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Based on document review, staff interview, and policy review, the hospital failed to ensure an appropriate medical screening exam (MSE) was provided for one of one sampled patients (Patient P22) who presented to the emergency room (ER) for treatment. The failure to provide an MSE to determine if an emergency medical condition existed and had the potential to place all patients who presented to the ER at risk for an appropriate screening and treatment of an emergency medical condition.

Findings include:

Review on 06/28/18 at 9:00 AM of the hospital's telephone grievance report, dated May 29, 2018 at 9:30 AM, revealed P22 presented to the ER on 05/26/18 around 11:00 or 11:30 AM with a complaint of a migraine. This was P22's first visit to the hospital so the registration clerk provided forms for the patient to fill out in-order to create a medical record. P22 filled out the forms and returned to the registration clerk who then told her that she could not be treated because she was "not Indian." The patients concern was that she had to complete the forms while having a migraine and then was told she could not be seen. The patient voiced that she had worked in hospital administration and was familiar with the EMTALA law and wanted to know what the process was for treating patients who were not native.

The Area Chief Medical Officer (CMO) was interviewed 06/25/18 at 1:10 PM and shared the hospital had recently identified an ER concern with registration and providing an MSE. The CMO revealed that a patient had presented to the ER registration area with a migraine. The patient requested an evaluation, the registered nurse (RN) went to the ER Doctor (Dr.) stating "we have a non-Indian patient" and the Dr. responded that "he could not write a prescription for someone outside here so there was not much I can do for her." The registration staff then told the patient she could not be treated here. The CMO revealed the Quality Manager (QA) received the grievance phone call and he was notified the day following the complaint. The CMO shared at the team meeting 06/07/18 the grievance was discussed with the executive leadership and the QM asked the ER to schedule training. He shared the ER MD felt an investigation needed to be completed with a concern for a potential for an EMTALA violation and shared the hospital has plans to re-educate all ER staff on EMTALA. The CMO verified that as of this date no education has been provided.

The Quality Manager (QM) was interviewed on 06/27/18 at 2:30 PM and shared she received the complainants phone grievance on 05/29/18. The QM shared she immediately reported the incident to the Acting CEO and notified the CMO. It was decided that all staff needed more training in the EMTALA law. The QM verified she sent an email on 06/08/18 to the Executive Leadership team regarding the training requirement for the executive members and how to manage the training for their staff. The QM shared she had been assigned to another location away from the facility since mid-April and returned within the last couple of weeks and are now ready to start the EMTALA training.

Review of the hospital's policy titled, "Emergency Policy Emergency Medical Screening," review date 08/01/2016, indicated the purpose was: "To assure ...patients are offered appropriate emergency medical services in compliance with EMTALA and COBRA guidelines." The policy indicated the following; " ...All persons requesting treatment will be offered appropriate emergency medical screening and stabilization within the capabilities of the hospital..."

This citation is related to an incidental finding during complaint investigation MN00036727.

Based on emergency room (ER) medical record review, staff interview, and policy review, the hospital failed to ensure an appropriate transfer for one of three sampled patients, (Patient P3), who was identified with suicidal thoughts. The facillity failed to provide stabilizing treatment and an appropriate transfer to a higher level of care for a patient identified with suicidal ideation. This had the potential to place the suicidal patient at risk for self-harm.

Findings include:

P3 was admitted to the ER on 04/04/18 at 12:24 PM with complaints of DTs (Delirium tremens (also known as alcohol withdrawal delirium or the DTs) and causes sudden critical mental and neurological changes.) drinking, nightmares, and hearing voices. The triage registered nurse (RN) determined an Emergency Severity Index (ESI-a five-level emergency department (ED) triage algorithm that bases the patient's clinical presentation into five groups from 1 (most urgent) to 5 (least urgent) based on acuity and resource needs) of a level 3 (non-urgent) and P3 returned to the waiting area. At 2:50 PM the ER RN took P3 into ER room 4, (known as the safe room for patients presenting with mental concerns), and completed the nursing assessment. The Nurse Practitioner (NP), at 3:28 PM, completed the medical screening exam (MSE) with P3 stating he/she had suicidal thoughts, heard voices, had last consumed alcohol around midnight after drinking for one week and requested psychiatric treatment. The NP noted they did not see evidence of DTs. The NP diagnosed P3 with suicidal thoughts, anxiety, and depression, The NP recommended P3 for placement in a mental health hospital and contacted the social worker (SW) to complete P3's suicidal risk assessment. The SW noted on 04/04/18 at 4:31 PM after completion of the risk assessment that P3's suicidal risk is high and, " ...is asking for help ...We are seeking further medical evaluation at this time in a psychiatric facility ...." The ER Medical Doctor (MD) on 04/04/18 at 7:18 PM noted in the ER medical record "Pt {sic} has outstanding warrants and so no Beh.[sic} Health facility will accept him. r[sic]eview of chart indicates pt [sic] is medically cleared to be taken into police custody." The SW noted in the ER record on 04/04/18 at 7:19 PM, "four facilities declined our patient due to "legal issues". The SW notified the tribal police to be for placed in police custody. The ER RN at 7:31 pm completed and signed the "Medical Clearance Form," stating the patient "had received a Medical Screen and is Medically Cleared for incarceration by ...NP" The NP and ER RN completed the discharge summary with a departure time of 7:33 PM in police custody.

The triage nurse RN was interviewed by phone on 06/26/18 at 11:10 AM and shared when he/she completed the triage assessment P3 was hearing voices and had been drinking for a few days because they just broke up a relationship with a friend. The triage RN stated the ER was busy and the rooms were full and because the patient was triaged at an ESI 3 (a non-urgent emergency) the patient could go back into the waiting room to wait for a ER room.

The ER RN was interviewed on 06/26/18 at 7:50 AM and verified he/she completed the nursing assessment for P3 after being taken to ER room #4. The ER RN shared the patient stated they had DTs, hearing voices, and drinking but when they talked to the NP they stated they were suicidal. ER RN shared ER nurses follow the ESI algorithm for acuity level and because P3 failed to state he/she was suicidal the ESI 3 was an appropriate acuity level to triage P3. The RN shared the NP recommended the patient to be transferred to a mental health facility but when four facilities would not accept the patient due to legal issues the ER MD said to medically clear the patient for incarceration.

The NP was interviewed on 06/28/18 at 9:40 AM and verified that he/she was the medical provider on duty when P3 was admitted to the ER on 04/04/18. The NP shared P3 stated they were suicidal with a plan during the MSE. The NP stated that he/she notified the SW to complete a suicidal assessment and then referred the patient to have treatment in a mental health facility. He/she shared that finding a placement for P3 became difficult because of the patient has legal issues and when the oncoming provider arrived at shift change he/she determined that because of the outstanding warrants and failure to find placement in a facility P3 could be medically cleared and released into police custody.

The SW was interviewed on 06/26/18 at 10:25 AM shared he/she had completed a Columbia-SSRS, (an assessment tool used to assess suicidal patients), which identified high-risk findings. The SW verified they accessed the state website to find openings in a mental health facility located within a two to three-hour driving distance. He/she confirmed they contacted four facilities listed with potential openings and after following procedures for transfer, each one of the four facilities declined to accept P3 due to pending legal issues. The SW verified he/she notified the police because he/she felt P3 could be lodged in jail for their own safety.

The Quality Manager (QM) was interview on 06/26/18 at 2:30 PM and shared the hospital started a "Root Cause Analysis and Action Plan" on 4/11/18 with the Clinical Director, FNP, Physician Assistant-Certified (PA-C), SW, Director of Nursing (DON), ER RN, and QM to review of P3's ER record. The QM shared the hospital identified deficient practices with the ER visit and had interviewed each staff member involved P3's ER visit. The QM shared he/she was assigned to another location for the middle of April and had just returned within the last 2 weeks. He/she shared the hospital is in the process of re-educating all staff in the ER on EMTALA.

Review of the hospital's policy titled, "Emergency Policy Emergency Medical Screening," review date 08/01/2016, indicated the purpose was: "To assure ...patients are offered appropriate emergency medical services in compliance with EMTALA and COBRA guidelines." The policy indicated the following; " ...C. A patient who has an emergency medical condition and has not been stabilized or is in active labor may not be transferred unless: 1. The patient or legal representative request the transfer: 2. A physician has signed a certification that the medical benefits reasonably expected from the medical treatment at another medical facility outweigh the increased risks to the individual's medical condition from effecting the transfer; and 3. The transfer is an appropriate transfer ...E. A patient may only be transferred if the receiving medical facility has: 1. Available space, 2. Has agreed to accept transfer of the patient..."

This citation substantiates complaint MN00036727.