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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:

Tag 2407: Necessary Stabilizing Treatment for Emergency Medical Conditions. Based on interviews and document review the facility failed to provide psychiatric patients stabilizing treatment after an emergency medical condition (EMC) was determined to exist for the patient. Specifically, the facility failed to ensure staff implemented suicide precautions, adequate patient supervision and safety interventions for five of six suicidal psychiatric patients reviewed that were seen in the Emergency Department (ED). (Patient #2, #3, #5, #9 and #20)

Based on interviews and document review the facility failed to provide psychiatric patients stabilizing treatment after an emergency medical condition (EMC) was determined to exist for the patient. Specifically, the facility failed to ensure staff implemented suicide precautions, adequate patient supervision and safety interventions for five of six suicidal psychiatric patients seen in the Emergency Department (ED). (Patients #2, #3, #5, #9 and #20).

Findings include:

Facility policies:

The Suicide Ideation and Prevention Policy read, the registered nurses (RN) or Licensed independent providers (MD/NP/PA) will identify patients at risk for serious self-harm due to suicidal ideation by asking all patients if they have any suicide ideation thoughts or intentions. If a positive suicide ideation screen is noted, nursing staff or security staff will provide constant observation (continuous visual contact) of the patient in order to provide a safe environment of care.

Patients who have suicidal ideation are to be immediately placed on a 1:1 observation. The patient will remain on the 1:1 observation until a psychiatrist determines it is no longer necessary. The patient care attendant conducting the 1:1 should be the same gender as the patient whenever possible and patient family members are not permitted to provide the 1:1 observation.

The patients' belongings are to be searched, including the pockets in clothing and any purse/bag the patient has. The search is to be done by two hospital employees and it will be done in the presence of the patient. Employees are to explain to the patient why their belongings are being searched and advise the patient the search is being conducted for their safety and according to facility policy. If the patient's physical person is searched, a staff member of the same gender as the patient must assist in performing the search. All patient belongings are to be documented and removed from the patient room. Patient belongings are to be secured or provided to a family member and to be taken away from the hospital (this includes cell phones).

Patients must be assessed by a registered nurse (RN) on admission, during each shift and when there is a reported change in behavior. The assessment is to be documented within the electronic health record of the patient. The RN assessment will include: The last time the patient had thoughts about hurting him/herself. How the patient planned to hurt themselves and how the patient stopped themselves from inflicting self-harm. If a patient is found to be at risk for serious self-harm due to suicidal ideation during the RN assessment, the patient is to be immediately placed on Suicide Precautions and the physician notified a Suicide Precautions order is needed.

Staff will implement suicide precautions for a patient immediately upon suspicion or confirmation the patient is at risk for serious self-harm. Staff will maintain continuous visual contact with patients placed on suicide precautions. Suicide precautions will remain in place until a behavioral and mental health evaluation has occurred for the patient and the patient has been deemed no longer at risk for self-harm.

The Zero Suicide Program for suicide prevention is implemented throughout the facility to ensure every patient is screened for self-harm by a nurse or provider and to ensure the self-harm screening process is documented within the electronic health record of each and every patient.

The Nursing Assessments policy read, patients' needs must be reassessed throughout the course of care, treatment, and services. Patient screenings must be completed as part of the admission assessment process or when new information is ascertained for the patient. Patient assessments and reassessments are documented by each member of the multi-disciplinary team. All patients will be assessed by an RN a minimum of every shift and documented. The timing, scope and intensity of patient reassessments are based on the patient's diagnosis, acuity, desire for care, response to any previous care, and change in condition and/or diagnosis.

The policy defined an admission assessment as the initial assessment performed in order to formulate an initial individualized plan of care for the patient. A patient screening is defined as a data collection process, which determines whether a more detailed assessment or evaluation is needed for the patient. A patient evaluation is defined as an assessment performed after a physician order is part of the continual evaluation process. An evaluation assesses a patient's abilities and limitations and identifies or confirms the appropriate resources needed to aid or treat the patient.

The Assessment Documentation Policy read, nursing staff should document any interventions which are implemented for the patient. Documentation of interventions should include physiological factors, psychological factors, environmental factors, patient/family/significant other educational needs, discharge planning, all other action taken to assist the patient. The nurse will document what actions were taken to alleviate a patient's problem and only interventions actually implemented are documented. Emergency Department (ED) nurses will document the following within the patient medical record. A complete patient assessment of the patient's Level of Care (acuity) and immediate needs of the patient. Nursing staff will document any ongoing interventions/treatments in place for the patient and changes in a patient's condition and/or changes in the patient's plan of care. Nursing staff will perform ongoing assessments until the time patient is discharged from the Emergency Department.

The Admitting the Patient and Initial Nurses Notes policy read, patient information and data essential to the implementation of individualized nursing care shall be gathered and utilized to identify patient problems. Additionally, the information will be used to determine patient specific nursing interventions. Patient information obtained from the nursing assessment is to be entered into the patient's electronic medical record within two hours of when the assessment is performed.

1. The facility failed to ensure staff implemented suicide precautions and patient safety interventions for psychiatric patients who attempted self-harm.

A. Facility documents and medical records were reviewed and revealed from 9/8/21 to 1/5/22, patient self-harm assessments, suicide precautions and/or patient safety interventions were not implemented for multiple suicidal psychiatric patients in the ED.

a. Review of medical records for Patient #20 revealed the patient presented to the ED on 9/8/21 and on 10/19/21 for self harming. Both of Patient #20's medical records lacked evidence staff immediately implemented suicide precautions for the patient. Furthermore, the medical records lacked evidence suicide precautions were ordered, patient safety interventions were performed and the continuous staff 1:1 observations to prevent the patient from self-inflicted harm occurred.

i. On 9/8/21 at 1:35 a.m., Patient #20 arrived by ambulance to the ED. Prior to his arrival Patient #20 stabbed himself with a pocket knife in the neck.

There was no evidence registered nursing staff performed an assessment to determine risks of self harm in accordance to facility policy. Additionally, at 7:45 a.m., six hours after Patient #20 arrived at the facility with a self-inflicted stab wound, staff initiated suicide precautions for the patient. The precautions implemented were placement of the patient on continuous 1:1 observation.

ii. On 10/19/21 at 5:08 p.m., Patient #20 was transported by ambulance to the ED. Patient #20 had attempted suicide and self-inflicted a laceration (a cut caused by a sharp object) to his left forearm with a razor blade . Patient #20's medical record lacked evidence a suicide precaution order was entered for the patient.

b. On 11/23/21 at 10:14 a.m., Patient #2 was transported by emergency medical services (EMS) to the ED. Patient #2 self-inflicted cuts to his wrists with a razor blade then subsequently swallowed the razor blade in an attempt to commit suicide.

Patient #2's medical record lacked evidence facility staff performed a self-harm assessment, initiated suicide precautions and conducted 1:1 continuous patient observations for the patient throughout the patient's stay in the ED .

c. Patient #5 was seen in the ED on 9/19/21 at 12:51 a.m. The ED physician caring for Patient #5 evaluated him for suicidal ideation and alcohol intoxication. A suicidal, 72-hour hold was initiated for Patient #5 by the physician. An Emergency Suicidal Commitment Application was completed and read, Patient #5 threatened to commit suicide and posed a danger to his own health and safety.

Patient #5's medical record lacked evidence of a self-harm assessment, initiation of suicide precautions and continuous staff 1:1 observation of the patient.

d. On 12/17/21 at 12:15 p.m., Patient #9 was transported to the ED after he attempted to commit suicide. Patient #9 attempted to hang himself and was found in the shower with a sheet around his neck.

Patient #9's medical record lacked evidence of a suicide precaution order, a patient self-harm assessment and continuous staff 1:1 observation of the patient.

Medical record review of Triage and Nursing Progress Notes for Patient #9 on 12/17/21 at 12:17 p.m. read, Patient #9 had active suicidal thoughts and no longer wanted to live. The medical record lacked evidence a patient self harm assessment, continuous 1:1 observation and suicide precautions had been implemented on 12/17/21.

However, on 3/15/22 at 12:09 p.m., two months and 26 days after Patient #9 had been discharged from the ED, Director of Nursing (DON) #5 placed several late Nursing Progress Note entries into Patient #9's medical record. The late entries were backdated to 12/17/21 and read, a self-harm assessment was performed, suicide precautions were implemented and continuous 1:1 observation of Patient #9 was performed by law enforcement officers.

i. On 3/17/22 at 11:56 a.m., an interview was conducted with DON #5. DON #5 stated a patient assessment was performed by nursing staff at the time the patient was triaged. DON #5 stated nursing staff will conduct additional patient assessments until the patient has been discharged from the facility. DON #5 stated nursing staff were required to enter patient assessments into the patients' electronic health record (EHR) by the end of the nurse's shift or at the time the patient assessment was performed.

The late medical record entries in Patient #9's medical record on 3/15/22 were in contrast to the Admitting the Patient and Initial Nurses Notes policy and the Nursing Assessments policy which stated, nursing assessments will be entered into the electronic medical record within two hours of being performed. Additionally, the RN will document patient interventions and activities implemented for the patient.

ii. On 12/19/21 at 1:17 p.m., two days after his prior visit to the ED, Patient #9 was seen at the ED after he attempted suicide. Patient #9 tried to hang himself with a towel in the shower and injured his neck.

Patient #9's medical record lacked evidence a self-harm assessment and continuous staff 1:1 observation of the patient had been performed.

e. On 11/9/21 at 12:41 p.m., Patient #3 was seen in the ED. Patient #3 had held a gun to his head and was suicidal.

Patient #3's medical record lacked evidence of a suicide precaution order and continuous staff 1:1 observations for the patient.

f. The failures to implement interventions by facility staff for psychiatric patients determined to be suicidal in the ED were in contrast to the following facility policies:

i. According to the Suicide Ideation and Prevention Policy, nursing staff performed suicide ideation screening (self-harm assessment) to identify suicidal patients. Patients with suicidal thoughts and intentions to commit and/or engaged in self-harm activities were considered to have active suicidal ideation. Staff will ensure a safe environment of care was provided to patients who screened positive for suicidal ideation continuous 1:1 patient observation will be implemented.

Additionally, RN assessments for suicidal patients will include a self-harm screening to obtain the following information from the patient: The last time the patient had thoughts about self-harm. How the patient planned to inflict self-harm and how the patient stopped themselves from inflicting self-harm. Patients found to be at risk for serious self-harm due to suicidal ideation will be immediately placed on Suicide Precautions and the patient's physician notified a Suicide Precautions order was needed.

g. Interviews with facility staff were conducted and revealed patient self-harm assessments, suicide precautions and continuous 1:1 patient observations safety interventions were not implemented for multiple suicidal psychiatric patients in the ED.

i. On 3/15/22 at 4:34 p.m., an interview was conducted with RN #2. RN #2 stated patient self-harm assessments were required for all patients admitted to the ED. RN #2 stated patients who answered yes to any question in the self-harm assessment were be placed on suicide precautions. RN #2 stated the physician did not enter suicide precaution orders for suicidal patients. RN #2 stated suicide precautions were initiated and implemented by the nurse and a physician would not place an order for a patient to be placed on suicide precautions. RN #2 stated suicide precautions implemented by the nurse included placement of the patient in a room close to the nurses' station, an environmental safety check of the patient's room and continuous 1:1 patient observation. RN #2 stated an environmental safety check consisted of the removal of items which could potentially be used to inflict self-harm. RN #2 stated suicidal patients not placed on suicide precautions had an increased risk for inflicting self-harm.

ii. On 3/16/22 at 9:43 a.m., an interview was conducted with ED Physician (Physician) #2. Physician #2 stated there were processes and protocols in place at the facility for suicidal patients. Physician #2 stated suicidal patients were to be roomed directly in front of the nurse's station and suicidal patients were placed on 1:1 continuous observation. Physician #2 stated facility staff were to always have a visual line of sight on suicidal patients. Physician #2 stated suicidal patients were continuously observed by a nurse, law enforcement, facility security officers or a member of the patient's family.

Physician #2 stated physicians were unable to enter suicide precaution orders for patients. Furthermore, he stated he was not aware a suicide precaution order existed. Physician #2 stated patient care orders were entered into the patient's medical record to standardize the care the patient received. Physician #2 stated physician orders communicated the specific care needed for the patient.

2. Medical record review and interviews revealed continuous 1:1 observations (supervision) were conducted by law enforcement officers and patient family members instead of facility security or nursing staff.

a. Medical record review of Triage and Nursing Progress Notes for Patient #3 read, a law enforcement officer performed the continuous 1:1 observations for the patient on 11/9/21 at 12:45 p.m. to 11/9/21 at 3:45 p.m. when the patient was discharged.

i. Medical record review of Triage and Nursing Progress Notes for Patient #5 read, on 9/19/21 at 12:50 a.m. to 9/19/21 at 1:15 a.m., the patient was handcuffed and the law enforcement officers present in Patient #5s' room performed the continuous 1:1 observation of the patient.

ii. Record review of Triage and Nursing Progress Notes for Patient #9 on 12/17/21 at 12:17 p.m. read, Patient #9 had active suicidal thoughts and no longer wanted to live. The medical record lacked evidence a patient self-harm assessment, continuous 1:1 observation and suicide precautions were implemented on 12/17/21.

However, the medical record for Patient #9 for his ED visit on 12/17/21 had backdated entries entered by DON #5 on 3/15/22 at 12:09 p.m., which read, a self-harm assessment was performed, suicide precautions were implemented and continuous 1:1 observation of Patient #9 was performed by law enforcement officers.

The backdated entries entered into Patient #9's medical record on 3/15/22 were in contrast to the Admitting the Patient and Initial Nurses Notes policy, information obtained from the patient during a nursing assessment was to be entered into the patient's electronic medical record within two hours of when performed as the information obtained will be used to determine patient-specific nursing interventions.

A second medical record for Patient #9 was reviewed. The Triage and Nursing Progress Notes for Patient #9 on 12/19/21 at 1:26 p.m. to 12/19/21 at 2:45 p.m. read, suicide precautions and continuous 1:1 observations were implemented and maintained for Patient #9 by law enforcement officers.

iii. Record review of Triage and Nursing Progress Notes for Patient #20 revealed on 10/19/21 at 6:17 p.m. to 10/19/21 at 6:55 p.m. when the patient was discharged, law enforcement officers were present at Patient #20s bedside and performed the continuous 1:1 observations of the patient.

These examples were in contrast to the Suicide Ideation and Prevention policy, which stated to ensure a safe environment of care and the patient's safety, patients screened positive for suicidal ideation were to have continuous 1:1 patient observation performed by nursing staff and/or security staff.

b. On 3/16/22 at 9:43 a.m., an interview was conducted with Physician #2. Physician #2 stated dependent on the acuity the level of the patient and the level of self-harm inflicted by the patient determined who performed the 1:1 continuous observation of the patient. Physician #2 stated law enforcement and the patient's family were allowed to perform the 1:1 continuous observation and monitoring of suicidal patients. Physician #2 stated family members of the patient had conducted the continuous 1:1 observation required for suicidal patients. Additionally, Physician #2 stated law enforcement officers routinely performed 1:1 continuous observation of patients who were suicidal. Physician #2 stated suicidal patients not provided continuous 1:1 observation were at risk for continued self-inflicted harm and even death.

i. On 3/15/22 at 4:44 p.m., an interview was conducted with RN #2. RN #2 stated continuous 1:1 observation was required for all suicidal patients. RN #2 stated law enforcement officers were utilized as patient sitters (a trained healthcare worker who works under the supervision of a nurse to ensure patients do not injure themselves) for suicidal patients. RN #2 stated any staff member or law enforcement officer was able to perform continuous 1:1 patient observations. RN #2 stated suicidal patients were at an increased risk for harm and even death when suicide precautions were not properly implemented.

ii. On 3/14/22 at 4:25 p.m., an interview was conducted with RN #1. RN #1 stated patients who presented to the ED with suicidal ideation were to be kept safe at all times. RN #1 stated suicidal patients were placed close to the nurse's station in order for the patient to be visually observed at all times. RN #1 stated a sitter (a facility staff member who provides individualized monitoring of patients who require continual observation), a nurse, facility security officers and law enforcement officers were allowed to perform 1:1 continuous observation of suicidal patients.

This was in contrast to the Suicide Ideation and Prevention Policy which stated nursing staff or security staff will provide constant observation and supervision of suicidal patients. A suicidal patient will immediately be placed on a continuous 1:1 observation to ensure the patient does not injure themselves and to provide a safe environment of care. Patient family members were not permitted to provide continuous 1:1 observation.