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Based on hospital policy review, medical record review, physician and staff interviews the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

1. The hospital's Dedicated Emergency Department (DED) failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 29 sampled DED patients (#25) who presented to the DED for evaluation and treatment.

~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A2406.

2. The hospital's DED failed to provide further medical examination and treatment to stabilize a patient with an EMC for 1 of 29 sampled DED patients who presented to the DED for evaluation and treatment. (#18)

~ Cross refer to §489.24(d)(1-3) Stabilizing Treatment - Tag A2407.

3. The hospital's DED failed to provide an appropriate transfer for 1 of 29 sampled DED patients who presented to the DED for evaluation and treatment. (#18)

~ Cross refer to §489.24(e)(1)-(2) Appropriate Transfer - Tag A2409.

Based on policy review, medical record review, and physician interview, the hospital's Dedicated Emergency Department (DED) failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 29 sampled DED patients (#25) who presented to the DED for evaluation and treatment.

The findings include:

Review of a hospital policy titled [(Healthcare System Initials] Emergency Medical Treatment and Labor Act (EMTALA)", effective date 05/16/2018, revealed "Policy Statement...It is the intention of [Healthcare System Initials] to act in full compliance with federal EMTALA.....regulations in assessing the condition, treatment, stabilization, and, if appropriate, transfer of any such patient. Definitions....Emergency Medical Condition: Any medical condition manifested by acute symptoms.... of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in: -placing the health of the patient (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.... Labor : The process of childbirth beginning with the latent or early phase of labor and continuing through delivery of the placenta. A woman experiencing contractions is considered to be in labor unless a physician certifies that, after a reasonable time of observation, the woman is in false labor. A woman experiencing contractions is in true labor unless a physician, certified nurse-midwife, or other qualified medical person....certifies that, after a reasonable time of observation, the woman is in false labor. Medical Screening Examination [MSE]: A process of sufficient scope to conclude, with reasonable clinical confidence, whether an emergency medical condition does or does not exist and that utilizes necessary ancillary services that are routinely available to the hospital. ..."

Medical record review on 09/02/2020 revealed Patient #25, a 21-year-old female arrived to the Hospital's DED on 06/28/2020 at 1115 via private vehicle with a chief complaint of "Vaginal Bleeding-Pregnant". Review of the Vital Signs taken at 1117 revealed "Temp [temperature]: 36.8°C [Celsius, 98.2°Fahrenheit] Heart Rate: 100 Resp [respirations]: 18 BP [blood pressure]: 115/62 SpO2 [oxygen saturation percent]: 98%, Pain: 8 [on a pain scale of 0-10 with 10 being the worst pain] Pain Type: Acute pain Pain Loc [location]: Abdomen Pain Descriptors: Cramping Pain Frequency: Intermittent Pain Onset: Gradual Clinical Progression: Gradually worsening ..." Review of the triage notes performed at 1123 revealed "Pt [patient] from home, sts [states] she is 25 wks [weeks] pregnant, cramping and spotting started apx [approximately] 5 am today, last OB visit in April was normal". The patient was triaged as an "ESI of 3, Stable". Review revealed a MSE was performed at 1126. Review of the MD note at 1126 revealed Patient #25 was "G [Gravida] 1 P [Para] 0 ... 25 weeks pregnant reports lower abdominal cramping and vaginal bleeding this morning.... states she did feel her baby will remove this morning [sic]. She is receiving OB care in [name of a town] and plans to deliver at [Name of Hospital]. She was visiting family in [name of town] today ... Gastrointestinal: Negative for abdominal pain ... Genitourinary: Positive for vaginal bleeding and vaginal discharge. Negative for dysuria and flank pain. Musculoskeletal: Negative for back pain ... Physical Exam ... Exam conducted with a chaperone present ... Abdominal: ...Palpations: Abdomen is soft. Tenderness: There is no abdominal tenderness (suprapubic). There is no guarding ... Number of Diagnoses or Management Options Oligohydramnios [low level of amniotic fluid surrounding the baby during pregnancy] in second trimester, single or unspecified fetus: new and requires workup .... Urinary tract infection without hematuria, site unspecified: new and requires workup ....Vaginal bleeding in pregnancy, second trimester; new and requires workup. ... Diagnosis management comments: Good fetal heart tone and movement with closed eyes per ultrasound tech. Patient has oligohydramnios. We will treat UTI [urinary tract infection] with Macrobid [antibiotic]. OB/GYN follow-up for oligohydramnios recommended. ED return precautions were discussed in detail, the patient will return for any concerning, new, or worsening symptoms. ..." Review of the US [Ultrasound] OB performed 06/28/2020 at 1155 revealed "NUMBER FETUSES: One FETAL HEART RATE: 153 beats per minute. FETAL POSITION: Cephalic AMNIOTIC FLUID VOLUME: Oligohydramnios, total fluid 4.05 cm [centimeters] ... CERVICAL LENGTH: 3 cm ... Impression: 1. Oligohydramnios 2. Single live intrauterine gestation with best estimate of gestational age 24 weeks and 3 days and fetal heart rate of 153 beats per minute. Cephalic presentation ... 3. No emergent placental abnormality. ..." Review of the eMAR revealed Patient #25 was given nitrofurantoin [Macrobid] 100 mg capsule at 1232. Review of the ED Pain Assessment/Reassessment at 1235 revealed a pain score of "4" and identified as "Acute Pain". Review of the After-Visit Summary dated 06/28/2020 at 1251 revealed "... Reason for Visit: Vaginal Bleeding: Pregnant Diagnoses: *Vaginal bleeding in pregnancy, second trimester *Urinary tract infection without hematuria, site unspecified *Oligohydramnios in second trimester, single or unspecified fetus. ..."

DED record review revealed Patient #25 returned to the DED on 06/28/2020 at 2228 [9 hours, 28 minutes after discharge]. Review of the ED Provider note at 2238 revealed "... Initial Clinical Impression: 1. Active preterm labor... ." Further Provider Note review revealed "...Plan for transfer to [Hospital B] for further management of active preterm labor..." and revealed Patient #25 was transferred to Hospital B via Emergency Medical Services (EMS) on 06/29/2020 at 0015.

Review of Hospital B's medical record revealed Patient #25 arrived on 06/29/2020 at 0026 and delivered at 0540.

Interview with MD (Medical Doctor) #1 on 09/03/2020 at 1330 revealed the MD remembered Patient #25. Interview revealed Patient #25 arrived with lower vaginal pain. Interview revealed the pelvic ultrasound showed a long cervix and live baby. Interview revealed MD #1 probably did a pelvic exam and would have looked for pooling of fluid and fetal parts. Interview revealed it was not documented. Interview revealed "the standard of care would be to get ultrasound first". Interview revealed MD #1 remembered Patient #25 was not having rhythmic pain and not in labor when she saw her. Interview revealed Patient #25 did not have any bleeding when seen in the ED. Interview revealed Patient #25 "did not have an emergency. She had oligohydramnios." Interview revealed MD #1 has "seen many people in labor, she had nothing rhythmic or close together while in the DED on the first visit. Interview revealed MD #1 was told by the ultrasound tech the cervix was 3 cm and the os [opening in center of cervix] was closed. Interview revealed MD #1 thought she did a thorough MSE and if she had thought Patient #25 was in labor, she would have transferred her. Interview revealed a UTI is one of the number one causes of preterm labor. Interview revealed MD #1 did not feel like Patient #25 was in labor and treated her for a UTI.

Review revealed Patient #25 was discharged home ambulatory with family at 1300. DED Record review did not reveal an explanation for the patient's intermitten cramping abdominal pain and did not reveal a determination that Patient #25 was not in labor. DED record review did not reveal documentation of consultation or consideration of contacting an obstetrician.

Based on policy review, medical record review and physician and staff interview, the hospital Dedicated Emergency Department (DED) failed to provide further medical examination and treatment to stabilize an Emergency Medical Condition (EMC) for 1 of 29 sampled DED patients who presented to the DED for evaluation and treatment. (#18)

The findings include:

Review of a hospital policy titled "[Healthcare System Initials] Emergency Medical Treatment and Labor Act (EMTALA)", effective date 05/16/2018, revealed "Policy Statement...It is the intention of [Healthcare System Initials] to act in full compliance with federal EMTALA.....regulations in assessing the condition, treatment, stabilization, and, if appropriate, transfer of any such patient. Procedure: .... Provision of Stabilizing Treatment for Transfer ...If an emergency medical condition is determined to exist, the Dedicated Emergency Department of the ....Hospital shall provide such treatment within its capabilities as is necessary to stabilize the individual, or shall arrange an appropriate transfer... ."

Review of a closed DED medical record on 09/02/2020 for Patient #18 revealed a 16-year old female transitioning to male who presented to Hospital A's DED via private vehicle on 07/02/2020 at 1928 with a chief complaint of suicide attempt by cutting earlier that day. Review of triage vital signs documented at 1930 revealed a temperature [T] of 97.5 degrees Fahrenheit; pulse [P] 63; respirations [R] 16; blood pressure [BP] 109/74; oxygen saturation of 99 %, pain assessment indicated "denies", and the Richmond agitation Sedation Scale indicate Patient #18 was "alert and calm." Review of an ED Triage Note dated 07/02/2020 at 1934 revealed, "Patient presents to ED today after self-inflicting cuts to LUE [left upper extremity] around 1300 today ...States that he did this because he wanted to kill himself and that he has felt this way for a long time ..." Review of the DED record revealed at 1939 a "Suicide Risk Rating Scale" and "Housing Screening" were completed. Patient #18's "Suicide Rating Score" was "Moderate-High Risk," and an "Initiate Petition for Commitment" order was entered by a physician, MD (Medical Doctor) #13. Patient #18 was assigned an Emergency Severity Index [ESI] of 2 [on a scale of 1-5 with 1 being the most severe] at 1940, assigned to room ED 14 at 1950, and at 1951 orders for laboratory studies, suicide precautions, and initiation of a petition for commitment were acknowledged by RN (Registered Nurse) #10. An attending physician, MD #11, was assigned to Patient #18 at 2003, and a note at 2004 indicated, " ...self inflicted laceration LUE sustained at 1300 today with the intent to ultimately self-harm commit suicide. He notes he cut himself in the L [left] arm in an attempt 'to get up the courage to kill himself'." At 2009 laboratory studies were collected and orders for consults to Psychiatry and Case Management were entered and acknowledged by RN #10. Review revealed at 2039, an order was placed to allow Patient #18 to keep his chest binder, results from laboratory studies began to become available at 2041 and Dermabond® was ordered for repair of the "superficial" left upper arm wound. At 2044 MD #11 placed an order that "Mom may stay as long as no obvious escalation during interactions (interactions have been calm/supportive thus far it appears)." Review of an "ED Provider note" completed by MD #11 at 2050 revealed, "Will repair superficial laceration and plan to medically clear. Labs ordered. Will IVC (involuntary commitment). Sitter at bedside." Review of the DED record revealed the urine toxicology screen was positive for benzodiazepine and tetrahydrocannabinol. Review revealed orders entered by MD #11 at 2222 for "Aripiprazole tablet 5 mg (milligrams); Nursing: DC home for Mom to take patient directly to [Facility C]." Review revealed an after-visit summary (AVS) was printed at 2228. Review of ED Notes at 2250 by RN # 10 revealed, "Discharge instructions and follow up care reviewed patient and mother. Emphasized the importance of them reporting directly to [Facility C] as discussed with therapist and [MD #11] ...Also stated that if he is unable to be seen at [Facility C] to return to the emergency department for observation and monitoring ..." Review revealed after obtaining discharge vital signs, Patient #18 was listed as discharged from the DED on 07/02/2020 at 2258. Record review did not reveal documentation that an IVC hearing was initiated at Hospital A. Record review did not reveal any documentation of additional stabilizing treatment or that a transfer to a facility with psychiatric services was initiated or considered for Patient #18 and did not reveal an accepting facility for Patient #18.

Review of Facility C's website revealed "[Facility] will provide emergency psychiatric evaluations for those individuals experiencing acute mental health and/or substance abuse crises ... [Facility] is an outpatient clinic that provides behavioral health and substance abuse walk-in services including crisis screening, assessment, intervention and stabilization."

Review of Patient #18's medical record received from Facility C on 09/11/2020 revealed he arrived at Facility C voluntarily on 07/02/2020 at 2334 accompanied by a parent and was placed in a room at 2350. Review revealed Patient #18 scored as "High Risk" on the initial Columbia Suicide Severity Rating on 07/03/2020 at 0101 and 1 to 1 observation with a sitter at the bedside was initiated. Patient #18 was evaluated in triage by a PhD Psychologist on 07/03/2020 at 0112 who noted, "He is admitting to feeling actively suicidal, that this was a suicide attempt, and is cooperative with the assessment process," and "psychiatric hospitalization" was discussed. Record review revealed Patient #18 was transported to an inpatient behavioral health hospital, Hospital D, on 07/04/2020 at 1347.

Interview on 09/02/2020 at 1400 with RN #10 revealed she was the nurse assigned to Patient #18 after he presented to the DED at Hospital A on 07/02/2020. Interview revealed Patient #18 "was close with his mom" and RN #10 recalled an outpatient psychiatrist had sent him to the ED. RN #10 recalled the parent and the psychiatrist "were in communication," during the ED visit and "at discharge the mom had agreed to take him to [Facility C], and return immediately if no room was available ...I went over the discharge instructions."

Telephone interview on 09/03/2020 at 1026 with MD #11 revealed he had been Patient #18's physician in the ED. Interview revealed he had reviewed Patient #18's record and "vaguely recalls" the patient but did not currently have access to records. Interview revealed "I think I forgot to update the charting ...don't remember the child was an imminent risk to himself. He was calm and cooperative," and MD #11 had spoken with both the parent and "a therapist," name unknown, about "the best course of action." Interview revealed "there was some discussion about EMS [emergency medical services] transport and since the patient was not IVC'able, I don't know if that was feasible." Interview revealed MD #11 "vaguely remembered that they called and said, 'we're here'," and thought the ED charge nurse may have received the incoming call.

In summary, Patient #18 arrived to the hospital's DED after a suicide attempt seeking emergency care and treatment. A MSE was performed and the patient was medically cleared and determined to need psychiatric care. The patient was held in the ED with a one to one sitter. There was indication in the medical record that an IVC was to be placed. The patient was discharged in the care of a parent to go to Facility C for psychiatric care. Record review did not indicate why a patient with moderate to high suicide risk on screening was allowed to be discharged rather that be transferred via an appropriate transport agency for patient safety. The record review did not show that the patient was accepted to the facility. The patient was discharged without patient transfer and or stabilizing treatment for a psychiatric condition which may have caused a delay in appropriate stabilizing treatment.

Based on policy review, medical record review and physician and staff interviews the hospital's Dedicated Emergency Department (DED) failed to provide an appropriate transfer for 1 of 29 sampled patients who presented to the DED for evaluation and treatment. (#18)

The findings include:

Review of a hospital policy titled "[Healthcare System Initials] Emergency Medical Treatment and Labor Act (EMTALA)", effective date 05/16/2018, revealed "Policy Statement...It is the intention of [Healthcare System Initials] to act in full compliance with federal EMTALA.....regulations in assessing the condition, treatment, stabilization, and, if appropriate, transfer of any such patient. Procedure: .... Transfer of Unstable Patient ....If a patient's medical condition has not been stabilized, the...Hospital shall not transfer him or her to another facility unless: - the patient (or a legally responsible person acting on the patient's behalf), after being informed of the ....Hospital's obligation and of the risk of transfer, requests transfer to another facility in writing....or- a physician....has signed a certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of medical treatment at another medical facility outweigh the increased risks to the patient....from effecting the transfer. ..."

Review of a closed DED medical record on 09/02/2020 for Patient #18 revealed a 16-year old female transitioning to male who presented to Hospital A's DED via private vehicle on 07/02/2020 at 1928 with a chief complaint of suicide attempt by cutting earlier that day. Review of triage vital signs documented at 1930 revealed a temperature [T] of 97.5 degrees Fahrenheit; pulse [P] 63; respirations [R] 16; blood pressure [BP] 109/74; oxygen saturation of 99 %, pain assessment indicated "denies", and the Richmond agitation Sedation Scale indicate Patient #18 was "alert and calm." Review of an ED Triage Note dated 07/02/2020 at 1934 revealed, "Patient presents to ED today after self-inflicting cuts to LUE [left upper extremity] around 1300 today ...States that he did this because he wanted to kill himself and that he has felt this way for a long time ..." Review of the DED record revealed at 1939 a "Suicide Risk Rating Scale" and "Housing Screening" were completed. Patient #18's "Suicide Rating Score" was "Moderate-High Risk," and an "Initiate Petition for Commitment" order was entered by a physician, MD #13. Patient #18 was assigned an Emergency Severity Index [ESI] of 2 at 1940. Review of the physician note, at 2004 indicated, " ...self inflicted laceration LUE sustained at 1300 today with the intent to ultimately self-harm commit suicide. He notes he cut himself in the L arm in an attempt to 'to get up the courage to kill himself'." Review revealed Dermabond® was ordered for repair of the "superficial" left upper arm wound. Review revealed orders at 2222 for "Aripiprazole tablet 5 mg; Nursing: DC home for Mom to take patient directly to [Facility C]." Review of ED Notes at 2250 by RN # 10 revealed, "Discharge instructions and follow up care reviewed patient and mother. Emphasized the importance of them reporting directly to [Facility C] as discussed with therapist and [MD #11] ...Also stated that if he is unable to be seen at [Facility C] to return to the emergency department for observation and monitoring ..." Review revealed after obtaining discharge vital signs, Patient #18 was listed as discharged from the DED on 07/02/2020 at 2258. Record review failed to reveal a transfer was considered to a facility with psychiatric services for Patient #18.

Review of Patient #18's medical record received from Facility C on 09/11/2020 revealed the patient arrived at Facility C voluntarily on 07/02/2020 at 2334 accompanied by a parent and was placed in a room at 2350. Review revealed Patient #18 scored as "High Risk" on the initial Columbia Suicide Severity Rating on 07/03/2020 at 0101 and 1 to 1 observation with a sitter at the bedside was initiated. Patient #18 was evaluated in triage by a PhD Psychologist on 07/03/2020 at 0112 who noted, "He is admitting to feeling actively suicidal, that this was a suicide attempt, and is cooperative with the assessment process," and "psychiatric hospitalization" was discussed. Record review revealed Patient #18 was transported to an inpatient behavioral health hospital, Hospital D, on 07/04/2020 at 1347.

Interview on 09/02/2020 at 1400 with RN #10 revealed she was the nurse assigned to Patient #18 after he presented to the DED at Hospital A on 07/02/2020. Interview revealed Patient #18 "was close with his mom" and RN #10 recalled an outpatient psychiatrist had sent him to the ED. RN #10 recalled the parent and the psychiatrist "were in communication," during the ED visit and "at discharge the mom had agreed to take him to [Facility C], and return immediately if no room was available ...I went over the discharge instructions."

Telephone interview on 09/03/2020 at 1026 with MD #11 revealed he had been Patient #18's physician in the ED. Interview revealed he had reviewed Patient #18's record and "vaguely recalls" the patient but did not currently have access to records. Interview revealed "I think I forgot to update the charting ...don't remember the child was an imminent risk to himself. He was calm and cooperative," and MD #11 had spoken with both the parent and "a therapist," name unknown, about "the best course of action." Interview revealed "there was some discussion about EMS (emergency medical services) transport and since the patient was not IVC'able, I don't know if that was feasible." Interview revealed MD #11 "vaguely remembered that they called and said, 'we're here'," and thought the ED charge nurse may have received the incoming call.

In summary, Patient #18 presented with a suicide attempt, had a medical screening examination and was determined to need psychiatric care. The patient was discharged from the DED in the company of a parent to travel by private vehicle when he needed stabilizing treatment and appropriate transfer. There was no indication in the record of an accepting physician or facility or of medical records being sent. The patient was noted to be given discharge instructions but not that a copy of the medical record was provided for the receiving facility.