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Based on record review and interview, the hospital failed to ensure compliance with the requirements of CFR 489.24 as evidenced by:

Failing to ensure an appropriate MSE (Medical Screening Examination) was performed that was appropriate to the patient's presenting signs and symptoms and failing to involve other QMP (Qualified Medical Personnel) available within the hospital's resources and services according to hospital policy for 1 of 1 (Patient #1) patient to determine whether a Psychiatric Emergency Condition existed out of a sample 24 Medical Records from the ED (Emergency Department) log. (See A-2406)

Failing to ensure an appropriate MSE (Medical Screening Examination) was performed that was appropriate to the patient's presenting signs and symptoms and failing to involve other QMP (Qualified Medical Personnel) available within the hospital's resources and services according to hospital policy for 1 of 1 (Patient #1) patient to determine whether a Psychiatric Emergency Condition existed out of a sample 24 Medical Records from the ED (Emergency Department) log.

Findings:

A review of the hospital policy titled "Psychiatric Services- Emergency Psychiatric Services", provided by S1ED/Dir, as the most current, revealed in part: Patients presenting to the Emergency Department (ED) with a psychiatric emergency will be evaluated, treated and stabilized in accordance with established hospital policy.

A review of the hospital policy titled "Management of the Mental Health Patient in the ED", provided by S1ED/Dir, as the most current, revealed in part: The triage nurse and/or the primary nurse in collaboration with the medical provider, to determine the patient's capacity to harm self and others, will interview patients presenting with behavior that is high risk for violence. Medical evaluations and mental health screenings will be completed through a collaborative effort of physicians, nurse practitioners, nurses and mental health specialists. Psychiatric Services Mental Health Specialists will screen patients and in collaboration with the Emergency Room (ER) physician, Psychiatrist on-call, and ER nursing staff will provide and coordinate patient care. The Psychiatric Services Mental Health Specialist will complete the psychiatric screening.

A review of Patient #1's EMS (Emergency Medical Service) (Ambulance Report) report revealed in part: The EMS provider's behavioral impression of Patient #1 was documented as a 51 year old male with a Behavioral Disorder with hallucinations and homicidal ideations. Documented on the ambulance report was "51 year old male presented seated on the sofa of his residence at arrival on scene. Pt (patient) contacted 911 approx (approximately) 15 to 20 min (minutes) prior to our arrival stating that he suffocated and murdered a baby. (Local Police Department) was present on scene stating that the res (residence) is clear and that no baby was found. Pt (patient) is awake, oriented at arrival stating that he thinks that he may have stated it, but isn't saying anything to incriminate himself. He stated that he will no longer be answering any questions or communicating for the duration of the trip. Pt was x-ported (transported) 10/5 (EMS code) and turned over to staff with verbal report given". Patient #1 was transported by ambulance to the hospital's ED and a verbal report was documented as being given to the triage nurse, S4RN/ED.
A review of Patient #1's ED medical record revealed in part: The patient arrived by ambulance on 04/03/15 at 9:53 a.m. and was triaged by S4RN/ED and included a brief "self harm assessment" (per hospital policy) with negative findings. The medical record revealed the chief complaint upon admit to the ED was "bizarre behavior". S4RN/ED's documentation in the triage section (under history) revealed in part: the patient claims he suffocated and killed a baby but the local police department could not locate a baby. S4RN/ED's documentation further revealed the patient had a history of substance abuse and schizophrenia, the patient initially refused to talk to ER (Emergency Room) staff upon his arrival to the hospital ED and the patient was uncommunicative and affect appears flat. On 04/03/15 at 9:59 a.m. the patient was seen by S2FNP/ED (Family Nurse Practitioner) in the ED and a MSE was performed. S2FNP/ED indicated in his ER notes that the patient was sent to the ER by police through EMS for (psychiatric) evaluation and the patient's chief complaint was "Depressed and Psychiatric Evaluation Requested". S2FNP/ED performed the MSE that included a psychiatric screening component. A further review of Patient #1's ED medical record revealed no documented evidence that a further collaborated psychiatric screening and/or evaluation was performed by the Psychiatric Services Mental Health Specialist or that an MD/ED (S3MD/ED) had seen the patient. A review of S2FNP/ED documented notes revealed the patient's "Clinical Impression", upon discharge on 04/03/15 at 10:02 a.m., was "Depression" and the patient's discharge instructions were to follow up with a physician in 3 days and/or return to the ED if the patient's condition worsens or changes unexpectantly. A review of Patient #1 ED medical record further revealed that S3MD/ED, electronically signed Patient #1's ED medical record on 04/04/15, and indicated that he reviewed S2FNP/ED notes and agreed with the findings and the discharge plan on Patient #1.
In an interview on 03/04/16 at 2:30 p.m. with S2FNP/ED, he indicated that he performed the MSE that included a psychiatric screening section and that he did not feel that a further psychiatric evaluation was warranted. S2FNP/ED indicated that he did not consult with a Psychiatric Services Mental Health Specialist or with S3MD/ED who was on duty in the ED that day. S2FNP/ED indicated that an MD/ED was not required to see all patients who presented to the ED and that a NP (Nurse Practitioner) could assess and discharge patients depending upon the patient's MSE and condition. S2FNP/ED indicated that all NPs who worked in the ED have collaborative agreements with all the ED physicians.
In an interview on 03/04/16 at 3:00 p.m. with S3MD/ED, he indicated that he did not see the patient in the ED that day (04/03/15) and further indicated that he reviewed S2FNP/ED notes on 04/04/15 and that he agreed with the findings, the MSE, and the discharge plan on Patient #1 by S2FNP/ED. S3MD/ED further indicated that he did not feel that a further psychiatric evaluation was warranted at that time. S3MD/ED indicated that the ED physicians did not have to see all patients who presented to the ED and that the NPs were experienced in ER care and could assess and discharge patients. S3MD/ED indicated that all NP medical records are reviewed by the ED physicians. S3MD/ED indicated that a patient presenting to the ED with a psychiatric complaint who was alert, oriented, and able to answer questions appropriately and who were not exhibiting any unusual behaviors would normally meet discharge criteria. S3MD/ED further indicated that if he had assessed Patient #1 he would have also discharged him.