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Based on event/visit review, medical record review and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24. The hospital's Dedicated Emergency Department [DED] failed to provide an appropriate Medical Screening Examination [MSE] within the capability of the hospital's DED, for a minor patient that walked into their emergency department and guardian requesting an evalutation for 1 if 30 patients (Patient #3).

Findings include:

~ Cross refer to Medical Screening Examination - Tag A2406.

Based on policy review, event/visit review, medical record review, public safety report, and staff interviews, the hospital failed to provide an appropriate Medical Screening Examination [MSE] as requested by Patient #3's legal guardian for a minor patient that walked into their emergency department for one (1) of 30 sampled patients (Patient #3).

Findings included:

Review of the EMTALA policy dated 12/2023 revealed "Emergency services and care, including an appropriate Medical Screening Examination, will be provided to individuals who 'come to the Hospital's Emergency Department' ... and request examination or treatment of a medical condition ... A Medical Screening Examination will be performed to determine if an Emergency Medical Condition exists. If the individual has an Emergency Medical Condition, the Hospital will either stabilize the medical condition within its available staff, facilities, and resources, or, if stabilization at the Hospital is not possible, appropriately transfer the individual to a qualified receiving facility ... PROCESS I. Medical Screening Examination: A. Request for MSE: An appropriate Medical Screening Examination will be performed on any individual who 'comes to the emergency department,' which means: 1. The individual presents to the Hospital's dedicated Emergency Department, and, either personally or through someone else, requests examination or treatment for a medical condition. 2. The individual presents anywhere on the Hospital Property and, either personally or through someone else, requests examination or treatment for what may be an Emergency Medical Condition. In either situation, even if there has been no formal request for treatment, a request is considered to have been made if a prudent layperson observer would believe that the individual needs emergency examination or treatment ..."

Review of the electronic log of emergency department encounters for Patient #3 revealed Patient #3 had a visit entered on 01/10/2024 at 1630 [3 hours and 6 minutes after discharge from the hospital's (Hospital A Campus A) emergency department. The patient was transported via law enforcement.

Review of the Hospital A Campus A Case Management Note on 01/10/2024 at 1649 revealed "01/10/2024 @ [at] 1630 - Social Worker [SW #4] (hospital employee) received a call from ED (emergency department) RN (registered nurse) stating pt (patient #3) just walked past her and into the hospital. SW #4 found patient in ED lobby with no guardian. Pt stated she walked on foot from [DSS D] office to ED by herself after getting into a fight with her SW. Pt stated when she got to DSS, they went through and took her belongings, including her computer. Pt got upset about this and stated she was going to leave, and did. [SW #4] did not receive a call from [DSS D] (DSS county office staff) regarding this, and [DSS D] did not arrive to the ED with pt. [SW #4] asked pt if she is having feelings of harming herself or others, pt denied this. [SW #4] asked if pt is not feeling well and needs to be checked in, pt denied this as well. PS [#1] (Public Safety Officer) arrived at the ED and met with [SW #4] and pt in SW office. [SW #4] attempted call to [DSS Appointed #5] (County DSS employee) cell phone, who did not answer. [SW #4] called [Guardian #2], pt's guardian. [Guardian #2] advised she does not know what to do and will ask supervisors/program managers ... all got on the call with [SW #4], stating pt has been displaying 'behavioral issues' within the 'first four minutes' of pt being at their office. DSS representatives stated pt walking to ED also shows impulsivity, and they would like pt to be evaluated. [SW #4] advised this is not a reason to IVC (Involuntary Commitment) or telepsych pt, and [SW #4] will reach out to Hospital administration on what to do from here. [SW #4] advised by [PS #1] Public Safety that they were told to bring pt back to DSS. Pt went willingly to LE [law enforcement] car and left [Hospital A Campus A] with [PS #1] ..."

Review on 08/05/2024 of Hospital B's open medical record for Patient #3 contained a form "PARENT OR GUARDIAN'S APPLICATION FOR A MINOR'S ADMISSION TO [Hospital B] AND CONSENT TO TREATMENT FOR MENTAL ILLNESS" on 01/10/2024 at 1804 filled out with Patient #3's name and signed by [DSS D] (DSS county) social worker. Review of the EVALUATION FOR ADMISSION /CONTINUAL STAY form revealed " ... The above named [check box] minor ... was examined on 01/10/2024 at 2000 o'clock ... DESCRIPTION OF FINDINGS: ... Patient requests admission. Has continued to engage in disruptive, aggressive, and some self injuries (sic) behaviors saying to DSS staff she will escalate if not admitted ..." Review of the Provider note dated 01/10/2024 at 2041 revealed " ... Reason for Admission: ... a 16-year-old Caucasian female ... who presented to the Admissions Office at [Hospital B] as a volunteer (by guardian) walk-in early on the evening of 01/10/2024. She was brought ... by staff from [DSS D]. The patient's guardian of person is [Guardian #2] ... Because of behavioral problems (arguments, physical aggression, property destruction), the patient was taken to the emergency department at [Hospital A Campus A] on multiple occasions. However, after undergoing telepsychiatry evaluations, it appears that the decision was made not to admit her to the hospital because of a lack of suicidality or sufficient risk of harm to others. The patient has been staying in the [DSS D] offices since then, under staff supervision. After eloping from the [DSS D] offices and walking back to [Hospital A Campus A] earlier today, the patient was brought to [Hospital B] to seek admission ... PLAN: 1. The on-call attending psychiatrist ... made the decision to admit the patient to [Hospital B] this evening. The patient is going to be admitted ..." Review of the "Psychiatric Assessment" at 2025 revealed " ... 2. Chief Complaint or Patient's Response to Hospitalization (in patient's own words): 'I wanted to come here because the last time, this was the only place where the groups actually helped and I learned to use good coping skills. 3. Present Illness (onset and circumstances leading to admission): 16-year-old female with a long history of psychiatric illness with multiple placements and hospitalizations throughout the years. She is in the custody of DSS. She was admitted as a volunteer and volunteer by guardian for mood stabilization and behavioral stabilization ... Upon seeing her and interviewing her, she is calm, pleasant, cooperative. She tends to minimize her role in all of this, minimizing the degree of aggression and disruptive behaviors she has been engaging in. She tends to externalize things onto others. She blames DSS social workers for either not being attentive or not caring, etc. She blamed her aunt for getting angry that the boyfriend left, etc. She also stated she was put in the hospital by DSS simply because they did not want to babysit her in their office on Christmas. In any case, she has definitely been aggressive, disruptive, and oppositional in these situations. That said, [Patient #3] states plainly that she has been using poor coping skills and recalls how much she learned here and how much she thinks our hospital helped her, and so she desires to come back to relearn, strengthen and refresh her coping skills ... 27. Initial Plan including Pharmacological Formulation (strategies to deal with identified problems, rationale for medication choices): Admit to the unit for safety and stabilization. She will receive a multidisciplinary evaluation and treatment in the unit. She will receive a physical exam addressing any health concerns. Further collateral information will be obtained. Will continue her current medications ... 34. Admission: Approved ..."

Review of the PS [Public Safety] #1 report dated 01/10/2024 at 1624 revealed "... JUVENILLE [sic] PROBLEM ... SUBJ [subject] LEFT OF [sic] FOOT ... HEADING TOWARDS HOSPITAL ... CALLER IS WITH DSS AND SAID SUBJ WANTS TO BACK [sic] TO HOSPITAL ... HAS BEEN COMBATIVE ... JUVENILE IS POSSIBLY IN THE HOSPITAL WAITING ROOM ... IM [I am] OUT AT HOSPITAL ... IM OUT WITH THAT FEMALE ... MAKE CONTACT BACK WITH CALLER AND HAVE SOMEONE EN ROUTE TO PICK UP JUVENILE WE WILL BE IN ED DEPT [department] ... CALLER ADVISED THEY ARE ON THE PHONE WITH ER NOW ... I WILL BE ENROUTE BACK TO DSS SHORTLY IF SOMEONE WILL STANDBY ... WAS RETURNED TO [DSS D] AFTER LOCATED AT THE ER LOBBY. DSS WOULD NOT COME TO HOSPITAL TO PICK UP FEMALE THEY HAVE CUSTODY OF WHILE RETURNING FEMALE BACK TO DSS, THE CALLER MET OFFICERS AT THE DOOR AND ADV [advised] TO TAKE HER TO [Hospital B]. THE CALLER VERBALLY TOLD OFFICERS THAT DSS HAD CUSTODY OF THE FEMALE AND OFFICERS STILL HAD TO EXPLAIN WHY FEMALE HAD TO BE LEFT AT DSS ..."

Interview on 08/01/2024 at 1305 with SW #4 revealed she was notified by the ED Nurse Manager that Patient #3 had just walked past the nurse in the ED. SW #4 met Patient #3 in the ED waiting room. SW #4 called DSS Appointed #5 (County DSS employee) and Guardian #2 and while SW #4 was on the telephone with DSS, Patient #3 left the ED with law enforcement.

Telephone interview on 08/01/2024 at 1441 with Guardian #2 revealed Patient #3 was driven to Hospital B (psychiatric hospital) on the day she returned (01/10/2024) to the DSS office because Patient #3's behaviors had escalated.

Interview on 08/02/2024 at 1220 with Provider #6 revealed Patient #3 should have been seen and evaluated on the the 01/10/2024 walk-in visit. Provider #6 was not aware of Patient #3 walking into the ED on 01/10/2024. He was notified a couple of weeks later. Interview revealed the note (SW #4 01/01/2024 at 1649) is different than what Provider #6 was told. Provider #6 was told Patient #3 came in asking to stay here as the people were nicer.