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Based on document review, video 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 ensure that a patient presenting to the Emergency Department was listed in the centralized log. See deficiency at A-2405.

2. The Hospital failed to ensure that a patient presenting to the Emergency Department received a Medical Screening Examination (MSE). See deficiency at A-2406.

Based on document review, video review, and interview, it was determined that for 1 of 10 patients (Pt. #1) that presented to the Hospital's Free Standing Emergency Center (Facility A), the Hospital failed to ensure that the patient was listed on the Emergency Department (ED) centralized log.

Findings include:

1. The Hospital's policy titled, "EMTALA: Emergency Medical Treatment and Labor Act" (effective 3/20/15), was reviewed on 10/31/18 and required, "...A centralized (by reference) log of all individuals presenting to a Dedicated Emergency Department... for emergency medical treatment is maintained, one per dedicated emergency department. The log includes the name of the individual, whether s/he refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, or was discharged..."

2. Facilty A's ED centralized logs from 10/14/18 to 10/20/18 were reviewed on 10/30/2018, and the logs failed to include the name of Pt #1.

3. The EMS (Emergency Medical Services) run log (received from Pt. #1's record at Facility C), dated 10/19/18 at 7:17 AM, was reviewed on 10/31/18 and included, "...Upon arrival at [Facility A's] ED verbal report given to staff and patient care transferred... After transfer of care Patient relayed to [Facility A's] ED staff and [MD#2] that he [Pt. #1] wanted to kill himself and shoot himself multiple times. [MD#2] stated that patient was drunk and that he [MD#2] was going to send patient back to jail because there is nothing that he can do for patient... Crew left [Facility A] at [6:26 AM]..."

4. The EMS Radio Log (undated, timed at 5:53 AM), identified by Facility A as call log for Pt. #1 on 10/19/18, was reviewed on 10/31/18 and indicated that a 22 year old male, arrested for alcohol on board/driving under the influence, was on the way to Facility A with EMS and local police. The log included, "SI [suicide ideation] 6 months ... PMH [Past Medical History]: anxiety, bipolar [disorder]... Orders: continue to treat, transport, and monitor... call back with any problems... ETA [estimated time of arrival]: 7-10 minutes..."

5. Video recordings of Facility A's ambulance bay and ED hallway on 10/19/18, between 5:30 AM and 6:30 AM, were reviewed on 10/31/18, at approximately 9:00 AM, with Security Officer (E#3). The video footage showed the following:
- At 6:09:25 AM, a young male (Pt. #1) arrived by EMS, with a police officer present, in the ambulance bay and entered Facility A at 6:09:35 AM.
- At approximately 6:10:50 AM, the patient was placed in exam room 3 (designated for Psychiatric patients).
- A physician [identified as MD#2 by security officer E#3] and a RN [identified as E#6 by E#3] were standing in the ED hallway during this time.
- At approximately 6:17:33 AM, MD#2 entered exam room 3. MD#2 exited the room at approximately 6:20:10 AM and spoke with the police officer.
- At approximately 6:25:45 AM, the patient was escorted back towards the ambulance bay entrance/exit. At approximately 6:27:13 AM, the patient was strapped into the transport cart and then loaded back into the ambulance. The ambulance left at approximately 6:28:35 AM.

6. An interview was conducted with the Director of Emergency Services (E#2) on 10/31/18 at 10:07 AM and with the ED Assistant Medical Director (MD#1) on 10/31/18 at approximately 10:38 AM. Both E#2 and MD#1 stated that every patient presenting to the ED should be recorded in the ED (centralized) log even if the patient refused treatment.

7. An interview was conducted with the Charge Nurse (E#4) on 10/31/18 at approximately 12:13 PM. E#4 stated that he did recall this patient coming in the morning of 10/19/18. E#4 stated that he received a radio call from EMS prior to the patient's arrival, and confirmed his (E#4) signature on the (undated) radio log. In regards to this case (a patient with suicide ideation), E#4 stated, "We never divert these kinds of cases... We can take care of this here..." E#4 stated that the patient "wasn't here that long," but there should be a record that he [Pt. #1] was here.

Based on document review, video review, and interview, it was determined that for 1 of 10 patients (Pt. #1) that presented to the Hospital's Free Standing Emergency Center (Facility A), the Hospital failed to ensure that the patient received a Medical Screening Examination (MSE).

Findings include:

1. The Hospital's policy titled, "EMTALA: Emergency Medical Treatment and Labor Act" (effective 3/20/15), was reviewed on 10/31/18 and required, "...All individuals who come to the emergency department... requesting care for emergency medical conditions (or where such requests are made on their behalf) receive an appropriate medical screening prior to admission, discharge or transfer to another facility..."

2. The Hospital's document titled, "The Medical Staff Bylaws" (dated 10/30/17) was reviewed on 10/30/18 and included, "...Individuals who present to the hospital for emergency care will receive an appropriate medical screening examination by qualified medical personnel to determine if the individual has an emergency medical condition ..."

3. Pt. #1's ED (Emergency Department) record was requested on 10/30/18 at approximately 10:00 AM. At approximately 11:30 AM, the Accreditation Manager (E#1) stated that there was no record for Pt. #1.

4. The clinical record from the recipient Hospital (Facility C) of Pt. #1 was reviewed on 10/31/2018, at 8:30 AM. Pt. #1 was 22 year old male, who presented to Facility C's ED on 10/19/18 at 6:42 AM, with a diagnosis of suicidal ideation (SI). A physician's note, dated 10/19/18 at 6:47 AM, included, "22 y/o [year old] male presents to the ED via EMS [Emergency Medical Services] for a psychiatric evaluation secondary to a SI [suicide ideation]... Per police, pt [patient] was pulled over for a traffic stop and while at booking began stating that he was suicidal and has been thinking about killing himself for the past six months. Pt states, "I am going to shoot myself." Per EMS, Pt was taken to a free standing emergency department [Facility A] and ED physician refused to see pt. History is limited due to uncooperative pt."

5. The EMS (Emergency Medical Services) run log (received from Pt. #1's record at Facility C), dated 10/19/18 at 7:17 AM, was reviewed on 10/31/18 and included, "...Upon arrival at [Facility A's] ED verbal report given to staff and patient care transferred... After transfer of care Patient relayed to [Facility A's] ED staff and [MD#2] that he [Pt. #1] wanted to kill himself and shoot himself multiple times. [MD#2] stated that patient was drunk and that he [MD#2] was going to send patient back to jail because there is nothing that he can do for patient... Crew left [Facility A] at [6:26 AM]..."

6. Video recordings of Facility A's ambulance bay and ED hallway on 10/19/18, between 5:30 AM and 6:30 AM, were reviewed on 10/31/18, at approximately 9:00 AM, with Security Officer (E#3). The video footage showed the following:
- At 6:09:25 AM, a young male (Pt. #1) arrived by EMS, with a police officer present, in the ambulance bay and entered Facility A at 6:09:35 AM.
- At approximately 6:10:50 AM, the patient was placed in exam room 3 (designated for Psychiatric patients).
- A physician [identified as MD#2 by security officer E#3] and a RN [identified as E#6 by E#3] were standing in the ED hallway during this time.
- At approximately 6:17:33 AM, MD#2 entered exam room 3. MD#2 exited the room at approximately 6:20:10 AM and spoke with the police officer.
- At approximately 6:25:45 AM, the patient was escorted back towards the ambulance bay entrance/exit. At approximately 6:27:13 AM, the patient was strapped into the transport cart and then loaded back into the ambulance. The ambulance left at approximately 6:28:35 AM.

7. An interview was conducted with the Security Officer (E#3) on 10/31/18 at approximately 9:00 AM, during the review of the ED video recordings. E#3 stated that the patient [Pt. #1] was not cooperative. E#3 stated that MD#2 spoke with the police officer after seeing the patient, and decided to send the patient back to jail.

8. An interview was conducted with the Director of Emergency Services (E#2) on 10/31/18 at 10:07 AM and with the ED Medical Director (MD#1) on 10/31/18 at approximately 10:38 AM. Both E#2 and MD#1 agreed that every patient presenting to the ED should receive a MSE; however, if the patient refused treatment, documentation should be made to show that a MSE was attempted.

9. An interview was conducted with the ED physician (MD#2) on 10/31/18 at 1:40 PM. MD#2 stated that the patient [Pt. #1] refused to be seen by ED staff on 10/19/18 and refused to give any information. MD#2 stated that he [MD#2] discussed the situation with the police officer and told the officer that ED staff could not touch the patient since he [Pt. #1] was refusing care. MD#2 stated that Pt. #1 was "not in my custody because he [Pt. #1] had cuffs on." When asked about documentation of the encounter, MD#2 stated that during the incident on 10/19/18 he [MD#2] asked whether a chart needed to be made. MD#2 stated that someone (did not recall who) told him that since the patient was going back to jail, a chart would not be created for this patient [Pt. #1].