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Based on document review and interview the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide an appropriate medical screening exam, see A 2406; and the failure to document the risks and benefits of transfer, see A 2409.

Based on document review and interview, the facility failed to provide an appropriate medical screening exam to one of nineteen patients (#4) reviewed resulting in the potential for poor patient outcomes.
Findings include:

On 2/7/2017 at 0900 medical record review revealed the patient of concern (patient #4) presented to the ED on 11/12/2016 at 1246. Triage was initiated by Registered Nurse (RN) staff H at 1304. Arrival Method: Walking; Priority: Urgent (3). The chief complaint was documented as Behavioral Problem. "Per Mother patient here at request of therapist from "Facility A" for Psychiatric Eval." The patient was a 15 year old female with a history of "cutting, she has been in therapy since April of 2016." Patient had history of myringotomy tubes in her ears but had no other medical history and was not on any medications. Staff H completed a nursing assessment at 11/12/2016 at 1312 at which time a Mental Health Assessment was completed. The patient was asked if she ever thought about harming herself or others to which staff H had checked the "Yes" box. Behavior was documented as "agitated, angry, no eye contact, restless, would not answer about date, time, and place. Patient was also documented as refusing to have vital signs taken, to allow ID band to be placed, or to change clothing. Staff H documentation further stated "communicate at times by speaking to mother and would not allow staff to visualize cutting on right thigh that mother reported occurred three days ago. Staff H checked the "No" box under Suicide precautions initiated.

At 1305 ED physician staff K documented his assessment of the patient. "History of present Illness" he stated "Per patient and mother, she has been having suicidal ideation's for the past several months but does not have a specific plan." He continued with past history "no pertinent history", are you pregnant now "No", Review of systems "all systems negative except "Psychiatric/Neurological reports: Emotional problems, Suicidal." A physical exam was completed it included: Neurological/Psychiatric- "alert, agitated, aggressive" Skin- "Normal color, warm/dry, Self-mutilation old, well-healed scars on right arm with semi-old wounds to right thigh."

At 1306 ED physician Staff K ordered the following labs: CBC with Differential (complete blood count- Hematology), Comprehensive Metabolic Panel (Chemistry of the blood), Amylase, Lipase, Thyroid Stimulating Hormone, Toxicology, Salicylate, Acetaminophen, Drug screen, Urine, pregnancy. At 1400 ED physician Staff K documented "results reviewed, laboratory values normal".

The medical record did not contain documentation of additional mental health assessments or interviews by the physician of record, a social work referral, or contact with the on call Psychiatrist.

At 1504 the physician staff K documented under "Progress/re-eval-Improved, doing well here, mom feels comfortable taking patient home and to follow up with psych on Monday (11-14-2016)." Patient was discharged by staff I at 1542.

On 2/15/2017 at 1400 ED Physician staff K was interviewed by phone. Staff K stated "I do not really remember this patient, but if after assessing her, completing labs, and collecting history; if she had been in therapy for a while and she verbalized that she did not have a plan that may have been why I did not have a psych eval completed or had her admitted. I do not know for sure."

On 2/7/2017 at 1100 the policy titled "Care of Psychiatric Patients" #521.012D dated July 2012 was reviewed. The policy states on page 1 of 2 under 1. "Patients who present with psychiatric complaints will be interviewed...to determine patients need for safety (i.e., harm to self/others.)" Under 3. "Emergency Department physician will evaluate patient and medically clear patient and determine need for psychiatric intervention."

Based on document review and interview the facility failed to document the risks and benefits of transferring a patient to another medical facility for 1 out of 8 transfer patients ( #4) reviewed resulting in the potential for less than optimal patient outcomes. Findings include:

On 2/7/2017 at 0845 medical record review for patient #4 revealed the patient had presented to the ED on 11/29/16 with a chief complaint of "Anxiety". Patient #4 was evaluated in the ED and subsequently transferred to an accepting psychiatric facility. Further review of the medical record for the 11/29/16 date of service revealed a completed "Medical Transfer Form" could not be located. This form includes the signature of the "Legally responsible Individual signing on patient's behalf for Transfer Consent."

On 2/7/2017 at 0900 Staff A was asked where the completed Medical Transfer Form would be located. Staff A stated "It would be scanned into the medical record."

On 2/8/2017 at 0905 staff J the ED Physician was asked if he had completed the transfer form including risk and benefits of transfer. Staff J stated "I do not remember. Transfer forms are filled out by the nurse and I am given a packet to sign."

On 2/7/2017 at 1100 the policy titled "Care of Psychiatric Patients" #521.012D dated July 2012 was reviewed. On page 2 of 2 it states under instructions 7. Adolescent (under 18 years of age) psychiatric patients...if admission to a psychiatric facility is determined...This is considered a transfer and all EMTALA and COBRA forms will be complied with."