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Based on medical record (MR) review, document review, and interview,the facility failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA).

Findings:
The hospital failed to provide, within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilized the medical condition for patients presenting to the Emergency Department ( ED). ( Patient #1, Patient #21 and Patient #23).

See Tag A 2407.

Based on observation and interview, the facility failed to post EMTALA signs conspicuously in places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment.

Findings:

Review of policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Requirements" (Revised: 05/2023) revealed the following, "A sign conforming to applicable Federal requirements and guidelines informing patients of their rights regarding examination and treatment for emergency medical conditions and the Hospital's participation in the Medicaid program will be conspicuously posted in the Emergency Department, including its admitting areas, waiting areas, and treatment areas. Areas such as Labor and Delivery, main hospital entrance, Psychiatric Patient Evaluation & Referral Center (PERC), shall also maintain EMTALA signs."

During the tour of the Emergency Department (ED) on 11/01/2023, at approximately 10:00 AM, it was noted that the sign was not posted conspicuously. The sign was posted in the enclosed registration area and was unreadable from a distance.

During interview on 11/01/2023, at 10:30 AM, Staff B (Vice President of Emergency Care) stated that "this will be corrected."

Based on medical record review, document review and interview, the facility failed to ensure three patients ( patients 1, 21 and 23) presenting to the Emergency Department (ED) received treatment and management to stabilize their emergency medical condition (EMC) prior to discharge.

Findings include:

Review of the medical record for patient #1 revealed that on 07/29/2023, at 15:01, (3:01 PM), this 18 y/o male patient with history of Cannabis use, ADHD, and Suicidal Attempt was admitted to the facility's Behavioral Health Unit where he was treated for Major Depressive Disorder and Anxiety.
On 08/30/2023, at 15:38, the patient was discharged to a residential facility where he used to reside prior to this admission.

On 08/31/2023, at 18:56 (6:56 PM), the patient was brought to the facility by correctional officers. This time, patient came from prison, and not the residential facility he was discharged to. The chief complaint was suicidal ideations, post a suicidal attempt by hanging. Based on CSSRS (Columbia Suicide Severity Rating Scale), the patient wished to be dead. He had thought and a plan on how to carry his wish out.
At 20:02 (8:02 PM), the patient was triaged. Patient had no complaints of physical pain.

At 20:05 (8:05PM), the patient was evaluated by a provider who documented, "Discharged from BHC to correctional facility since his bed placement at "village" was lost during hospital. While at jail today, he felt suicidal thoughts with plan to jump out of building. He is prescribed Lexapro (medication to treat depression and generalized anxiety disorder) however admits to noncompliance. He reports past alcohol and marijuana use but none recently. Denies other psychiatric symptoms of auditory or visual hallucinations, and HI (homicidal ideation). No medical complaints."

At 20:15 (8:15 PM), patient was evaluated by a psychiatrist. Documentation stated ...."On the basis of this examination, the patient has no apparent acute or chronic medical condition which would contraindicate evaluation and treatment of present psychiatric symptoms and is therefore medically cleared. Arrangements made for bed placement at BHC. "

Health Care Team documented, "Psychiatry recommends: Admission on a forensic unit. Please keep on 1:1 monitoring until he can get to forensic unit. Continue Lexapro 5mg, trazodone 50mg (antidepressant) every day at bedtime."

On 09/01/2023, at 19:55 (7:55 PM), patient was discharged to a correctional facility.

During an interview on 11/02/2023, at 11:05, Staff D (MD, Chief Psychiatrist), stated, " I spoke to one of the Administrators at the Correctional Facility. They said, they will keep him on one to one until proper placement in Forensic Unit." Staff D stated, "I am not sure if they have a psychiatrist on staff." Staff D was unable to clarify who she spoke to at the Correctional facility. She said, "I cannot confirm her rank or title." Further, she said, "I only give recommendations. It is their responsibility to escalate or implement recommendations."

Review of the facility policy titled, "Emergency Department /Discharge Instructions" (Reviewed: 03/2019) revealed a procedure: "If forensic psychiatric placement is required for patient, the detention center will be contacted to assist with placement in a locked facility, or, patient may be discharged back to the detention center on constant observation if approved by discharging physician and the detention center."

Similar findings were observed in medical records for patients #21 and #23.

Patient #21: This patient is a 17-year-old male with a past medical history of attention deficit hyperactivity disorder and post-traumatic stress disorder. The patient arrived at ED on 06/27/2023 at 13:30 (1:30 PM) via EMS. The patient was triaged at 13:30 PM.
The provider's note dated 06/27/2023 at 13:38 stated that the patient reported that he tried to strangle himself this morning by wrapping a sweatshirt around his neck and pulled it. baseline rash on his face. At 14:30 the provider placed the patient in observation status for evaluation of suicidal ideation.

The patient was assessed by psychiatric ED on 06/27/23 at 18:41 (6:41 PM), and the provider states, "patient poses an imminent risk to self, and patient would likely benefit from inpatient forensic psychiatric hospitalization for safety disposition, symptom stabilization, and medication optimization, pending medical clearance ".

The patient was discharged on 06/27/2023 at 22:15 (10:15PM) to a correctional facility with discharge instructions of maintaining the patient on a 1:1 observation until they can find an inpatient forensic unit.


Patient #23: This patient is a 45-year-old male who arrived at the ED via EMS on 5/17/23 at 13:20 (1:20PM) brought in from correctional facility where it was reported that he attempted to hang himself using a shoelace and a bedsheet.

On 5/17/2023 at 17:47 (5:47 PM), the provider note states, "given the patient's risk, the patient appears to meet criteria for acute inpatient psychiatric hospitalization. Due to patient currently being incarcerated patient will need to be placed at a forensic psychiatric facility. Patient will be discharged to correctional facility with recommendation to be placed on 1-to-1."

At 19:50 (7:00 PM), ED provider placed a call to correctional facility watch commander informing him that the patient would be discharged on a 1:1 observation at all times and will need to be transferred to a psychiatric facility.

The patient was discharged on 5/17/2023 at 19:54 (7:54 PM) back to correctional facility.


On 11/02/2023, at 04:10PM, these findings were brought to the attention of Staff K (Chief Medical Officer), Staff I and J (Chief Psychiatrists), and other facility's administrative personnel.