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Based on document review, interview, and medical record review the hospital failed to follow their provider agreement and hospital policies to provide a medical screening exam for one of 20 patients (Patient 1) reviewed upon arrival to the behavioral health unit (BHU) for admission from the transferring hospital emergency department. Failure of the hospital to provide a medical screening exam places patients at risk for unidentified and untreated mental health emergencies placing them at risk of injury or death.

Findings Include:

Review of Patient 1's medical record from the transferring Critical Access Hospital's (CAH) emergency department (ED) showed he arrived by private vehicle on 09/28/19 at an undocumented time with complaints of suicidal ideation (SI), feelings of anger, and depression. Orders included a mental health screening by an unidentified crises center using a telehealth system. Completion of the screening at 7:00 AM resulted in a recommendation that Patient 1 receive acute inpatient behavioral health treatment. Patient 1 was transferred on 09/28/19 at 8:52 AM, from the CAH ED with directions to go directly to the Salina Regional Health Center's (SRHC) behavioral health unit (BHU) for admission.

During a telephone interview on 12/05/19 at 8:21 AM, Advanced Practice Registered Nurse (APRN) S at the transferring CAH Emergency Department (ED) stated she contacted on-call Psychiatrist B at SRHC, regarding admission of Patient 1 after he presented to the CAH ED with suicidal ideation (SI). A telehealth crisis center performed a mental health screening at the CAH ED and determined Patient 1 required intensive inpatient mental health services. Patient 1 agreed to voluntary admission to the BHU at SRHC.


Document review of the SRHC policy titled, "EMTALA Screening, Stabilization, Management of Transfer" dated "Revised: May 2018" showed, ..."It is SRHC's policy to provide an appropriate medical screening examination to individuals (patients, visitors, and employees) who present in an area of the hospital's main campus other than the emergency department and requesting examination or treatment of an emergency medical condition; and either to seek to stabilize an emergency medical condition if one exists or to transfer the individual appropriately and in conformity with legal and regulatory requirements."


Review of the SRHC's Medical Staff Rules and Regulations, ...Emergency Services showed ... "An appropriate medical record shall be kept for every patient receiving emergency services and shall be incorporated into the patient's hospital record when direct admission to the hospital follows such treatment. The record shall include: A. Adequate patient identification; B. Information concerning the time of the patient's arrival, means of arrival and by whom transported; C Pertinent history of the injury or illness, including details relative to first aid or emergency care given the patient prior to arrival at the hospital; D. Description of significant clinical, laboratory and roentgenologic [radiology] findings; E. Diagnosis; F. Treatment given; G. Condition of the patient upon discharge or transfer; and H. Final disposition, including instructions given to the patient and/or his family, relative to necessary follow-up care recorded by the physician.

Review of SRHC BHU's document titled, "Admission Rotation Log" showed Patient 1's name with a date of 09/28/19, both Patient 1's name and the date were crossed out with several lines.

SRHC could not provide a copy of patient 1's medical record or documented evidence that staff performed an assessment or screening for Patient 1 when he arrived at SRHC BHU on 09/28/19.

During an interview on 12/04/19 at 10:15 AM, BHU on-call Psychiatrist B stated the CAH ED staff contacted him about Patient 1 and he did agree to admit him after arrangements were made for secure transportation. Psychiatrist B stated that Patient 1 did arrive by private vehicle at a time when he was off the unit. The BHU nurse notified him of Patient 1's arrival, and Psychiatrist B requested the nurse perform a quick assessment of the patient. He then stated the nurse reported to him that Patient 1 did not meet admission criteria (criteria elements include suicidal ideation (SI), suicidal ideation with a plan, homicidal ideation (HI), homicidal ideation with a plan, psychosis, delusional, or experiencing hallucinations) and a safety plan was developed including follow up with his outpatient provider the following Monday. Staff B stated that he could have sent Patient 1 to the ED for another medical screening exam (MSE), however the ED "only provides a medical clearance and that would be another delay and cost to the patient that was unnecessary."

Refer to tag A 2406 for further details.

Based on document review and staff interview, the hospital failed to provide a medical screening examination (MSE) for one of 20 medical records reviewed (Patient 1). Failure to provide a medical screening examination has the potential to delay care and places patients at risk for unidentified and untreated mental health emergencies placing them at risk of injury or death.

Findings Include:

Review of Patient 1's medical record from the transferring Critical Access Hospital's (CAH) emergency department (ED) showed the patient arrived on 09/28/19 at 1:32 AM with complaints of suicidal ideation (SI), feelings of anger, and depression. Orders included a mental health screening by a crisis center using a telehealth system. Completion of the screening at 7:00 AM resulted in a recommendation that Patient 1 receive acute inpatient behavioral health treatment. Advanced Practice Registered Nurse (APRN) S documented in the medical record that Dr. [name of on-call psychiatrist at Salina Regional Health Center] will only accept patient "if he is transferred with an escort." "He states he will refuse the pt [patient] if he does not have an escort." "I explained that pt has not been violent and has been cooperative, and Dr. states that he does not need to be seen as inpt [inpatient] unless he comes with an escort." At 7:45 AM APRN S contacted the Police who declined to transport patient 1 because patient is "voluntary." At 8:00 AM APRN S documented that "The Center is called again and discussions were made." Further documentation in patient 1's medical record showed "Discussion with Center, Police Department and family, and patient and family feel comfortable taking patient POV [private operated vehicle] and, if necessary, having Salina Police escort patient into facility there for voluntary admission." "Family will have driver and second person in vehicle, and are in agreement." "Patient has had no threats to family, self or staff during ER visit, has remained cooperative and calm during stay." "Will transfer patient POV to facility (Salina Regional Health Center) for voluntary mental health admission." Patient 1 departed the CAH on 09/28/19 at 8:52 AM.

During a telephone interview on 12/05/19 at 8:21 AM, Staff S, Advanced Practice Registered Nurse (APRN) at the transferring CAH Emergency Department (ED) stated she contacted Staff B, on-call Psychiatrist B at Salina Regional Health Center (SRHC) regarding admission of Patient 1 after he presented to the CAH ED with suicidal ideation (SI). A telehealth crises center performed a mental health screening at the CAH ED and determined Patient 1 required intensive inpatient mental health services. Patient 1 agreed to voluntary admission to the Behavioral Health Unit (BHU) at SRHC.

Review of SRHC's Behavioral Health Unit (BHU) document titled, "Admission Rotation Log" showed staff had entered Patient 1's name in the log on 9/28/18. However, patient 1's name and the date were crossed out with several lines.

When requested SRHC could not provide a medical record or any evidence to indicate that patient 1 received an assessment when he arrived on the BHU on 09/28/19.

During an interview on 12/04/19 at 10:15 AM, BHU Psychiatrist B, stated the CAH ED staff contacted him about Patient 1 and he did agree to admit him after arrangements were made for secure transportation. Psychiatrist B stated that Patient 1 did arrive by private vehicle at a time when he was off the unit. The BHU nurse notified him of Patient 1's arrival, and Psychiatrist B requested the nurse perform a quick assessment of the patient. Psychiatrist B stated the nurse reported to him that Patient 1 did not meet admission criteria (criteria elements include suicidal ideation (SI), suicidal ideation with a plan, homicidal ideation (HI), homicidal ideation with a plan, psychosis, delusional, or experiencing hallucinations) and a safety plan was developed including follow up with his outpatient provider the following Monday. Psychiatrist B stated that he could have sent Patient 1 to the ED for another medical screening exam (MSE), however the ED "only provides a medical clearance and that would be another delay and cost to the patient that was unnecessary."

During a telephone interview on 12/05/19 at 1:55 PM, BHU registered nurse (RN) Q stated she did not remember Patient 1's name, however stated she vaguely remembered an instance several months prior of a patient arriving by private vehicle with his mother and presenting at the BHU for admission. She stated the staff were unaware of his planned admission. She spoke with the patient outside of the unit and he stated he had an appointment the next day with an outpatient mental health clinician that he would like to keep. She stated she discussed a safety plan with him and provided the BHU number to him to contact if he got into trouble. She further stated she might have spoken with Hospital BHU psychiatrist B. She stated that the notes she took regarding that patient have been "trashed." She further stated when staff know a patient is coming they are pre-registered and given a visit number but may not receive a medical record number until full registration is complete. She was unable to provide any further information.

During an interview on 12/05/19 at 9:20 AM, Lead RN R for the Hospital BHU stated that the admission log is updated with the patient's name and the date only. RN R stated that she made "cheat sheets" for staff to obtain initial information "like an initial report sheet." Once the patient arrives, those sheets are thrown away.