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Based on review of facility policy and procedure, personnel records and employee interview, the Department determined the administrator failed to comply with EMTALA regulations by not establishing formal In-service training program records, schedules and reports. This deficient practice could result in staff being not adequately trained by a qualified/certified professional in a formalized manner that could result in inappropriate patient placement and/or patient harm.

Findings Include:

A request was made for facility policy and procedure regarding an EMTALA training program and facilitator requirements. Interview with Employee #1 on August 30, 2024, confirmed that a facility policy regarding an EMTALA training program and facilitator requirements was not available.

Employee #1 provided a document titled "EMTALA Quick Sheet" with no date or identifying information, on August 30, 2024, that Employee #1 stated they review with staff. From this document, they provide a quiz to employees. A request for a policy on when, how often, which staff, and who can facilitate the training was requested on August 30, 2024. No policy was provided on EMTALA training requirements.

Documentation for EMTALA staff training was requested for Employees (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) on August 30, 2024. The following EMTALA quizzes were not provided as follows:

Employee #1 No EMTALA annual competency were provided.
Employee #4 No EMTALA quiz at hire were provided.
Employee #6 No EMTALA quiz at hire were provided.
Employee (#15) No EMTALA quiz at hire were provided.
Employee (#16) No EMTALA quiz at hire were provided.

Employee #12 No EMTALA quiz at hire, but annual competency was completed 4/26/2024.
Employee #14 was missing an EMTALA quiz at hire, but annual competency was completed 4/22/2024.

Employee #6 confirmed in an interview on August 30, 2024, that the above listed Employee's did not have the required EMTALA in-service training's available for review and no formal policy was available for review.

Based on review of policies and procedures, medical records and staff interviews, it was determined that the hospital failed to ensure the medical record was maintained with all required documentation for at least 5 years. This deficient practices can result in a patient not getting appropriate psychiatric and medical care if they need further treatment.

Findings Include:

Policy titled "Medical Staff Bylaws, Rules and Regulations" last revised May 2024, policy #15934421, states "...The attending Practitioner shall be responsible for the preparation of a complete and legible medical record for each patient...."

Policy titled "Intake Admission Process" Effective August 2024, policy #16418805, states "...When a call or fax is received regarding a potential admission, registered nurse (RN), or Social Worker assigned to screen for admission will complete a clinical review...i. If the potential admission is coming directly from another facility, such as an emergency department, long term care facility, or in another inpatient unit, the patient is considered a Direct Admission. Upon receiving notification of a potential admission from another facility, the RN will complete a Nurse to Nurse staffing and obtain admission orders from a physician. Clinical data will be requested that includes: 1. Lab work obtained within the past 30 days
2. Nursing notes, including documentation of specific reason why the patient requires inpatient psychiatric hospitalization 3. If nursing notes do not specifically indicate clear admission criteria, additional clinical information may be requested... ii. If the potential admission is a referral from an outpatient provider's office or a self-referral/ walk-in, the patient is considered an unscheduled Admission. The RN and/ or the Social Worker assigned to the Admission Department will complete an assessment of criteria, making every attempt to gather all possible information...."

A request was made on August 29, 2024, for the clinical review, nursing review, nursing notes on specific reasons for referal, and all assessments including the MSE in the patient medical record was requested for Patient #24, #25, #26, #27, #28, #29, #30, #31, #32 who were reported to have been admitted but did not stay for treatment. None were provided. Telephonic interview with Employee #1 confirmed on August 29, 2024, that the paper portion of the assessment was also no longer available and had been shredded.

Interview with Employee #3 on August 29, 2024, stated "If the patient does not stay after being assessed, the medical record is deleted." Employee #3 confirmed that a MSE was performed on Patient #24, #25, #26, #27, #28, #29, #30, #31, #32, to determine if they were a psychiatric emergency, they were accepted for admission, and for reasons unknown to Employee #3, they did not stay for treatment and they no longer had a medical record available for review.

Based on document review and interview, it was determined that the facility failed to complete a medical screening examination (MSE) conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations to be qualified to complete an MSE. This deficient practice poses a risk to the health and safety of patients if life-threatening or potentially life threatening conditions are not recognized and stabilizing treatment provided.

Findings include:

The policy titled "EMTALA" states "... 'Qualified Medical Person' or 'Qualified Medical Personnel' means an individual or individuals determined qualified by Hospital bylaws or rules and regulations (and consistent with state licensure) to perform a Medical Screening Examination. In the Hospital, qualified medical personnel are limited to physicians, physician assistants, nurse practitioners, and registered nurses who have been deemed qualified...."

Policy titled "Intake Admission Process" effective August 2024, policy #16418805, states "...the RN will complete the medical/ infection screening...."

Patient #8's medical record dated contained a MSE completed on March 14, 2024, by an LPN with no other signatures.

Patient #13's medical record dated contained a MSE completed on July 11, 21024, by a Social Worker with no other signatures.

Employee #3 confirmed in an interview on August 30, 2024, that Patient #8 and Patient #13's MSE's were not completed by qualified individuals.

Based on review of clinical records, policies and procedures, hospital documents, and staff interviews, it was determined the hospital the hospital delayed screening and treatment 7 out of 11 Patient's to inquire about the individual's method of payment or insurance status. This deficient practice resulted in unduly discouraging individuals from obtaining further evaluation.

Findings include:

Hospital policy titled, "EMTALA" effective August 2024, policy #16418781, states "...The Hospital will not base the provision of emergency services and care upon an individual's race, ethnicity, religion, national origin, citizenship, culture, language age, sex, preexisting medical condition, physical or mental disability, insurance status, sexual orientation, gender identity or expression, economic status or ability to pay for medical services, except to the extent that a circumstance is relevant to the provision of appropriate medical care...."

Document titled "Referral log" had the following patients and "Disposition" noted:
3/10/24 Patient #1 "no insurance" "0553am"
3/10/24 Patient #2 "Admitted" With insurance "903am"
3/10/24 Patient #3 "Declined no insurance" "1029am"
3/10/24 Patient #4 "Declined no insurance" "1031am"
3/10/24 Patient #5 "Declined no insurance" "1056am"
3/10/24 Patient #6 "Accepted" with insurance "1059am"

3/12/24 Patient #7 "Decline-no insurance" "2300pm"
3/12/24 Patient #8 "Accepted" with insurance "2357pm"

3/21/24 Patient #9 "Denied-No insurance" "947am"
3/21/24 Patient #10 "no insurance" "253pm"
3/21/24 Patient #11 "Accept" with insurance "308pm"

Documentation regarding the Patient #1, 3, 4, 5, 7, 9, & 10's referal was requested. None was provided.

Interview with Employee #1 on August 29, 2024, stated that they were all shredded and the patient charts were not available.

Interview with Employee #2 August 30, 2024, stated there should be a chart without a picture that is available for review but was not able to produce a chart for Patient #1, 3, 4, 5, 7, 9, & 10.

Interview with Employee #2 confirmed that when a person is referred for intake for a psychiatric emergency, the facility reviews the packet for medical criteria to determine if they can support the patient's needs. If they determine they can accept the patient they then provide the patient with a list of fees for services so that the "patient can decide if they want to get services here or not. They often decide not to because of the cost." Interview with with Employee #2 confirmed on August 30, 2024, that patients are referred for psychiatric emergencies and the above patient's did not get treatment at the facility due to not accepting the rates being billed reiterating that they don't have insurance and have to agree to the rates prior to receiving any services at the hospital.

Interview with Employee #3 on August 30, 2024, stated the patient charts were deleted if a patient did not stay for treatment after assessment. Interview with Employee #3 confirmed that the above patients were identified as having a psychiatric emergency and need for transfer to the facility and were not transferred and no charts were available for review.

Based on review of clinical records, policies and procedures, hospital documents, and staff interviews, it was determined the hospital the hospital refused to receive patients with a psychiatric emergency if they did not have the ability to pay. This deficient practice can result in patient harm or death.

Findings include:

Hospital policy titled, "EMTALA" effective August 2024, polic #16418781, states "...The Hospital will not base the provision of emergency services and care upon an individual's race, ethnicity, religion, national origin, citizenship, culture, language age, sex, preexisting medical condition, physical or mental disability, insurance status, sexual orientation, gender identity or expression, economic status or ability to pay for medical services, except to the extent that a circumstance is relevant to the provision of appropriate medical care...."

Document titled "Referral log" had the following patients and "Disposition" noted:
3/10/24 Patient #1 "no insurance" "0553am"
3/10/24 Patient #2 "Admitted" With insurance "903am"
3/10/24 Patient #3 "Declined no insurance" "1029am"
3/10/24 Patient #4 "Declined no insurance" "1031am"
3/10/24 Patient #5 "Declined no insurance" "1056am"
3/10/24 Patient #6 "Accepted" with insurance "1059am"

3/12/24 Patient #7 "Decline-no insurance" "2300pm"
3/12/24 Patient #8 "Accepted" with insurance "2357pm"

3/21/24 Patient #9 "Denied-No insurance" "947am"
3/21/24 Patient #10 "no insurance" "253pm"
3/21/24 Patient #11 "Accept" with insurance "308pm"

Documentation regarding the Patient #1, 3, 4, 5, 7, 9, & 10's referal was requested. None were provided.

Employee #1 stated that they were all shredded and the patient charts were not available. Employee #3 stated the patient charts were deleted if a patient did not stay for treatment after assessment.

Interview with Employee #2 confirmed that when a person is referred for intake for a psychiatric emergency, the facility reviews the packet for medical criteria to determine if they can support the patient's needs. If they determine they can accept the patient they then provide the patient with a list of fees for services so that the "patient can decide if they want to get services here or not. They often decide not to because of the cost." Employee #2 stated there should be a chart without a picture that is available for review but was not able to produce a chart for Patient #1, 3, 4, 5, 7, 9, & 10.

Interview with with Employee #2 confirmed on August 30, 2024, that patients are referred for psychiatric emergencies and the above patient's did not get treatment at the facility due to not accepting the rates being billed reiterating that they don't have insurance and have to agree to the rates prior to receiving any services at the hospital.

Interview with Employee #3 confirmed that the above patients were identified as having a psychiatric emergency and need for transfer to the facility and were not transferred and no charts were available for review.