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Based on observations, record review and interview the facility failed to meet the Statutory Requirements to conspicuously post appropriate EMTALA (Emergency Medical Treatment and Labor Act) signs, failed to have an on-call list that covered all services that may be needed, failed to provide appropriate medical screenings, failed to provide stabilizing treatment and failed to obtain informed consent for transfer. The deficient practice could possibly lead to patients not receiving necessary medical care and not understanding the risks of refusing medical care.

The findings are:
A. Failed to provide a medical screening exam for patients presenting to the hospital for behavioral health concerns. Refer to tag 2406.

B. Failed to provide stabilizing treatment and did not explain risks of refusing treatment. Refer to tag 2407.

Based on observation and interview the facility failed to post signage informing patients of their rights presenting to the emergency department through the ambulance bay. This deficient practice can lead to patients not being aware of their rights as a patient in the emergency department.

The findings are:

A. During an observation on 08/20/2024 at 12:00 PM in the ambulance bay where patients are brought into the emergency department a sign was not posted that informed patients of their right to be seen for any emergency condition per EMTALA (Emergency Medical Treatment and Labor Act) regulations.

B. During an interview on 08/20/2024 at 12:00 PM with S(Staff)2, non-clinical, confirmed that there should be a sign posted in the ambulance bay.

Based on record review and interview the facility failed to have a process in place to cover necessary services when an on-call provider is not available for 1 (P[patient]1) out of 20 (P1-P20) patients that presented to the emergency department seeking medical care. This deficient practice could possibly lead to patients not receiving the care they need when presenting to the emergency department.

The findings are:

A. Record review of the facility's document titled, "On-Call Assignments" for the date range 02/21/2024-08/26/2024 revealed that a psychiatric provider was not on call from 08/06/2024 at 5:00 PM to 08/07/2024 at 8:00 AM.

B. Record review of P1's "ED [emergency department] Provider Note" for visit date 08/06/2024 revealed P1 presented to the emergency department with a psychiatric complaint of being homicidal and reported that he was suicidal to the provider. The medical record did not contain any evidence that a psychiatric provider was consulted.

C. During an interview on 08/21/2024 at 11:00 AM with S(Staff)3, clinical, it was explained that psychiatric providers are not available to the emergency department at night and patients would have to wait until the next day to get services.

D. During an interview on 08/21/2024 at 4:28 PM with S4, clinical, it was explained that a psychiatric provider should be available to consult with the emergency department physician at night.

Based on record review and interview the facility failed to provide an appropriate medical screening exam for 1 (P[patient]1) out of 20 (P1-P20) patients reviewed for seeking emergency care. This deficient practice could possibly lead to patient's medical conditions being untreated, resulting in harm.

The findings are:

A. Record review of the facility's policy titled, "Medical Screening Exam EMTALA [Emergency Medical Treatment and Labor Act]" dated 03/05/2021 under "Policy" stated, "Any patient who comes to the hospital requesting emergency services is entitled to and will receive a Medical Screening Examination performed by individuals qualified to perform such examination to determine whether an emergency medical condition exists." On page 3, under, "D. How to Provide the Medical Screening Examination" stated, ". . . 4. The Medical Screening Examination includes both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of an emergency medical condition.
5. A hospital, regardless of size or patient mix, must provide screening and stabilizing treatment within the scope of its abilities, as needed, to the individuals with emergency medical conditions who come to the hospital for examination and treatment. . . .
10. If the Medical Screening Examination indicates that the individual has an Emergency Medical Condition, he or she must be given such further examination and treatment as required to stabilize the medical condition within the staff and facility capabilities available in the hospital or appropriately transfer the individual. On page 7 under "Definitions" stated "Emergency Medical Condition means: (i) 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 (A) Placing the health of the individual. . . in serious jeopardy. . ."

B. Record review of the facility's policy titled, "Patient Suicide Risk Prevention" dated 06/26/2023 under, "Purpose" stated, "This policy enhances patient safety by establishing guidelines to ensure that patients who are being seen with a primary diagnosis or complaint of an emotional or behavioral disorder are managed safely." On page 2, under "Procedure" stated, ". . .2.5.2. Risk Level Minimal [low]: 2.5.2.1. Provider monitors and re-assesses as clinically indicated and treat as usual. 2.5.2.2. Consider safety precautions if indicated by professional judgement and on-going assessment. . .2.5.4. Risk Level High: 2.5.4.1. Ensure the patient is monitored and environment is safe. 2.5.4.2. Patient placed on 1:1 observation. 2.5.4.3. Complete room safety checklist. 2.5.4.4. Implement Safety Interventions in section 5. 2.5.4.5. The nurse or clinical designee who has initial contact with the patient ensures that the patient's immediate environmental safety needs are addressed..." On page 4 under "Provider Assessment" stated, "The provider determines and documents the appropriate risk for the patient and may choose to escalate or deescalate suicide precautions by adding or removing orders as needed for the safety of the patient. 3.3. The provider assessment is accomplished by the use of a validated tool or validated process. . . 3.4. The assessment includes directly asking about: 3.4.1. Suicidal ideation 3.4.2. Plan 3.4.3. Intent 3.4.4. Suicidal or self-harm behavior (i.e.: eating/swallowing non-food Items) 3.4.5. Risk Factors 3.4.6. Protective Factors" On page 5 under "Discharge Planning" it stated, "6.1. Prior to discharge, the physician, the physician's designee, or discharge planners meet with the patient to identify the patient's post-discharge plan of care. The post discharge plan of care includes informing the patient, the patient's family members, and/or significant others (as appropriate) about how to deal with crisis situations. The patient, patient's family members, and/or significant others (as appropriate) are given the phone number to the National Suicide Prevention Lifeline hotline, at 1-800273-TALK, as well as other local resources they should use, as determined by the patient's physician.
6.2. Patients are scheduled for follow-up visits with their Primary Care Physician, and/or a Behavioral Health clinic/professional."

C. Record review of facility's policy titled, "Detaining Criminal Suspects" dated 2/15/2023 under "Responsibilities" it is stated, ". . . A Security Officer will remain with subject until the appropriate law enforcement agency arrives and never lose visual observation of the detainee. . . A subject may only be detained for a reasonable amount of time. If the detention period exceeds 2 hours, a hospital manager or security on-call manager will be contacted to determine if immediate release is appropriate, or if extenuating circumstances will warrant an extension of time. If law enforcement does not arrive within the two-hour detention, the subject may be let go and this will be documented in the Security Officer's report."

D. Record review of P1's medical record for emergency department visit dated 08/06/2024, arrival time 10:19 PM, revealed the following:

1. Review of P1's "ED [emergency department] Provider Note" for visit date 08/06/2024 revealed P1 presented to the emergency department with a psychiatric complaint of being homicidal and reported that he was suicidal to the provider. Under "Medical Decision Making" it stated, ". . . Prior to my evaluation of patient, he punched an EMS [emergency medical services] worker who was transferring another patient in the room next to him. . . [Patient] is reporting auditory and visual hallucinations. States that the voices are telling him violent things and that they will hurt him and steal his money. . . He would like to go back to jail because he states that he feels more safe there then out in public. He states that 'if I am in public, I will kill myself.' Patient will be discharged to [police] custody and I do recommend a [behavioral health] evaluation while in custody."

2. P1 had a suicide screening done on 08/06/2024 at 10:41 PM and was scored as "Low Risk." P1's medical record did not contain any evidence that P1 received a psychiatric medical screening, after P1 reported suicidal ideations a suicide screening was not done.

3. P1's discharge instructions stated, "[Patient] will be discharge to [Name of Police department] custody after hitting EMS worker. Please have behavioral health evaluate this while in custody." Patient was discharged on 08/06/2024 at 11:41 PM. There was no psychiatric evaluation prior to discharge. There is no evidence that patient's family was notified of discharge.

E. Record review of facility incident log revealed an incident dated 08/06/2024 involving P1the comments stated, ". . . [P1] was escorted from [locked behavioral health unit] to [conference room] following the incident. [P1] remained in handcuffs while waiting for [police] to arrive to take patient into custody. . . [P1] stayed in security custody until the two-hour time limit approached. [P1] was escorted out the [conference] room to the edge of property. [P1] was released from custody and was advised he is free to go. [P1] stated he wanted to go to jail. [P1] was advised he is more than welcome to wait for [police] to arrive. [P1] walked back to the Emergency Department and used the phone in the lobby. [P1] hung up the phone and walked out the lobby. . ."

F. Record review of police report narrative dated 08/07/2024 at 1:34 AM regarding P1 stated, "Upon arrival, I was advised by [name of paramedic] with [name of ambulance company] that the pedestrian involved was deceased [2:15 AM]. I spoke with the driver of vehicle one who stated he was traveling west on [street name]. . . As he was approaching [address and name of business near hospital] he observed the pedestrian approximately 15 feet in front of him. The pedestrian was halfway in the roadway before leaping in front of vehicle as it was about to pass. I then spoke with security who work at [hospital address and name] who advised me that the pedestrian involved in the traffic accident does have a history of behavioral health issues. . ."

G. During an interview on 08/20/2024 at 10:45 AM with S(Staff)2, non-clinical, stated the current process for patients that are presenting with a psychiatric emergency is for the emergency department provider to make the call on whether to discharge and document their rationale. They are working on a new process since the incident with P1. S2 explained that if the patient needs to be discharged to law enforcement, then security will hold them for two hours. Facility was unable to show evidence of corrective actions.

H. During an interview on 8/20/2024 at 2:30 PM with S6, non-clinical, S6 explained that patients who have been discharged to police custody will be detained for 2 hours and then released. S6 explained that since these patients are already discharged, they would not check in with hospital staff prior to releasing them.

I. During an interview on 08/21/2024 at 4:30 PM with S5, clinical, confirmed that a patient stating they have suicidal ideations would be considered a high suicide risk. When asked about the use of a "psychiatric hold" (involuntary mental health hospitalization if a patient is a danger to themselves or others) for such patients, S5 explained that a "psychiatric hold" was not used in the emergency department. S5 was asked about the discharge of P1 prior to a psychiatric evaluation and S5 explained that P1 was to be detained by security until the cops arrived. S5 was not aware that patient would be released after two hours and was not alerted prior to security releasing P1.

Based on record review and interview the facility failed to provide stabilizing treatment for patients that present to the emergency department with a behavioral health crisis for 1 (P[patient]P2) out of 20 (P1-P20) patients reviewed for presenting to the emergency department. These deficient practices could possible lead to patients in a behavioral health crisis not receiving the necessary care and could lead to patient harm and/or death.

The findings are:

A. Record review of the facility's policy title, "EMTALA [Emergency Medical Treatment and Labor Act] Stabilization" dated 03/05/2021 stated, "Purpose: To ensure that all patients determined to have an emergency medical condition shall be stabilized as required under Emergency Medical Treatment and Active Labor Act (EMTALA). Policy: Patients being transferred or discharged will be stabilized as required under EMTALA. Procedure: . . . 3. For patients whose emergency medical condition has not been resolved, the determination of whether they are medically stable may occur in one of the following two circumstances:
a. Stable For Transfer - A patient is stable for transfer from one facility to a second facility if the treating physician has determined within reasonable clinical confidence that the patient is expected to leave the hospital and be received at the second facility with no material deterioration in his/her medical condition and the treating physician reasonably believes that the receiving facility has the capability to manage the patient's medical condition and any reasonably foreseeable complication of that condition.
i. For purposes of transferring a patient with a psychiatric condition between facilities, the patient is considered to be stable when he/she is protected and prevented from injuring himself/herself or others. b. Stable For Discharge - A patient is considered stable for discharge when, within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic workup and/or treatment, could be reasonably performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions.
For purposes of discharging a patient with a psychiatric condition, the patient is considered to be stable when he/she is no longer considered to be a threat to him/herself or to others. . . ."

B. Refer to tag 2406 for finding related to policy on medical screening.

C. Record review of P2's medical record for emergency department visit on 08/03/2024 revealed the following:

1. Review of P2's "ED Provider Note" for visit date 08/03/2024 at 4:04 PM revealed that patient (P2) presented after a suicide attempt and was diagnosed with overdose and altered mental status. Under "Medical Decision Making" it stated ". . . Here there is concern for overdose. Patient is a poor historian, but has some statements that are concerning for intentional overdose. . . It sounds like she [P2] was seen yesterday for similar symptoms of polypharmacy [when a patient takes several medications a day that can cause harmful drug interactions and increased side effects such as sedation] and drug overdose, at that time they [the previous hospital] let her go home. . . I do have discussion with our clinical liaison with behavioral health who agrees that patient is a poor candidate for just psychiatric assessment, recommends medical admission for further management, treatment and assessing polypharmacy, and states that [staff name] can follow for further inpatient psychiatric assessment while admitted."

2. On 08/04/2024 at 5:34 AM the note was updated with this statement, "Patient [P2] is verbally abusive to staff members. Patient would like to go home. She is alert and oriented x 3 [scale used to state patient know name, date of birth, and time]. No delirium [confusion] She has no suicidal or homicidal ideation. She lives with her daughter. Will call her daughter to pick her up." There was no psychiatric evaluation or evidence that patient's discharge was discussed with the behavioral health liaison.

3. The patient was discharged on 08/04/2024 at 5:35 AM.

4. The patients "After Visit Summary" for visit on 08/03/2024 stated, "Instructions Please avoid taking excessive amounts of benzodiazepines. Continued use can lead to serious bodily harm or even death. Follow-up with your primary care provider and return to the hospital with any concerns." The After Visit Summary did not contain any evidence of medication adjustments based on identified concerns.

D. During an interview on 08/21/2024 at 4:28 PM with S4, clinical, it was confirmed that a patient presenting with homicidal ideations, suicidal ideations or hallucinations would warrant a psych consult.

E. During an interview on 08/22/2024 at 10:06 AM with S3, clinical, it was explained that the facility does not have a "psychiatric hold" (involuntary mental health hospitalization if a patient is a danger to themselves or others) if needed the behavioral health department and the emergency department would communicate that the patient is involuntary.