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Based on hospital policy review, closed DED (Dedicated Emergency Department) medical record reviews, and physician interview, the hospital failed to ensure that an appropriate medical screening examination was provided related to an individual's presenting signs and symptoms of behavior consistent with schizophrenia at the time of arrival to the hospital for 1 (#22) of 30 sampled patients.

~cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

Based on hospital policy review, closed DED (Dedicated Emergency Department) medical record reviews, and physician interview, the hospital failed to ensure that an appropriate medical screening examination was provided related to an individual's presenting signs and symptoms of behavior consistent with schizophrenia at the time of arrival to the hospital for 1 (#22) of 30 sampled patients.

The findings include:

Review of hospital policy titled "EMTALA GUIDELINES", revised May 2016, revealed, "...DEFINITIONS:...Medical Screening Exam: The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not... POLICY... All patient shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal Law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic..."

Closed medical record review for Patient #22 revealed a 63 year old Caucasian male that presented to Hospital A's DED in police custody, on 10/04/2016 at 1924, with a complaint of mental health evaluation. Review indicated Patient #17's vital signs on 10/04/2016 at 1943 as follows: BP (Blood Pressure) 132/90 mmHg (normal); P 97 BPM (normal); R 18 RPM (normal); T 97.5° F (normal); and SpO2 97 % RA (normal). Review of an ED Provider Note, written by DED MD #2 on 10/04/2016 at 2143, revealed, "... HPI (history of present illness): (Named Patient) is a 63 y.o. (year old) male who presents to ED with c/o (complaint of) involuntary commitment for paranoid schizophrenia (mental disorder characterized by a breakdown in the relation between thought, emotions and behavior) and depression. Patient has a history of mental illness and has been hospitalized twice for paranoid delusions. Last admission to (Named Facility) he was discharged on a monthly shot but family states this was not continued by (Named Local Behavioral Health Service). Patient apparently left home on Sunday in a car. He states he was driving to California to find his boat. He was located in Tennessee confused and disoriented. He was held there until family could pick him up last night they brought him back home but he's refused to reenter the hospital. So they've initiated IVC (Involuntary Commitment). Patient has refused to eat because he is afraid he is being poisoned. He denies hearing voices. Review of Systems: All other systems reviewed and negative ... Initial Impression and Clinical Course Family requesting placement at (Named Facility) they felt they were holding a bed for him tonight. I spoke with the intake coordinator at (Named Facility) no beds available. They're requesting routine labs and they will assess him for admission in the morning. Screening labs ordered. Regular diet. Family request (Named Local Behavioral Health Service) not be involved in patient's care. We'll plan on case management making placement in the morning. I will uphold the IVC as patient is unable to care for himself ...Medically clear for psychiatric placement. We'll hold overnight and tried (sic) to place at (Named Facility) in the morning..." Review revealed the following laboratory examinations were ordered and performed: Complete Blood Count with Differential, Comprehensive Metabolic Panel, Urine Drug Screen, and Ethanol Level. Upon completion all laboratory values were negative or normal, as appropriate. Physician order review revealed as needed medication orders were written for Tylenol (a medication for pain or fever), Ibuprofen (a medication for pain), and Ativan (a sedative), however Patient #22 never needed any medications during this DED admission. Review of a Progress Note written by Case Manager (CM) #6 on 10/05/2016 at 1110, revealed, "Completed MH (Mental Health) / risk assessment by review of historical documentation, ER staff report from observation / interaction, and current ER documentation - patient was asleep at time and CM unable to wake; CM spoke w/ (with) (Named Staff) at (Named Hospital) re: (reference) patient's step-son's report of prior contact w/ understanding that patient transfer there for tx (treatment) (Named Staff) verified this was not the case); (Named Staff) requested referral be faxed for review / possible placement if bed is available; referral faxed per request; CM also faxed referral to additional geri-psy (geriatric psychiatric) units for review; ER physician and RN notified of status. CM to f/u (follow up) w/ pending referrals as needed." Review of a Progress Note written by CM #6 on 10/05/2016 at 1545, revealed, "Return phone call to patient's step-son (Named) to provide update re: placement efforts - informed (Named) that referral sent to (Named Facility) and other geri-psy units for review / request for placement; CM obtained additional patient hx (history) re: patient symptoms and onset - Taylor stated symptoms presented over past year or two - No hx of symptoms or behaviors; he stated that he was dx (diagnosed) w/ Schizophrenia approx. (approximately) 1 year ago-CM inquired about possible early onset Dementia and family hx; (Named Family) reported that patient's father presented similar symptoms around the same age; He also said 'that's why (Named Local Behavioral Health Service) stopped his Invega (an antipsychotic medication) shot, because they couldn't dx him w/ Schizophrenia, referred him for medical tests to r/o anything medical and also discussed a possible dementia dx, but he doesn't have any insurance; he didn't meet Medicaid requirements, and he can't apply for healthcare until 11/1 (November 1st), so I couldn't get anything done and he has gotten back where he is now'; CM thanked (Named Family) for information, provided direct contact number/verified ER direct line, and informed that he would be kept updated on status; CM also requested he provide copy of HCPOA (Health Care Power of Attorney) documentation for electronic record-he agreed to provide copy. CM to f/u w/ pending referrals as needed." Review of a Progress Note written by CM #6 on 10/07/2016 at 1020, revealed, "Follow up / continued placement efforts including: (Multiple Named Facilities): Denied... CM to cont (continue) placement efforts as needed." Review of an ED Provider Note, written by DED MD #7 on 10/08/2016 at 1841, revealed, "RN was concerned that patient has been refusing all by mouth for the last several days. She says she is unsure if he is truly not taking anything by mouth but she has not witnessed him eat or drink anything today. I did repeat a CMP (Complete Metabolic Panel) on him today to check for dehydration. His creatinine is actually improved from a few days ago and his electrolytes are normal." Review of an ED Provider Note, written by DED MD #2 on 10/11/2016 at 2124, revealed, "...IVC has ran out. Patient does not meet criteria for repeat IVC. He's not harmful to himself or others... We'll continue Ativan as an outpatient until patient can follow-up with (Named Local Behavioral Health Service) to schedule ongoing medication. He probably should be put on something for his schizophrenia. He was instructed to contact (Named Local Behavioral Health Service) tomorrow for an appointment. Patient stable for discharge at this time." Patient #22 was discharged to the care of his family on 10/11/2016 at 2132.

The EXAMINATION AND RECOMMENDATION TO DETERMINE NECESSITY FOR INVOLUNTARY COMMITMENT (IVC) for Patient #22 DATED 10/14/2016 AT 2045 PM was reviewed. The IVC stated in part, "Section I-CRITERIA FOR COMMITMENT. inpatient. it IS MY OPINION THAT THE RESPONDENT IS ..MENTALLY ILL DANGEROUS TO SELF.... Current medications: None...Impression/Diagnosis: Schizophrenia...SECTION III-RECOMMENDATION FOR DISPOSITION. Inpatient for commitment for 10 days."

Physician interview was conducted on 10/27/2016 at 0730 with DED MD #2, who recalled Patient #22. Interview revealed he was confused, but cooperative. Interview revealed Patient #22 had been on a monthly medication injection, which his outpatient therapy providers had discontinued. Interview revealed Patient #22's family did not want the outpatient providers contacted, or to assist in guiding Patient #22's care. Interview revealed the particular outpatient therapy group is the only psychiatric resource in the area, and are who Hospital A utilizes for psychiatric consults. Interview revealed DED MD #2 normally does not normally start psychiatric medications, "because I'm not a psychiatrist." Interview revealed on the day the IVC papers ran out, he performed a patient assessment, and Patient #22 was no longer a danger to himself or others. Interview revealed no other facility had been able to provide an open bed to provide further inpatient care for Patient #22, so he had to be discharged.

The facility failed to ensure that patient #22 received an appropriate medical screening examination by a psychiatrist. The facility failed to transfer patient #22 to psychiatric facility in order to receive the psychiatric inpatient treatment that he needed as as stated on the IVC papers, instead patient #22 was discharged for emergency department after being in the emergency department for 7 days (10/04/2016-10/11/.2016) without being assessed or managed by a psychiatrist.