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Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The hospital failed to determine whether or not an emergency medical condition existed, appropriate to the individual's presenting signs and symptoms. See A-2406.

Based on document review and interview, it was determined that for 1 (Pt. #1) of 5 psychiatric clinical records reviewed for individuals that presented to the Emergency Department (ED), the hospital failed to determine whether or not an emergency medical condition existed, appropriate to the individual's presenting signs and symptoms.

Findings include:

1. On 12/22/2023, the hospital's "Non-Discrimination in Providing Emergency Medical Care" (updated 12/14/2022) included, " ...IV. Attachments ...Emergency Medical Treatment and Active Labor Act (EMTALA) ... 1. A medical screening exam must be performed ...2. If an emergency medical condition exist, treatment must be provided and continue until the patient is stabilized ...Tips for Avoiding EMTALA violations: 1. ...when treatment is provided, document what was done and why. If it was not documented, it did not happen ...3. Document the stability of the patient before discharge ...A psychiatric patient is not stable unless they are protected and prevented from harming themselves or others ..."
On 10/20/2023, the hospital's "Medical Staff Rules and Regulations" (2021) included, " ...E. Admission, Discharges and Transfer ...1. A medical screening examination is required for any patient who presents to the Emergency Department for treatment."

2. On 12/20/2023, the hospital's "Screening and Care of the Suicidal Patient" (8/26/2022) policy was reviewed and included, " ...purpose of this policy is to identify patients in the emergency department ...who are at high risk for suicide ...and provide protective interventions during their treatment course ...3. One to one constant visual observation can be initiated ...it is required when patient has diagnosis of suicidal ideation ...13. c. completes a follow-up assessments of the patient's suicidal ideation using the CSSRS to assess the past 48 hours ...d. documents that the above steps have been completed and that the sitter may be safely discontinued."

3. On 12/20/2023, the clinical record of Pt. #1 was reviewed. On 10/19/2023, Pt. #1 was brought to the Emergency Department (ED/hospital A) by ambulance due to Pt. #1 having homicidal thoughts to hurt others with no plan or intent. Pt. #1was examined and diagnoses included: polysubstance abuse, schizoaffective disorder, passive suicidal ideation, and COVID-19. The clinical record included:

-On 10/19/2023, Pt. #1's Ambulance Run Sheet (to Hospital A) included, " ... (Pt. #1) walked up to ambulance stating that (Pt. #1) wants to go to the hospital to talk to a therapist because (Pt. #1) wants to hurt himself and hurt other people ...Chief Complaint: Mental Status Change. Behavioral/psychiatric."

On 10/19/2023 at 6:26 PM, Pt. #1 was triaged. At 6:30 PM, (Pt. #1's) ED Initial Screening: Columbia Suicide Scale indicated that Pt. #1 verbalized suicidal ideation with no plan or intent within the past month.

On 10/19/2023 at 6:53 PM, a 1:1 (constant visual monitoring) Safety Assistant was initiated for Pt. #1 for suicidal ideation. The safety assistant intervention remained in place throughout Pt. #1's hospital course.

. -On 10/19/2023 at 8:43 PM, Emergency (ED) first encounter with (Pt. #1) ...Chief complaint: Psychiatric Problem ... (Pt. #1) states (Pt. #1) would like to harm multiple people ...No current plan. (Pt. #1) would like to speak with a therapist. Hx (history) of schizophrenia ... (MD #3) believe based on (MD #3's) time spent with (Pt. #1) ... (Pt. #1) care meets: HIGH complexity of care. As such (MD #3) have addressed a chronic illness with severe exacerbation that poses a risk of morbidity or mortality to (Pt. #1) ..."
-On 10/20/2023 at 6:54 AM, ED Physician's (MD #2) 'ED Note' included, " ...(MD #2) reviewed the result of the C-SSRS (Columbia Suicide Severity Rating Scale) screening (10/19/2023) ...reported observations include: (Pt. #1) endorsing active suicidal thoughts and ideation ...(MD #2) conducted a suicide risk assessment including the following risk and protective factors: ...recent clinical status: major depressive disorder, command hallucinations to hurt self, highly impulsive behavior, and substance abuse or dependence ...Suicide Risk Assessment: based on this evaluation, (Pt. #1) is at high risk for suicide in the healthcare setting ...Suicide Risk Formulation: (Pt. #1) endorsing active suicidal ideation with plan to run in front of traffic ...Recommendations: Continue 1:1 safety assistant and constant visual observation ...Specific interventions to mitigate future risk: escalate level of care: Inpatient psychiatric hospitalization." No other C-SSRS screenings for Pt. #1 were available for review.

-On 10/20/2023 at 6:54 AM, Attending Physician's (MD #2) 'ED Note' included, "(Pt. #1) is awake, clinically sober. (Pt. #1) continues to endorse active suicidal or homicidal ideation and does not feel safe leaving the emergency department. Will work on inpatient psychiatric transfer ... (Pt. #1) is medically appropriate for inpatient psychiatric care."

On 10/20/2023 at 9:34 AM, Attending Physician's (MD #1) 'ED Note' included, "(Reevaluation: ... (Pt. #1) states that (Pt. #1) is having passive SI thoughts due to wanting to feel better. (Pt. #1) states that (Pt. #1) would prefer to be sent to a detox center to get better. (MD #1) believes that (Pt. #1) is a low risk for any self-harm as some of (Pt. #1's) smptoms is directly related to (Pt. #1) polysubstance abuse ...(MD #1) also believes that (Pt. #1) is no immediate threat to any other individuals ...case was discussed with social worker who evaluated (Pt. #1), states that (Pt. #1) can be discharged to (hospital B) for detox intake as they also have accommodations for COVID positive patients. (MD #1) discussed this plan with (Pt. #1), agrees that (Pt. #1) would like to be sent to (hospital B) for detox. Will discharge (Pt. #1) at this time."

The clinical record did not include Social Worker notes or social worker assessments.

-On 10/20/2023 at 9:40 AM, Hospital A's 'After Visit Summary' included, " ... (Pt. #1) stated that (Pt. #1) is most interested in going to a detox center, (Pt. #1) was sent to (hospital B) for polysubstance detox intake ...Follow-up with Substance Use Intervention Team Clinic ..."

4. On 12/20/2023, the clinical record of Pt. #1 was reviewed. On 10/20/2023, Pt. #1 was brought to the Emergency Department (hospital B) by taxi from (hospital A) for detoxification program. Pt. #1was examined and diagnoses included: schizophrenia, covid positive and polysubstance abuse. The clinical record included:

-On 10/20/2023 at 10:29 AM, the Registered Nurse's (E #/Hospital B) 'Nurses Note' included, " ...AOx3 (alert and oriented) (Pt. #1) sent from (Hospital A) ER (Emergency Room) via taxi for SI (suicidal ideation), HI (homicidal ideation), polysubstance abuse. (Pt. #1) states that (Pt. #1) has been feeling these feeling for two days. Positive plan to poison self. (Pt. #1) states that he wants to hurt people on the North side. Positive THC (marijuana), ETOH (alcohol intoxication), Cocaine (stimulant drug), Meth. (methamphetamine/stimulant drug) (Pt. #1) is cooperative and sleepy."

5. On 12/21/2023 at approximately 10:03 AM, an interview with the Attending physician (MD #1) was conducted. MD #1 stated that (MD #1) received (Pt. #1) from (MD #4). MD #1 stated that (MD #4) reported that (Pt. #1) presented to Emergency Department for questionable SI/HI concerns. MD #1 stated that (MD #4) reported that (Pt. #1) was positive for polysubstance intoxication and that plan is to re-evaluate (Pt. #1) when clinically sober with possible inpatient psychiatric placement. MD #1 stated that (MD #1) re-evaluated (Pt. #1) when clinically sober and (Pt. #1) expressed thoughts of not wanting to live were due to (Pt. #1's) polysubstance use. MD #1 stated that (MD #1) and (Pt. #1) discussed detox program, with (Pt. #1) wanting to voluntarily attend program upon discharge. (MD #1) stated that (Pt. #1) was not a harm to self or others and was medically appropriate for discharge. MD #1 stated that (MD #1) did not use a specific assessment form to complete re-assessment of Pt. #1, rather (MD #1) asked (Pt. #1) suicide screening questions and documented (Pt. #1's) assessment in a provider's note.

6.On 12/21/2023 at approximately 10:36 AM, an interview with the Attending Physician (MD #4) was conducted. MD #4 stated (Pt. #1) was at (Hospital A) due to endorsing vague suicidal and homicidal ideation along with polysubstance abuse. MD #4 stated when (Pt. #1) was reassessed, (Pt. #1) continued to state active suicidal thoughts. (MD #4) stated that (MD #4) will not discharge a patient who states such thoughts, even with no plan or intent. MD #4 stated that (MD #4's) recommendation/plan for (Pt. #1) was to admit to an inpatient psychiatric facility if (Pt. #1's) suicidal thoughts continued. E #4 stated suicide risk assessments are completed on patients to determine safety and plan of care.

7. On 12/21/2023 at approximately 1:45 PM, an interview with the Attending Physician (MD #3) was conducted. MD #3 stated that (Pt. #1) was brought to the ED for suicidal and homicidal ideations. E #3 stated that (Pt. #1) was assessed and plan was to evaluate, complete labs, observe patient due to polysubstance intoxication and re-evaluate. MD #3 stated that (Pt. #1's) care was handed off to (MD #4).

8. On 12/22/2023 at approximately 9:44 AM, an interview with the Director of Case Management (E #7) was conducted. E #7 stated that initially (Pt. #1) was identified as a psychiatric patient that would need to be transferred to a medical floor with psychiatric consult due to being COVID positive. E #7 stated that (Pt. #1's) attending physician (E #1) re-evaluated (Pt. #1) and (Pt. #1) wanted detox treatment. E #7 stated that patients requesting detox programming would be seen by the hospital's social worker for evaluation. E #7 stated that there is no documentation that Pt. #1 was seen and evaluated by a social worker.