary treatment for psychiatric patients with suicidal ideations.

A. Medical records were reviewed for suicidal psychiatric patients seen in the ED between 10/11/21 to 1/5/22 and revealed the following:

a. On 11/12/21 at 11:26 a.m., Patient #10 was transported by ambulance to the ED. Patient #10 was found intoxicated in the parking lot of a retail shop. Patient #10's speech was slurred and he was unable to stand or walk independently. Additionally, Patient #10 stated he drank mouthwash as an alcoholic beverage substitute in order to become intoxicated.

i. At 11:36 a.m., the ED Triage Notes caring for Patient #10 read Patient #10 had made verbal suicidal statements. Additionally, the ED Provider Notes read Patient #10 was intoxicated and "will need to sober up".

At 4:11 p.m., the Clinical Notes for Patient #10 read Patient #10 was placed on an Emergency Commitment (EC) hold. According to the Management of the Behavioral Health Patient policy, EC holds are used for patients intoxicated or incapacitated by drugs and or alcohol for intoxication.

At 5:37 p.m., Patient #10's medical record stated Patient #10 would be transferred to a chemical dependency center.

ii. On 11/13/21 at 1:04 a.m., Patient #10 was discharged and transported by secure ambulance to a chemical dependency center.

There was no evidence Patient #10 had a mental health evaluation performed or was seen by a mental health evaluator for suicidal ideations.

b. On 1/5/22 at 3:26 p.m., Patient #11 was transported by emergency medical services (EMS) to the ED. According to the ED Provider Notes at 3:36 p.m., Patient #11 went to an inpatient psychiatric and chemical dependency facility for assistance with alcohol abuse. Patient #11 was transported to the ED by EMS to receive medical clearance. However, Patient #11 stated he was suicidal after he arrived in the ED.

i. The Clinical Notes for Patient #11 stated at 5:48 p.m., a Mental Health Evaluator was informed by the ED Provider that Patient #11 verbalized suicidal ideations.

There was no evidence Patient #11 received a mental health evaluation for suicidal ideations.

However, at 7:01 p.m., an EC hold was implemented for Patient #11 and a bed placement (the placement or transfer of a patient at a specific care facility, treatment program, or level of care) was secured for Patient #11 at a detox facility.

ii. At 9:18 p.m., a handoff report (staff communication from the transfer facility to the receiving facility with specific patient information) occurred between the ED nurse and a staff member at the detox facility.

iii. On 1/6/22 at 1:55 a.m., Patient #11 was transported by secure ambulance to a chemical dependency detox facility.

Further record review revealed the detox clearance form (a form for medical clearance used to authorize the transfer of a patient) stated Patient #11 had exhibited and verbalized active suicidal ideation.

These examples were in contrast to the Management of the Behavioral Health Patient policy, which read, suicidal patients will be placed on an M-1 hold. Once the patient has been medically stabilized the patient must be transferred to a facility appropriate for patients with mental health concerns including facilities A and B (which are inpatient mental health facilities).

Additionally, the policy read an EC hold will be implemented for patients intoxicated or incapacitated by drugs and or alcohol and who are also a danger to themselves due to being under the influence of a substance.

c. On 3/28/22 at 1:04 p.m., an interview was conducted with RN #7. RN #7 stated patients were screened for self-harm by the ED nursing staff. RN #7 stated suicidal patients were evaluated by a Mental Health Evaluator. RN #7 stated ED Providers will place a mental health evaluation consultation for suicidal patients. RN #7 stated the Mental Health Evaluator would oversee the transfer and placement of suicidal patients at psychiatric facilities.

i. On 3/30/22 at 1:02 p.m., an interview was conducted with LSW #3. LSW #3 stated patients who express suicidal ideation needed to be evaluated by a Mental Health Evaluator. LSW #3 stated patients with suicidal ideations were psychiatric patients. LSW #3 stated mental health evaluations were performed for patients with suicidal ideations, however, she stated the ED Provider would need to order the mental health evaluation to be performed. LSW #3 stated mental health evaluations were ordered for patients at the discretion of the ED Provider.