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Based on records reviewed and interviews the Hospital failed to provide Patient #65 with an appropriate medical screening exam when Patient #65 presented to Hospital Campus C's grounds seeking attention for difficulty breathing. Patient #65 made a 911 call to say that she was on the grounds of Hospital Campus C and that she could not access the Emergency Department. Emergency Dispatch called Hospital Campus C's Emergency Department to say that a Patient was on their grounds with difficulty breathing. Hospital staff did not conduct an outside search and Patient #65 was found by ambulance personnel outside of the Emergency Department's main entrance in full cardiac arrest. Patient #65 later died.

Based on records reviewed and interviews the Hospital failed to provide, for six of eight patients (Patients #65, #68, #69, #70, #71, and #74), an appropriate medical screening examination consistent with Medical Staff Bylaws and Emergency Medical Treatment and Labor Act (EMTALA) requirements.

Findings included:

1.) The Hospital failed to provide Patient #65 with an appropriate medical screening examination when Patient #65 presented on Hospital property at Hospital Campus C's dedicated Emergency Department (ED) for examination and treatment to determine if an emergency medical condition existed thus obligating the Hospital to provide an appropriate medical screening examination and subject to EMTALA requirements.

The Ambulance Service Report, dated 9/16/16, indicated local police notified the Hospital that Patient #65 was outside on the Hospital grounds having shortness of breath. Hospital staff could not find Patient #65 but first-responders found Patient #65 unconscious at the Emergency Department entrance. The report indicated first-responders started cardiopulmonary resuscitation and Emergency Department staff brought Patient #65 into the Emergency Department for care.

The Emergency Department Triage Note, dated 9/16/16 at 4:45 A.M., indicated that local police notified the Emergency Department that Patient #65 was having an asthma attack and was having trouble finding the Emergency Department.

The Surveyor interviewed Risk Manager #2 at 8:30 A.M. on 11/28/16 and Risk Managers
#1 at 10:30 A.M. on 11/29/16. Risk Manager #1 and #2 said the Hospital reviewed Patient #65's adverse patient event and the Hospital did not identify the event as a potential EMTALA violation.

Risk Manager #1 said Patient #65 was seeking the Emergency Department, walked up the hill and went to a locked door (on Hospital property), then to the ambulance bay and then to a bench outside Hospital Campus C's Emergency Department main entrance. Risk Manager #1 said the local police called Hospital Campus C's Emergency Department, spoke to the Emergency Department Charge Nurse and asked her if the Emergency Department was open because someone called the Emergency Response System (911) trying to access the Emergency Department for either an asthma attack or an anxiety attack. Risk Manager #1 said Patient #65 was not a patient.

2.) The Hospital failed to provide five psychiatric patients (Patients #68, #69, #70, #71, and #74) with appropriate medical screening examinations by a physician or other non-physician practitioner (allied health practitioner, qualified medical personnel), determined qualified by Medical Staff Bylaws or Rules and Regulations, to conduct medical screening examinations to determine if a psychiatric emergency medical condition (patient expressed suicidal or homicidal thoughts or gestures, if determined dangerous to self or others) existed regardless of prearranged State plans (contracts or agreements) for psychiatric patients.

The document titled Medical Staff Bylaws, dated 5/14/15, indicated the Medical Staff Credentialing Procedures Manual sets forth detailed requirements for the granting and delineation of clinical privileges and the Medical Staff granted clinical privileges to individual practitioners based on licensure, training, experience, capacity to perform and evidence of current competence.

The document titled Rules & Regulations of the Medical Staff Bylaws, dated 11/19/13, indicated non-physician practitioners (allied health professionals, qualified medical personnel) were Clinical Psychologists, Licensed Independent Clinical Social Workers, Certified Physician Assistants, and Certified Nurse Practitioners.

The document titled, Medical Staff Credentialing Procedures Manual, dated 11/11/11, indicated credentialing procedures for non-physician practitioners; Licensed Psychologist, Licensed Psychiatric Social Workers, and Psychiatric Clinical Nurse Specialists.

A.) The Emergency Department Physician Note, dated 11/20/16 at 1:19 A.M., indicated that an Emergency Department Physician medically cleared (a medical or surgical emergency condition did not exist) Patient #68 for psychiatric evaluation and Patient #68's disposition was based on Emergency Service Program (ESP) Provider Staff #68's evaluation. The Emergency Department Physician Note, dated 11/20/16 at 7:10 A.M., indicated ESP Vendor Staff #68 evaluated Patient #68 as needing inpatient psychiatric treatment. The Emergency Department Physician Note, dated 11/21/16 at 12:10 A.M., indicated ESP Vendor Staff #68 evaluated Patient #68 and recommended Patient #68 be admitted to an inpatient psychiatric hospital.

The Emergency Department Physician Note did not indicate the Emergency Department Physician evaluated Patient #68 for a psychiatric emergency medical condition or determine Patient #68's disposition.

The Psychiatric Emergency Evaluation, dated 11/20/16, indicated assessment of Patient
#68's chief concern, history of present illness, substance abuse history, medical issues and hospitalizations, social and family history, a diagnosis with a diagnostic code and treatment recommendations, all consistent with a medical screening examination to determine if a psychiatric medical emergency condition existed. The Psychiatric Emergency Evaluation indicated Patient #68 was at high-risk level for danger to self, a potential harm to others and had an inability to care for self. The Psychiatric Emergency Evaluation indicated ESP Vendor Staff #68 did not consult with a Psychiatrist. The Psychiatric Emergency Evaluation identified ESP Vendor Staff #68 with the credentials as a Licensed Clinical Social Worker (LCSW) as the individual who completed and signed the Psychiatric Emergency Evaluation.

The Medical Staff Bylaws, Rules and Regulations and the Medical Staff Credentialing Procedures Manual did not indicate Licensed Clinical Social Workers as approved by the Governing Body for Medical Staff credentialing and clinical privileges to perform components of an emergency psychiatric evaluation.

B.) The Emergency Department Attending Provider Note, dated at 6:05 P.M. on 11/21/16, indicated ESP Vendor Staff #69 at Hospital Campus C recommended discharge with outpatient treatment for Patient #69 . The Emergency Department Attending Provider Note did not indicate that the Emergency Department Physician documented a psychiatric emergency medical screening examination that included a plan for disposition, admission or discharge.

The Encounter View Form, dated 11/22/16, indicated ESP Vendor Staff #69 documented Patient #69's chief complaint, history of present illness and assessment and impression (evaluation) of Patient #69's condition, all consistent with a psychiatric medical screening examination. The Encounter View Form indicated that ESP Vendor Staff #69 spoke with Individual #1, made telephone calls to providers (health care professionals) and documented that Patient #69 could be discharged. The Encounter Form did not indicate who Individual
#1 was or whom Individual #1 was associated with, the Hospital or the ESP Service Provider. The Encounter Form indicated an evaluation with a physician and registered nurse; however, it did not indicate who the physician or registered nurse was or who they were associated with. The Encounter Form indicated that Patient #69 was safe for discharge. The Encounter View Form identified Vendor Staff #69 completed and signed the psychiatric evaluation with their credentials as "MA" (undefined).

The Medical Staff Bylaws, Rules and Regulations and the Medical Staff Credentialing Procedures Manual did not indicate a credentialing procedure for the credential abbreviation, "MA", approved by the Governing Body for Medical Staff credentialing and clinical privileges to perform components of a psychiatric emergency medical screening examination.

C.) The Emergency Department Physician Note, dated 10/17/16 at 6:34 A.M., indicated the Emergency Department Physician medically cleared Patient #70 for a behavioral health (psychiatric) evaluation by ESP Vendor Staff #70. The Emergency Department Attending Provider Note did not indicate the Emergency Department Physician documented a psychiatric emergency medical screening examination that included a plan for disposition, admission or discharge for Patient #70.

The Emergency Department Note, dated 10/17/16 at 9:09 A.M. and documented by ESP Vendor Staff #70, indicated documentation of a psychiatric medical screening examination, including history, mental status examination, risk assessment, diagnosis with diagnostic codes and recommended Patient #70 admission for inpatient psychiatric treatment, all consistent with a psychiatric medical screening examination. The Emergency Department Note identified Vendor Staff #70 completed and signed the psychiatric evaluation with a credential of "MS" (undefined).

Medical Staff Bylaws, Rules and Regulations and the Medical Staff Credentialing Procedures Manual did not indicate a credentialing procedure for the credential abbreviation, "MS", approved by the Governing Body for Medical Staff credentialing and clinical privileges to perform components of a psychiatric emergency medical screening examination.

D.) The Emergency Department Provider Note, dated 10/14/16 at 7:38 A.M. for Patient
#71, indicated a psychiatric examination identified that Patient #71 was calm, cooperative and had auditory hallucinations. The Emergency Department Provider Note indicated that a medical screening examination was performed, no emergent medical condition was identified, there was no contraindication to psychiatric evaluation and Psychiatry (ESP Provider Vendor A) was consulted. The Emergency Department Provider Note indicated that psychiatry evaluated Patient #71 and he/she needed inpatient psychiatric admission. The Emergency Department Provider Note did not indicate that the Emergency Department Physician documented a psychiatric emergency medical screening examination that included a plan for disposition; admission or discharge.

The ESP Adult Comprehensive Assessment, dated 10/14/16 at 1:27 A.M. for Patient #71 documented by ESP Provider Vendor Staff #71, indicated a psychiatric medical screening examination including history, mental status examination, risk assessment, diagnosis with diagnostic codes and recommendations for inpatient level of care, all consistent with a medical screening examination to determine if a psychiatric medical emergency condition existed. The ESP Adult Comprehensive Assessment identified Vendor Staff #71 with a credential of "MA".

The document titled ESP Adult Comprehensive Assessment Training Manual, undated, indicated the ESP Adult Comprehensive Assessment provided a mental health assessment for patients presenting for emergency behavioral health services.

Medical Staff Bylaws, Rules and Regulations and the Medical Staff Credentialing Procedures Manual did not indicate a credentialing procedure for the credential abbreviation, "MA", approved by the Governing Body for Medical Staff credentialing and clinical privileges.

E.) The Emergency Department Physician Note, dated 10/11/16, indicated Patient #74 was appropriate for age, time of day and situation. The Emergency Department Physician Note indicated that the Emergency Department Physician medically cleared Patient #74 for a psychiatric evaluation. The Emergency Department Physician Note indicated that ESP Vendor Staff #74 evaluated Patient #74 and cleared (approved) Patient #74 for discharge. The Emergency Department Physician Note did not indicate an Emergency Department Physician provided a psychiatric medical screening examination. The ESP Note, dated 10/11/16, indicated ESP Vendor Staff #74 provided a mental health examination. The ESP Note identified Vendor Staff #74 completed and signed the mental health examination with a credential of "MSMFT" (undefined).

The Medical Staff Bylaws, Rules and Regulations and the Medical Staff Credentialing Procedures Manual did not indicate a credentialing procedure for the credential abbreviation, "MSMFT", approved by the Governing Body for Medical Staff credentialing and clinical privileges to provide components of an emergency psychiatric medical screening examination.

The document titled Emergency Service Program (ESP) Provider Manual, dated 2013, indicated Vendor Staff provided crisis evaluation, intervention, stabilization and follow-up services during the initial evaluation; however, the document titled Medical Staff Bylaws did not indicate that ESP Licensed Clinical Social Workers or ESP Vendor Staff with the credentials of "MA", "MS" or "MSMFT" (Masters of Science in Marriage and Family Therapy) were approved by the Governing Body to provide crisis evaluation services.

The Hospital did not provide documentation of Medical Staff credentialing procedures, nor granting and delineation of clinical privileges based on licensure, training, experience, capacity to perform or evidence of current competence for five (Vendor Staffs #68, #69, #70, #71 & #74) of five ESP Vendor Staff consistent with Medical Staff Bylaws. Five Vendor Staff Personnel Records did not indicate documentation of an evaluation of clinical competence and three (Vendor Staffs #68,#69 & #74) of five Vendor Personnel Records did not indicate orientation to the Hospital.

Patient #68, #69, #70, #71, and #74's medical records did not indicate that a Clinical Psychologist, Licensed Independent Clinical Social Worker, Certified Physician Assistant, or Certified Nurse Practitioner performed the medical screening examination to determine if a psychiatric emergency medical condition existed consistent with Medical Staff Bylaws, Rules and Regulations and Medical Staff Credentialing Manual.

Patient #68, #69, #70, #71, and #74's medical records did not indicate that qualified medical personnel provided the psychiatric emergency medical screening examinations. Medical records indicated ESP Vendor Staff #68, #69, #70, #71, and #74 provided the psychiatric emergency medical screening examinations for Patients #68, #69, #70, #71, and #74 respectively.

The Surveyor interviewed the Chief Quality Officer at 12:00 P.M. on 11/21/16. The Chief Quality Officer said the Hospital did not complete credentialing (Hospital and Medical Staff procedures to establish qualifications of licensed professionals) for ESP Vendor psychiatrists.
The Director of Quality said that ESP Vendor Staff were not credentialed because it was the Hospital's belief the the evaluations completed by ESP Vendor Staff constituted insurance screenings only.