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Based on interview, review of Emergency Department (ED) logs, Medical Records, Policy, and video review, the facility failed to provide a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) within its capacity and capability for two patients (#22 and #9) of 23 ED records reviewed from November 2016 through April 2017. The facility also failed to place one of one patient (#9) on the ED log.

The facility had the ability to provide an MSE to Patients #22 and #9 to determine if they had an EMC, as well the ability to place Patient #9 on the ED log.

Please see the citations at A2405 and A2406 for further details.

Based on interview, record review and review of video surveillance, the facility failed to enter into the Emergency Department (ED) log one patient (#9) of 23 patients' medical records reviewed who presented to the ED for treatment. This failure had the potential to affect all patients who presented to the ED. The ED sees approximately 3026 patients per month.

Findings included:

1. Record review of the facility's policy titled, "Emergency Medical Treatment and Labor Act - EMTALA," dated 05/2015, showed:
-It was the policy for the facility to provide an appropriate medical screening exam to all persons presenting to the Emergency Department for evaluation of an emergency medical condition.
-A patient is said to "come to the Emergency Department" when they have come onto hospital property and is requesting care for what may be an emergency condition.
-Access to medical screening should not be delayed to obtain insurance, payment information, or to obtain pre-authorization for treatment.
-A patient who inquired about financial responsibility for emergency care will be encouraged to delay such discussions until after completion of the medical screening exam.
-These patients should be told that the hospital will provide medical screening examination and stabilizing treatment, regardless of their ability to pay.
-Prior insurance authorization shall not be required or requested before providing an appropriate medical screening examination and/or necessary stabilizing treatment.

2. Review of video surveillance dated 04/13/17 showed two women carrying a baby carrier (identified as Patient #9) presented to the ED front desk and spoke with Staff M (identified by facility staff). Staff M briefly spoke with the women, and then placed a phone call to contact registration (based on interview). The two women with Patient #9 remained at the desk while Staff M was on the phone, and then as Staff M hung up, the women picked up the baby carrier and walked from the ED out the doors, which were directly across from the desk of Staff M.

3. Review of the ED Log that contained the date 04/13/17 showed no evidence of Patient #9's arrival to the ED.

During an interview on 04/18/17 at 4:45 PM, Staff M, ED Unit Secretary, stated that:
-She was working on 04/13/17 when Patient #9 presented.
-Two women walked up to the desk and asked if the facility took Arkansas Medicaid.
-"I told them I can't answer that, and called back to the registration person who handled the insurance. I asked her and she said we only took Missouri and Illinois Medicaid. I repeated it back as I was on the phone, but before I could hang up and talk to them, they had turned around and walked out."
-They didn't ever ask to be seen in the ED.
-"I never ask information about insurance because I don't deal with that."
-"I thought I was just getting information for them and that they were just asking me a question."
-They had no indication of distress.
-"They left before I could ask if they wanted to be seen or before I could even get a name."
-They were not logged.

During an interview on 04/19/17 at 9:30 AM, Staff B, Director of Emergency Department, stated, "Due to recent education in the public regarding insurance issues, more people present to the ED and ask about insurance coverage.
Those questions are ok in an urgent care or doctor's office, but in the hospital it puts our staff in difficult situations.
This situation was the difference between answering a question that someone asked and determining if they needed care. When she attempted to get an answer they turned around and left before she could gather more information.
We already discussed this situation with our performance improvement group with ED staff and determined that we needed to educate on verbiage that 'we can't answer any insurance questions until after we check you in to be seen'."

Based on record review, policy review, video surveillance, and interview, the facility failed to provide a medical screening examination sufficient to determine the presence of a medical and or psychological emergency, within its capacity and capability, for two patients (#22 and #9) of 23 Emergency Department (ED) records reviewed. These failures had the potential to affect all patients who presented to the ED by risking the possibility of delayed treatment, injury or death for those who required immediate medical or psychiatric care. The ED sees approximately 3026 patients per month.

Findings included:

1. Record review of the facility's policy titled, "Emergency Medical Treatment and Labor Act - EMTALA," dated 05/2015, showed:
-It was the policy for the facility to provide an appropriate medical screening exam (MSE) to all persons presenting to the Emergency Department for evaluation of an emergency medical condition.
-A patient was said to "come to the Emergency Department" when they came onto hospital property and were requesting care for what may be an emergency condition.
-An emergency medical condition defined as acute symptoms of sufficient severity (including severe pain, psychiatric disturbance and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment of bodily functions or serious dysfunction of any bodily organ or part. It also presented a likelihood of serious physical harm to self or others.

2. Record review of Patient #22's ED record for Facility A, dated 11/22/16 showed:
-The patient arrived at the facility per Emergency Medical Services (EMS) on 11/22/16 at 10:35 AM;
-EMS patient care report showed that the patient tried to kill himself in the past by cutting his wrists and he stopped taking Lithium (medication used to treat bipolar disorder, which is a mental disorder that causes periods of depression and periods of elevated mood) three months ago.
-Staff F, Registered Nurse (RN), documentation showed that the chief complaint was request for evaluation for suicidal ideations (SI, thoughts about suicide), no plan and last used methamphetamine (an illegal recreational drug) yesterday.
-The RN's behavioral assessment at 10:41 AM showed that the patient was feeling sad, depressed and or hopeless and felt like harming himself and the psychiatric assessment at 10:45 AM showed that the patient was poorly groomed and came to the ED for SI with plan to cut his wrists.
-Staff D, ED Physician, assessed the patient at 10:44 AM and noted the patient was a 57 year old male who presented for evaluation of SI with a history of post-traumatic stress disorder (PTSD, a mental disorder that can develop after a person was exposed to a traumatic event) and bipolar disorder. The physician's psychiatric assessment showed that the patient had SI present. The physician ordered behavioral health interventions which included one-on-one monitoring or continuous visual monitoring via camera.
-The drug screen was positive for marijuana, amphetamines and benzodiazepines (class of psychoactive medications);
-Staff G, Social Worker (SW), documented at 11:15 AM that the patient requested evaluation for rehab; SW called and attempted to assist the patient to rehabilitation. Rehabilitation facility did not admit the patient and he was discharged with resources to area long term and detox resources.
-The ED physician documented at 12:39 PM that the patient was seen by the social worker and case discussed with Staff E, Psychiatrist. Patient stable currently, wants to go to drug rehabilitation facility, but there are no beds available today. No indication for inpatient psychiatric admission currently per psychiatrist.
- Plan: patient will be discharged to home.

During an interview on 04/18/17 at 2:50 PM, Staff G, SW, stated that the normal care process for a patient with SI, delusions or altered mental status was:
-ED staff contacted the SW on call who spoke with the ED physician;
-SW completed and documented a psychiatric evaluation and then contacted the Psychiatrist on call;
-SW and Psychiatrist determined disposition then the Social Worker informed the ED physician of recommended disposition.
- Staff G stated that she did not know why there was not a social work psychiatric evaluation in the medical record. She stated that sometimes the electronic record did not save documents correctly. She did not remember how Patient #22 went from SI to safe for discharge.

During an interview on 04/18/17 at 2:20 PM, Staff E, Psychiatrist, stated that he did not always write a note in the medical record when he was on-call for the ED. He stated that his expectation would be to have the social work psychiatric evaluation in the medical record and without it he could not remember how a decision was made to discharge Patient #22 to home. He stated that this patient had a history of depression, personality disorder (mental disorders characterized by enduring maladaptive patterns of behavior, which is continuing behavior often used to reduce anxiety, but the result is abnormal and non-productive) and no coping skills.

During an interview on 04/18/17 at 3:15 PM, Staff D, MD, stated that he did not remember Patient #22 but the normal process for a patient with SI was to notify SW to complete a psychiatric evaluation. The evaluation determined disposition. He stated this process usually works well and was a collaborative process.

During an interview on 04/19/17 at 8:40 AM, Staff C, ED Medical Director, stated that the psychiatric evaluation process worked well and was a collaborative process. He noted that patients often said they had SI when they were really seeking food, warmth, or drugs.

The facility failed to complete a medical screening examination sufficient to determine the presence of a psychiatric emergency when they assessed Patient #22 with suicidal ideations with a plan but discharged him to home.

3. Review of video surveillance dated 04/13/17 showed two women carrying a baby carrier (identified as Patient #9) came to the ED front desk and spoke with Staff M. Staff M briefly spoke with the women, and then dialed her phone. The two women with Patient #9 remained at the desk while Staff M was on the phone, and then as Staff M hung up, the women picked up the baby carrier and walked from the ED out the doors, which were directly across from the desk of Staff M.

During a telephone interview on 04/13/17 at 4:48 PM, Patient #9's (infant) mother stated that she came to the ED and asked if they took Arkansas Medicaid. She stated that she was told they did not take that insurance. She stated that she did not see a nurse, nor did the facility offer to see the baby. So she went to Facility B where the child was treated and released.

4. Review of the ED Log that contained the date 04/13/17 showed no evidence of Patient #9's arrival to the ED.

During an interview on 04/18/17 at 4:45 PM, Staff M, ED Unit Secretary, stated that:
-She was working on 04/13/17 when Patient #9 was brought into the ED.
-Two women walked up to the desk and asked if the facility took Arkansas Medicaid.
-She told them she couldn't answer that, and called back to the registration person who handled the insurance and asked her. She said the facility only took Missouri and Illinois so she repeated it back while she was on the phone but before she could hang up and talk to them they had turned around and walked out.
-They didn't ever ask to be seen in the ED.
-She never ask information about insurance because she doesn't deal with that.
-She thought she was just getting information for them and that they were just asking her a question.
-They had no indication of distress.
-They left before she could ask if they wanted to be seen or before she could even get a name.

During an interview on 04/19/17 at 9:30 AM, Staff B, Director of Emergency Department, stated that:
-Due to recent education in the public regarding insurance issues, more people present to the ED and ask about insurance coverage.
-Those questions are ok in an urgent care or doctor's office, but in the hospital it puts our staff in difficult situations.
-This situation was the difference between answering a question that someone asked and determining if they needed care.
-When she attempted to get an answer they turned around and left before she could gather more information.







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