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Based on staff interview, policy review, and medical record review, it was determined the hospital failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. This resulted in the failure to provide stabilizing treatment prior to discharge for a patient who presented to the ED seeking services. Findings include:

Refer to A2407 as it relates to the failure of the hospital to provide stabilizing treatment for an identified EMC prior to dischatrge.

Based on staff interview, and review of facility policies and medical records, it was determined the hospital failed to ensure 1 of 34 patients (Patient #1) with emergency medical conditions, whose records were reviewed, received necessary treatment required to stabilize his presenting emergency medical condition prior to discharge. This failure to stabilize placed the patient and the community at risk of injury. Findings include:

A facility policy titled "EMTALA - Medical Screening Examination and Stabilization Policy," dated 1/29/19, stated "if an EMC is determined to exist, the individual will be provided the necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA. Stabilization treatment shall be applied in a non-discriminatory manner..."

a. Patient #1's medical record documented a 22 year old male who was brought to the ED by local police on 7/06/19 at 5:48 PM, with a chief complaint of aggressive behavior. He was accompanied by staff from the group home where he resided.

Additional medical history, obtained during triage, included diagnoses of developmental disability, reactive attachment disorder, fetal alcohol syndrome, and schizophrenia.

A suicide assessment was performed on 7/06/19 at 6:35 PM by the admitting RN. She documented Patient #1 was at risk for suicide and his treatment room was secured with the removal of ligature prone items, extra linen, trash bags, unnecessary cords, and sharps.

Patient #1 completed a violence/aggression assessment on 7/06/19 at 6:40 PM. The assessment documented Patient #1 as being high risk with positive responses to irritability, verbal threats, physical threats, and attacking objects.

A face to face behavioral health assessment was performed on 7/06/19 at 8:24 PM by the facility's MSW. During the assessment, Patient #1 stated "I lost my temper. I can't go home. I can't be safe." He reported auditory hallucinations as "Voices interact with my mood and tell me things I don't want to do."

The assessment documented the following:

Staff from the group home stated Patient #1 had "increased physical aggression and homicidal ideation in the past week. Pt was admitted to the ED five days ago and was released on a safety plan. Staff and pt report that pt cannot be safe at home at this time. Pt reports suicidal ideation but denies having a plan. Staff states pt attempted to cut his wrists within the past two weeks and attempted to jump in front of traffic less than seven days ago. Pt reported homicidal ideation towards group home staff and clients."

The MSW's assessment stated Patient #1's thought processes were disorganized and illogical. She documented "Due to pt's increasing homicidal and suicidal ideation, he presents a danger to himself and others. Pt is seeking inpatient placement."

Her recommendation for Patient #1 was "Transfer to IP psych." Documentation showed this recommendation was discussed with the EDMD. She then contacted ARC to request they initiate the placement process for Patient #1.

On 7/06/19 at 9:06 PM, Patient #1 was given an IM injection of Geodon 10 mg (an antipsychotic medication used for treatment of bipolar disorder and schizophrenia.) His home medications included Geodon 160 mg daily.

b. The facility provided on site staff for behavioral assessments Monday through Friday from 8:00 AM until 11:00 PM, and on weekends from 1:00 PM until 9:00 PM. Assessments were provided during other hours by ARC, an off site, corporately owned, telehealth system.

Patient #1's record documented several attempts at inpatient placement beginning on 7/06/19 at 9:44 PM. Documentation showed a response from ARC stating "pt meets exclusionary criteria and will likely be denied by placement options."

The facility's Behavioral Health Center Admission Criteria was reviewed. It stated "There may be circumstances wherein a patient is determined not to be appropriate for an acute Behavioral Health setting due to factors such as TBI, intellectual disability, an acute medical condition, medically-based delirium, forensic issues, violent behavior, or poor impulse control beyond the capability and capacity of staff & environment to treat the patient in a safe manner. Status of such will be determined by the accepting psychiatrist. Patients must be free from mechanical restraints before admission takes place."

On 7/07/19 at 1:27 AM the facility's Behavioral Health Center, as well as all Behavioral Health Centers at hospitals owned by the corporation, denied Patient #1 admission due to exclusionary criteria. At 8:29 AM, two other in state facilities denied admission to Patient #1 with no reason documented.

The group home QIDP, the group home clinician, the facility's Behavioral Health Center supervisor, and Patient #1's guardian/mother requested that ARC continue to pursue inpatient treatment placement.

c. On 7/07/19 at 12:11 PM a behavioral assessment of Patient #1 was performed by a licensed professional counselor via the off site ARC telehealth system.

The assessment documented the following:

"Suicidal thoughts: Current."

"Patient reports he cannot be safe w/ group home staff and clients."

"Patient is at risk for suicide: Yes."

"Homicidal/violent ideation: Yes."

"Patient is at risk for committing homicidal/violent behavior: Yes."

"Pt is impulsive with SI and HI statements hx cutting anger [sic]."

"Pt and ALF is seeking medication evaluation for depression and aggressive behaviors before returning; spoke with [EDMD's name] supporting inpatient admission for further evaluation with medication and stabilization."

The counselor documented at 1:07 PM "Staffed with MSTAR Director [director's name] regarding disposition. Pt does not meet inpatient criteria with primary dx mental retardation."

The counselor then recommended Patient #1 be discharged from the facility and left a message at the group home to come and pick up Patient #1. Patient #1 was discharged from the facility on 7/07/19 at 3:15 PM to home/self care with a documented primary impression: Psychosis.

In an interview on 7/17/19 at 12:30 PM, the facility's BHC flow coordinator stated a psychiatrist was on call for the facility at all times and a consult could have been called by the EDMD. He confirmed this would have been the same psychiatrist included in the group determining Patient #1's admission to the facility's BHC. When asked what resources were available to Patient #1, he said there were none because DD services do not include patients with MI and MI services do not include patients with DD.

In an interview on 7/17/19 at 2:30 PM, the facility's BHC Director confirmed the exclusionary criteria. He stated a patient's admission could be decided by the center's administrative group that included the on call psychiatrist, or solely by the on call psychiatrist.

In an interview on 7/18/19 at 9:00 AM, Patient #1's admitting EDMD said he depended on behavioral health personnel to evaluate and place patients. He stated he would ask for a psychiatrist consult if a patient remained in the ED for greater than 24 hours and BHC personnel usually facilitated the consult. He also stated he would place a patient on an emergency hold if he knew the patient was an imminent risk to themselves or others. However, he said the BHC personnel play a big part in placing a patient on hold.

In an interview on 7/18/19 at 10:15 AM, Patient #1's discharging EDMD stated he never saw Patient #1. He said he was unaware Patient #1 was suicidal until he was told by surveyors in this interview. He also stated he rarely contacted the on call psychiatrist for an evaluation and would only do so if a patient had been in the ED for days and couldn't be placed. He stated he depended on behavioral health personnel to let him know what was going on with patients.

In an interview on 7/18/19 at 10:45 AM, the facility MSW, who performed the initial behavioral assessment on Patient #1 on 7/06/19 at 8:24 PM, confirmed her recommendation for inpatient treatment after the assessment. She said she had a conversation with ARC about Patient #1's need for placement. She said she was told it didn't matter what the patient was presenting with, he was excluded from admission because of his history of TBI, FAS, and MMR. She said this was the first time ARC had disagreed with her evaluation or recommendation. She asked ARC for resources to provide to Patient #1 and was told they did not have any and it was up to the group home to find resources. She said it was ARC's decision to discharge Patient #1.

She stated she could not assign a developmental age to Patient #1, but he understood her questions and his situation and knew what was going on with himself. She confirmed group home personnel wanted to pursue inpatient placement.

In an interview on 7/17/19 at 4:00 PM, the ARC counselor, who performed the behavioral assessment on Patient #1 on 7/07/19 at 12:11 PM, stated Patient #1 had indicated sorrow for his actions, did not want to be admitted as an inpatient, and had no intention of harming himself or others. When asked why this information did not match documentation, she had no explanation. She said she discussed Patient #1 with her supervisor and it was decided Patient #1 was not at risk. She said the group home staff at the bedside and the group home nurse assured her Patient #1 would be returned to the group home under suicide watch and would be safe.

The facility's Director of Quality, Risk and Patient Safety was present during the interview and confirmed the counselor's statements did not reflect documentation.

In an interview on 7/18/19 at 8:30 AM, the group home QIDP stated he, the group home nurse, the group home bedside staff and the group home clinician had informed the facility staff that Patient #1 could not be returned to the group home because it was not possible to keep him safe.

In an interview on 7/18/19 at 8:50 AM, the group home regional supervisor stated he was present at the facility when Patient #1 was discharged. He said facility staff told him Patient #1 was not admitted for inpatient mental health treatment because he would not be responsive to medication changes or counseling. He stated Patient #1 was not taken back to the group home due to safety concerns for Patient #1 as well as other group home residents and staff. He stated Patient #1 was discharged from the group home to the care of his guardian/mother.

In an interview on 7/18/19 at 9:15 AM, the group home clinician stated the facility's MSW contacted him on 7/07/19. She told him that, per her supervisor at ARC, Patient #1 was being discharged and it was the group home's responsibility to take care of him. When he asked her where the liability fell, she replied it was no longer the facility's concern or responsibility and it was up to the group home to figure it out. He asked her for resources for Patient #1's continued mental health care and was told she had no resource information to give him.

In an interview on 7/18/19 at 2:10 PM, the discharging RN stated he was aware the group home did not want to take Patient #1 back, but he did not know why. He said the group home bedside staff was on the phone to the group home regional supervisor. The RN overheard a discussion related to Patient #1 being taken to a hotel rather than back to the group home. He said he reported the conversation to the ED manager.

The facility failed to provide stabilizing treatment for Patient #1's presenting EMC prior to discharge.