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Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24. This affected 2 of 8 sampled patients (Patient #10 and Patient #7).

Findings included:

The hospital failed to ensure a complete medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 2 of 8 sampled patients (Patient #10 and Patient #7).

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

Based on policy and procedure review, medical record review, hospital data review and staff and physician interviews the hospital failed to ensure a complete medical screening examination was provided within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 2 of 8 sampled patients, (Patient #10 and Patient #7).

The findings included:

Review of the "EMTALA (Emergency Medical Treatment and Labor Act) - Medical Screening" effective 02/2021, revealed " PROCEDURE: A. When a Medical Screening Examination Is Required: 1. A person presents on their own. If an individual arrives at the hospital and is not technically in the emergency department, but on Hospital Property or Premises (as defined under this policy) and requests emergency care, he or she must receive a medical screening examination within the capabilities of the facility. 2. A person presents in a ground or air ambulance owned and operated by the hospital. 3. A person present in a Non hospital owned ambulance ... a. An individual in a non-hospital owned ambulance that is on hospital property is considered to have come to the hospital's emergency department ... C. Medical Screening Examination: 1. A medical screening examination will be provided when an individual comes by him/herself or with another person to the emergency department of the hospital, and a request is made on the individual's behalf for a medical examination or treatment. 2. The hospital will provide a medical screening examination by licensed qualified medical personnel to determine whether an emergency medical condition exists, or with respect to a pregnant woman having contractions, whether the woman is in labor. 3. A medical screening examination will be provided within the capability of the hospital's emergency department or with respect to a pregnant woman having contractions, .... including ancillary services routinely available to the emergency department. "

1. Review of a closed DED medial record on 10/26/2021 for Patient #10 revealed a 15- year-old female that presented to facility A's DED on 09/28/2021 at 1146 with a chief complaint of suicidal. Review of Chief Complaint Details Behavioral Health at 1147 revealed "Chief Complaint Details; Onset: Today; Chronicity: New; Observation of current behavior/appearance: Cooperative; Status: Voluntary; Accompanied by family." Review of the Screening Flowsheet at 1148 revealed "Suicide Risk: Is Patient at risk for suicide?: Yes; Suicide Risk Assessment: Attempted suicide within last 30 days?: No; Substance abuse history or abuse within last 30 days?: No; Attempting or threatening suicide/self harm?: Yes; Expressing suicidal/self harm thoughts without intent?: Yes; Recent evidence of psychiatric disorder?: Yes; Response to question indicating hopelessness?: Yes;" Review revealed at 1149 Patient #10 was assigned an ESI acuity of 2 (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute). Review revealed Patient #10 was roomed in the Emergency Department (ED) at 1150. Review of the Vital Signs at 1153 revealed "BP (blood pressure): 108/68; Temp (Temperature): 98.4 F (degrees Fahrenheit); Temp source: Oral; Pulse: 66; Resp (respirations): 18; SpO2 (oxygen saturation): 99%;." Review of the ED Provider Note dated 09/28/2021 at 1204 revealed "(Patient #10) is a 15 y.o. (year-old) female who presents to the emergency department for psychiatric evaluation. She has a history of depression. Was previously on Lexapro and was having worsening symptoms was just switched to Prozac. She had trigger at school today when a classmate was making fun of suicide. She became acutely worse. She states she wants to kill herself, wants to overdose on drugs ... Past Medical History: Depression ... Review of Systems ... Psychiatric: + (positive) suicidal ideation ... ED Course and Medical Decision Making: 15-year-old female with history depression presents with acutely worsening symptoms. Had a trigger at school today. Also has recently had a medication change from Lexapro to Prozac. She makes good eye contact but family is with her and there was obvious concerns patient's depression has significantly worsened to the point hours (sic) she has a plan of overdosing on drugs to kill herself. She will be placed on involuntary commitment papers."

Review of the Providers Orders dated 09/28/2021 at 1206 revealed an order "ED consult to Psychiatry; ... Who did you contact? Psychiatry; Reason for consult: suicidal ideation." Review of the Providers Orders revealed at 1206 orders for "Mental Health Assessment Order: BHH (behavioral health hospital) Nurse Performed Psychiatric Assessment: and Pysch (sic) Nursing Assessment Order: Nurse performed psychiatric screening." Review revealed at 1207 "ED Disposition set to Transfer to Outside Mental Health Facility." Review of the Involuntary Commitment (IVC) at 1211 revealed paperwork was initiated and faxed to the clerk of court for IVC for Patient #10. Patient #10 was transferred from the room in the ED to a BHO (behavioral health observation) room at 1236. Review of the "Urine Drug Screen" resulted at 1259 revealed a "Negative" for all drugs tested for in the urine. Review of the Nursing Assessment at 1507 revealed "Psychosocial: Patient Behaviors: Appropriate for age; Labile mood; Quiet; Suicidal; Cooperative; Calm. ... Family Behaviors: Appropriate for situation, Cooperative; Calm; Supportive." Review of the Involuntary Commitment (IVC) at 1453 revealed "Findings and Custody Served: Yes ..." Review of the ED Time Line at 1928 revealed "Team Member Assigned: ... Placement Specialist assigned ..." Review of the ED Notes dated 09/29/2021 at 0613 by PS #8 revealed "Pt has been accepted to Lighthouse ... Pt has mom has been informed." (sic) Review of the Nursing Assessment Flowsheet at 0800 revealed "Psychosocial: Affect: Appropriate to circumstances ... Speech Pattern: Appropriate or WNL (within normal limits); General Attitude: Cooperative; Pleasant; ... Thought Process: Coherency: Organized; Content: Unremarkable; Delusions: Controlled; Hallucinations: None; Judgement: Improved; ... Safety: Self Injurious Thoughts: Without plan for self injurious (sic) actions; Self Injurious Behaviors: None observed; Thoughts of Harming Others: Denies; Harmful Actions Toward Others: None observed." Review of the Mental Health Assessment Presentation/Disposition dated 09/29/2021 at 0800 revealed "Psychiatric Assessment: Complete; Psychiatrist Patient Presented To: (Provider #2's name)." Review of the EMTALA Transfer Form dated 09/29/2021 at 0856 revealed "Provider to Complete: Patient Condition: Patient Stable; Reason for Transfer: Medically Indicated; Benefits of Transfer: Obtain level of care/service not available at this facility; Risks of Transfer: Motion Sickness; Mode of Transportation: BLS (basic life support); Treatment during Transport: None; ... Accepting Facility: Lighthouse; ... Date Accepted: 09/29/2021; Time Accepted: 0857; ... MD Certification: Patient examined and risks explained." Review of the Vital Signs at 0901 revealed "Temp: 98.4 F; Temp Source: Oral; Heart Rate: 94; Resp: 20; SpO2 100% ; BP: 104/57." Review of the Progress Note date 09/29/2021 at 0936 revealed "ED MSW (social worker) met with pt's mother to provide information, emotional support. Pt's mother expressing concern that pt had not been seen by a psychiatrist while in the BHU, pt being transferred out of state to a facility. Discussed the IVC process with pt's mother, linked her with the nursing coordinator to further process her concerns." Review revealed Patient #10 was discharged on 09/29/2021 at 1200.

Review of Facility B's closed medial record on 11/15/2021 for Patient #10 revealed a 15- year-old female that was admitted to Facility B on 09/29/2021 at 1200 for "suicidal ideation with a plan to overdose." Review of "High Risk Notification Alert" form dated 09/29/2021 signed at 1539 revealed "Admission Date: 09/29/2021; Time: 1200; ... VOL (voluntary) [circled] / INV (involuntary) ...?'d (changed) to INV ..." Review of the History and Physical dated 09/30/2021 with a signed time of 1023 revealed "Chief Complaint/Nature of Presenting problem: MDD (major depressive disorder) ..." Review of the "INITIAL EVALUATION OF RISK TO SELF/OTHERS" form revealed no "INFORMANT" was identified and it was hand written in "Patient having suicidal thoughts with plan to overdose on pills."

Interview on 10/27/2021 at 1340 with Director #1 revealed it is the Provider's responsibility to put in a consult order and if a consult provider sees a patient there should be a note. Continued interview at 1600 revealed a referral to
"Psych consult" goes to a team that consist of a Patient Placement Specialist or a Social Worker (SW). Interview revealed the Patient Specialist or SW will review the medical record and determine what the patient needs. Interview revealed the "goal is to get the patient to the appropriate level of care, sometimes that is admission to inpatient facility and sometimes that is to a provider."

Interview on 10/28/2021 at 1018 with Medical Doctor (MD) #3, MD #4, and Administrator #5 revealed the ED Provider evaluates the patient and can make the determination if the patient needs to be admitted. Interview revealed when the ED Provider saw the patient and places them on IVC (involuntary commitment), they (ED Provider) thinks the patient needs inpatient care. Interview revealed the process is for the ED Provider to see the patient first, then an order for Psych consult is placed. Interview revealed the order for Psych consult goes to the team that consist of the Patient Placement Specialist and in some cases a psychiatrist could be involved. Interview revealed the order is a "cue" to begin immediately finding placement to where the patient can be seen and an evaluation performed as soon as possible. Interview revealed the hospital has a Psych provider in the ED during 0800 to 1700 hours, and that provider "gets to folks as they can and as fast as can." Interview revealed after 1700 there is not a Psych provider on call for the ED. Interview revealed the Psych provider listed on the on-call list is for the Behavioral Health Hospital only and the Telepsych is used for the medical floors. Interview revealed "the numbers are overwhelming" for new consults and if the patient is IVC'd the determination for inpatient need has already been determined. Interview revealed the "Psych Provider is not involved in the evaluation of the patient nor in the process of finding treatment for the patient." Interview revealed the Psych consult "may be to manage the medication" used to treat the psychiatric patient until placement can be found. Interview revealed the hospital bylaws says that a consulting provider has twenty-four hours to see the patient if possible and if cannot see the patient within twenty-four hours the consulting provider is to have a conversation with the ordering ED Provider. Interview revealed "the expectation is that the consult order is placed but not necessarily expected to be seen by psych if a facility that can evaluate the patient sooner can be found." Interview revealed IVC patients may be "medically stable" however "not necessarily psychiatrically stable."

Interview on 10/28/2021 at 1402 with MD # 2 revealed he remembered Patient #10. Interview revealed MD #2 did not see Patient #10 formally as a consult. Interview revealed MD #2 remembers seeing Patient #10 outside the ambulance bay. Interview revealed it is "impossible for every psychiatric patient to be seen by psych." Interview revealed if the patient is being IVC'd, don't want to lose a bed waiting for psych to evaluate the patient so the patient is sent on to the accepting facility. Interview revealed MD #2 did not see Patient #10. Interview revealed MD #2 was not aware the provider order for consult to Psych was documented "completed" under his name in Patient #10's electronic medical record.

Interview on 10/28/2021 at 1429 with MD #6 revealed "Psych has twenty-four hours to see the patient unless contacted by the provider to come right now." Interview revealed "the ED provider has the ability to have inpatient services and has to place the order." Interview revealed "per the bylaws, Psych has to cover on call after hours (after 5 pm)" and the providers are aware. Interview revealed "every psych patient doesn't need to see a psychiatrist." Interview revealed if the ED physician consults psych and then contacts the psych provider and says no longer needs the consult, that is "up to the individual provider to make that determination."

Interview on 10/28/2021 at 1552 with DO #7 revealed he remembered Patient #10. Interview revealed Patient #10 presented "expressing suicidal ideation and a plan to overdose on drugs." Interview revealed Patient #10's mom was concerned as she brought Patient #10 to the hospital. Interview revealed DO #7 took Patient #10 "seriously" and "went straight to IVC." Interview revealed DO #7 ordered the psych consult in case it took a long time to get Patient #10 accepted at another facility. Interview revealed DO #7 expected psych to see Patient #10 if she was "there an extended time." Interview revealed an "extended time" was clarified as more than three days. Interview revealed DO #7 was not sure if Patient #10's mom was aware Patient #10 was being IVC'd. Interview revealed "it is implied (being IVC'd and admitted) when you bring them (psychiatric patient) in." Interview revealed Patient #10 "was very receptive to the care."

Telephone interview on 10/28/2021 at 1700 with Placement Specialist (PS) #8 revealed she did not remember Patient #10. Interview revealed if a patient comes in suicidal or for a psychiatric evaluation, the ED provider clears the patient medically and then sends them to the BHU (behavioral health unit in the ED). Interview revealed the PS #8 automatically sends the patient out if the patient volumes are high. Interview revealed "only refer out if adolescent and if they suicidal or homicidal." Interview revealed PS #8 may not have to communicate with the psychiatrist about the patient. Interview revealed there "may not have (sic) a psychiatrist in the ED or at night." Interview revealed the ED does "not have tele psych past 6 pm" and does "not have it at night." Interview revealed PS #8 reads the ED providers note, and if the patient's parent is there will talk with them and tell the family what is going on.

A psychiatric evaluation was not done. The Patient #10 was transferred to an out of state hospital for evaluation and admission. This caused the delay in completion of the medical screening exam as well as delay in stabilizing treatment.


2. Review of a closed DED medial record on 10/27/2021 for Patient #7 revealed a 41- year-old female that presented to the DED on 09/28/2021 at 1236 with a chief complaint of "suicidal." Review revealed Patient #7 was roomed in the ED at 1236. Review of the Screening Assessments performed at 1241 revealed " ... 1. Have you wished you were dead or wished you could go to sleep and not wake up? (ALWAYS answer this question): Yes; 2. Have you actually had any thoughts of killing yourself? (ALWAYS answer this question): Yes; 3. Have you been thinking about how you might do this?: Yes; 4. Have you had these thoughts and had some intention of acting on them?: Yes; 5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?: Yes; 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? (ALWAYS answer this question): Yes; 7. Was this within the past 3 months?: No; Suicide Risk Level: High Risk ... Danger to Others: No ..." Review revealed at 1242 Patient #7 was assigned an ESI acuity of 2 (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute). Review of the ED Timeline revealed Patient #7 was transferred from the Main ED room to a room in the BHO unit at 1251. Review of the ED Provider Note dated 09/28/2021 at 1303 revealed " ... presents to the emergency department for psychiatric evaluation. She has a history of depression. Her husband has been lowering her medication doses at home and she feels like her symptoms of depression and suicidal ideation are worsening. She now feels like she wants to 'walk into traffic.' She reports her husband has been reducing her dose of fluphenazine (antipsychotic medication) ... Review of Systems: ... Psychiatric: Denies depression, suicidal ideation or homicidal ideation ... ED Course and Medical Decision Making: ... 41-year-old female who presents for psychiatric evaluation. She has good insight into her problems. Suspect likely related to decreasing the dose of her medication at home. She is having thoughts of wanting to harm herself but she is here voluntarily and wants to get treatment. May benefit just from increasing her medications again. Will place psychiatry consult ..." Review of the Providers Orders dated 09/28/2021 at 1301, revealed an order "ED consult to Psychiatry; ... Who did you contact? Psychiatry; Reason for consult: worsening depression, medication change." Review of the Providers Orders revealed at 1301 orders for "Mental Health Assessment Order: BHH (behavioral health hospital) Nurse Performed Psychiatric Assessment" and "Pysch (sic) Nursing Assessment Order: Nurse performed psychiatric screening." Review revealed the ED Disposition was set to "Admit to BHH" at 1303 ..." Review of the ED Time Line at 1928 revealed "Team Member Assigned: ... Placement Specialist assigned ..." Review of the Behavioral Health Transfers dated 09/29/2021 at 0017 revealed "Disposition for Transfers; Date Accepted: 09/29/2021; Time Accepted: 0017; ... Transferred to : Brynn Marr Hospital ... " Review of the Involuntary Commitment (IVC) at 0423 revealed paperwork was initiated and faxed to the Magistrate for IVC for Patient #7." Review revealed the SARS-COV-2 XPRESS PCR (Covid test) resulted a negative result at 0500. Review of the Involuntary Commitment (IVC) at 0539 revealed "Findings and Custody Served: Yes ..." Review of the Vital Signs at 0742 revealed "BP (blood pressure): 104/73; Temp (Temperature): 98.1 F (degrees Fahrenheit); Temp source: Oral; Pulse: 74; Resp (respirations): 21; SpO2 (oxygen saturation): 100%." Review revealed the ED Dispositions was set to "Transfer to Outside Mental Health Facility" on 09/29/2021 at 0913. Review of the EMTALA Transfer Form dated 09/29/2021 at 0913 revealed "Provider to Complete: Patient Condition: Patient Stable; Reason for Transfer: Medically Indicated; Benefits of Transfer: Obtain level of care/service not available at this facility; Risks of Transfer: Motion Sickness; Mode of Transportation: Law Enforcement; Treatment during Transport: None; ... Accepting Facility: Brynn Marr; ... Date Accepted: 09/29/2021; Time Accepted: 0913; ... MD Certification: Patient examined and risks explained." Review of the Vital Signs at 0922 revealed "Temp: 98.1 F; Temp Source: Oral; Heart Rate: 73; Resp: 16; SpO2 100% ; BP: 125/83." Review of the ED Notes at 0926 revealed "Pt escorted by hospital police out of facility." Review revealed Patient #7 was discharged on 09/29/2021 at 0947.

Interview on 10/27/2021 at 1340 with Director #1 revealed it is the Provider's responsibility to put in a consult order and if a consult provider sees a patient there should be a note. Continued interview at 1600 revealed a referral to
"Psych consult" goes to a team that consist of a Patient Placement Specialist or a Social Worker (SW). Interview revealed the Patient Specialist or SW will review the medical record and determine what the patient needs. Interview revealed the "goal is to get the patient to the appropriate level of care, sometimes that is admission to inpatient facility and sometimes that is to a provider."

Interview on 10/28/2021 at 1018 with Medical Doctor (MD) #3, MD #4, and Administrator #5 revealed the ED Provider evaluates the patient and can make the determination if the patient needs to be admitted. Interview revealed when the ED Provider saw the patient and places them on IVC (involuntary commitment), they (ED Provider) thinks the patient needs inpatient care. Interview revealed the process is for the ED Provider to see the patient first, then an order for Psych consult is placed. Interview revealed the order for Psych consult goes to the team that consist of the Patient Placement Specialist and in some cases a psychiatrist could be involved. Interview revealed the order is a "cue" to begin immediately finding placement to where the patient can be seen and an evaluation performed as soon as possible. Interview revealed the hospital has a Psych provider in the ED during 0800 to 1700 hours, and that provider "gets to folks as they can and as fast as can." Interview revealed after 1700 there is not a Psych provider on call for the ED. Interview revealed the Psych provider listed on the on-call list is for the Behavioral Health Hospital only and the Telepsych is used for the medical floors. Interview revealed "the numbers are overwhelming" for new consults and if the patient is IVC'd the determination for inpatient need has already been determined. Interview revealed the "Psych Provider is not involved in the evaluation of the patient nor in the process of finding treatment for the patient." Interview revealed the Psych consult "may be to manage the medication" used to treat the psychiatric patient until placement can be found. Interview revealed the hospital bylaws says that a consulting provider has twenty-four hours to see the patient if possible and if cannot see the patient within twenty-four hours the consulting provider is to have a conversation with the ordering ED Provider. Interview revealed "the expectation is that the consult order is placed but not necessarily expected to be seen by psych if a facility that can evaluate the patient sooner can be found." Interview revealed IVC patients may be "medically stable" however "not necessarily psychiatrically stable."

Interview on 10/28/2021 at 1402 with MD # 2 revealed it is "impossible for every psychiatric patient to be seen by psych." Interview revealed if the patient is being IVC'd, don't want to lose a bed waiting for psych to evaluate the patient so the patient is sent on to the accepting facility.

Interview on 10/28/2021 at 1429 with MD #6 revealed "Psych has twenty-four hours to see the patient unless contacted by the provider to come right now." Interview revealed "the ED provider has the ability to have inpatient services and has to place the order." Interview revealed "per the bylaws, Psych has to cover on call after hours (after 5 pm)" and the providers are aware. Interview revealed "every psych patient doesn't need to see a psychiatrist." Interview revealed if the ED physician consults psych and then contacts the psych provider and says no longer needs the consult, that is "up to the individual provider to make that determination."

Telephone interview on 10/28/2021 at 1700 with Placement Specialist (PS) #8 revealed if a patient comes in suicidal or for a psychiatric evaluation, the ED provider clears the patient medically and then sends them to the BHU (behavioral health unit in the ED). Interview revealed the PS #8 automatically sends the patient out if the patient volumes are high. Interview revealed "only refer out if adolescent and if they suicidal or homicidal." Interview revealed PS #8 may not have to communicate with the psychiatrist about the patient. Interview revealed there "may not have (sic) a psychiatrist in the ED or at night." Interview revealed the ED does "not have tele psych past 6 pm" and does "not have it at night." Interview revealed PS #8 reads the ED providers note, and if the patient's parent is there will talk with them and tell the family what is going on.

A psychiatric evaluation was not done. The patient was transferred for psychiatric treatment via police. This caused the delay in completion of the medical screening exam as well as delay in stabilizing treatment.