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Based on record review, interview, and review of the facility's policies, it was determined the facility failed to ensure compliance with 42 CFR 489.24 (a) related to the failure to provide an appropriate Medical Screening Examination (MSE) and 42 CFR 489.24(e)(1) and (2)(iv) Appropriate Transfer.

Cross Reference: A2406 The facility failed to provide an appropriate medical screening after it was determined Patient #1 required further psychiatric treatment.

Cross Reference: A2409 The facility failed to facilitate an appropriate transfer of Patient #1 to a Behavioral Health Facility by qualified personnel.

Based on interview, record review, review of the facility's policy for Emergency Medical Treatment And Labor Act (EMTALA), it was determined the facility failed to ensure one (1) patient (#1), in the selected sample of twenty (20) patients, received an appropriate Medical Screening Examination (MSE) consisting of both a medical and behavioral health screening to determine a psychiatric emergency medical condition existed.

The findings include:

Review of the facility's policy "EMTALA", last review date 06/27/18, revealed a Medical Screening Exam (MSE) is a process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition (EMC) existed. Screening should be conducted to the extent necessary, by Physicians and/or other Qualified Medical Person or Personnel (QMP) to determine whether an EMC existed. With respect to an individual with behavioral symptoms, an MSE consisted of both a medical and behavioral health screening.

Review of Patient #1's medical record revealed he/she arrived at Hospital #1's Emergency Department (ED) on 05/02/18 at 1:07 PM. Patient #1 was triaged at 1:16 PM by Registered Nurse (RN) #1. The patient described feelings of depression and had been confused. He/she had decreased oral intake, flank pain, dizziness, weakness, and experienced syncope (fainting), and reported muscle weakness and weight loss. Review of the chief complaint revealed confusion and thoughts of self harm. Review of the Self Harm Assessment revealed the patient answered "yes" to the question(s) "have you recently felt down, depressed, or hopeless?"; "have you noticed less interest or pleasure in doing things?"; and "do you have thoughts of harming or killing yourself?"; "do you have any dangerous items in your possession?" Record review revealed RN #1 was unable to assess Patient #1 in regard to the question(s) "have you ever tried to hurt yourself before today?" The family reported the patient's behavior included suicidal comments. In the ED, the patient had been confused, unable to cooperate, non-communicative, and withdrawn. Further review of the triage assessment conducted by RN #1 revealed Patient #1 was assessed at Acuity Level 2, which indicated the patient was evaluated according to Triage Categories Emergency Severity Index (ESI). This list included the following information: Emergency (Level 2) - major injury or illness but stable; bed placement, treatment and reassessment should occur within five (5) to fifteen (15) minutes, to include suicidal/homicidal behavior.

Review of the Advanced Practice Registered Nurse (APRN)'s assessment/evaluation of Patient #1, dated 05/02/18 at 1:27 PM, revealed the patient's history of present illness. Review of the chief complaint revealed he/she was withdrawn and had exhibited a recent behavior change. He/she had been withdrawn, depressed, had not been eating or sleeping, had been mildly paranoid, exhibited unusual behavior observed by family with no delusions, suicidal thoughts, self-inflicted injury or hallucinations. These symptoms were described as moderate. No injury was present. Review of additional history revealed his/her Aunt stated "read on social media last week that patient had posted a cry for help to brothers and sisters". Review of the physical exam by the APRN revealed she assessed Patient #1's appearance as alert, no acute distress, disheveled, and appeared detached (catatonic). Review of systems (Psych/Neuro) by the APRN revealed Patient #1 was oriented to name, place, and day, appeared depressed, flat affect, and speech was low. The patient exhibited altered thought processes with answers such as "I don't know" to most questions, cried and held his/her head in his/her hands, but was unable to explain why. No apparent hallucinations noted according to the APRN's assessment. He/she appeared to have religious delusions, stating "I disobeyed God", "I will be the Holy Ghost". The patient denied suicidal thoughts and did not express homicidal thoughts. The patient felt treatment was necessary of appeared concerned about his/her current condition, insight and judgement were normal, no motor and/or sensory deficit. The patient asked for help, stating, "I do not want to feel like this, I want to feel better". Review of Patient #1's diagnostic test received while in the Emergency Department (ED) included Computed Tomography (CT) of the head without contrast, Complete Blood Count (CBC), Thyroid Stimulating Hormone (TSH), Comprehensive Metabolic Profile (CMP), Thyroid Panel, Urinalysis, Urine Drug Screen (UDS), and Ethyl Alcohol. Review of the APRN's Progress and Procedures Course of Care revealed Patient #1 was accepted at a Behavioral Health Unit (BHU) which was thirty-eight (38) miles away from Hospital #1. The APRN discussed treatment options with the patient, who agreed to the transfer.

Interview with Patient #1's Aunt, on 06/27/18 at 10:58 AM, revealed she transported Patient #1 to Hospital #1's ED on 05/02/18. Further interview revealed Patient #1 was "psychologically unstable" as well as having medical problems. She stated Patient #1 had never been diagnosed with mental illness, although there was a family history. She revealed Patient #1 had used marijuana, cigarettes, caffeine and had tried to stop using all three (3). She revealed Patient #1's medical issues were assessed at the ED, and medically cleared. Interview revealed Patient #1 wanted inpatient treatment for his/her mental health and agreed to a voluntary admission to the BHU. She stated Patient #1 did not verbalize he/she was suicidal and had not expressed a plan of intent to harm self.

Interview with RN #1, on 06/26/18 at 4:30 PM, revealed she triaged Patient #1, on 05/02/18 at 1:07 PM, upon arrival to the Hospital #1 ED. Interview revealed the patient arrived to Hospital #1 ED by private auto accompanied his/her aunt and father. RN #1 stated "the aunt provided most of the information, the patient was not conversational with me, he/she was a poor historian related to medical/psychiatric history". RN #1 revealed Patient #1 answered "yes" to self harm questions, and his/her affect was flat; however, she could not determine if Patient #1 had thoughts of self harm at the time of his/her assessment, because he/she was not verbal enough to determine that information.

Interview with RN #2, on 06/23/18 at 12:45 PM, revealed she was the primary care nurse who cared for Patient #1 on 05/02/18 at 1:34 PM. Interview revealed Patient #1 complained of feeling weak, sick, and needed help; however, the patient did not specify whether he/she needed medical or psychiatric help. Further interview revealed Patient #1 did not verbalize thoughts or plans to harm self. She revealed the APRN asked Patient #1 "do you feel you need help for mental concerns?", and the patient agreed. She revealed she did not recall Patient #1 being evaluated or screened by a mental health professional prior to agreeing to transfer to the BHU.

Interview with the APRN, on 06/27/18 at 11:50 AM, revealed she was the attending medical professional who cared for Patient #1 in the ED, on 05/02/18 at 1:37 PM. She revealed Patient #1 was catatonic, quiet, withdrawn, made no eye contact, and revealed no previous history of mental illness. The APRN stated, "the patient's aunt and father were present, and the aunt provided information about the patient". Further interview revealed Patient #1 voluntarily agreed to inpatient treatment at the BHU; however, Patient #1 was not evaluated by a Qualified Mental Health Professional (QMHP) while in the ED. The APRN stated, "if a patient with psychiatric symptoms was seeking treatment, the patient did not have to be evaluated/assessed by a QMHP, even if it was determined inpatient treatment was recommended and agreed upon. I did not feel the patient was in an acute crisis or a harm to self; however, I felt Patient #1 needed mental health treatment, and the patient and family agreed". She revealed she discussed Patient #1's condition with the attending ED Physician; although, she was not certain if the Physician assessed the patient.

Interview with the Clinical Director of Emergency Services, on 06/28/18 at 1:05 PM, revealed Patient #1 was treated in Hospital #1's ED on 05/02/18. Interview revealed a MSE was completed, it was determined an EMC did not exist, the patient was medically cleared, and he/she was treated for symptoms that led to the ED visit. Interview revealed the patient volunteered to be transferred to a BHU for inpatient mental health treatment. Further interview revealed treatment at an inpatient BHU was recommended, the patient agreed, and arrangements were made. The Clinical Director of Emergency Services revealed a patient did not necessarily have to be assessed/screened by a mental health professional, if the patient voluntarily agreed to behavioral health treatment.

Based on interview, record review, and review of the facility's policy for Emergency Medical Treatment And Labor Act (EMTALA), it was determined the hospital failed to ensure an appropriate transfer to the receiving facility, thirty-eight (38) miles away for one (1) patient, in the selected sample of twenty (20) patients (Patient #1) . The facility also failed to document the patient's medical condition/diagnoses, reason for transfer, and the medical risks involved in the Documentation of Transfer.

The findings include:

Review of the facility's "EMTALA" policy revealed if a medically unstable individual, or legally responsible person requested a transfer to another hospital, the individual or the legally responsible person must first be fully informed of the risks of the transfer, the alternatives (if any) of the transfer, and the hospital's obligation to provide further examination and treatment sufficient to stabilize the individuals Emergency Medical Condition (EMC). The stability of the individual was determined by the Emergency Department (ED) Physician or other Qualified Medical Person/Personnel (QMP) in consultation with the Physician. After it was determined the individual was medically stable, the Physician or other QMP must accurately and thoroughly document the parameters of such stability.

Review of Patient #1's medical record revealed he/she presented to Hospital #1's ED on 05/02/18 at 1:07 PM. Record review revealed the patient was transported to the ED by private vehicle accompanied by family (aunt and father) with a chief complaint of confusion and thoughts of harming self. Patient #1 also complained of feeling depressed, decreased oral intake, flank pain, dizziness, weakness, and syncope (fainting). Patient #1 was assessed and evaluated by the Advanced Practice Registered Nurse (APRN) in the ED. A Medical Screening Examination (MSE), Laboratory Test, and a Computed Tomography (CT) Scan of Head was obtained and determined Patient #1 did not have an EMC and was medically cleared. Review of a clinical impression included Changed Mental Status, Schizophrenia, and Depression, and it was determined the patient would benefit from treatment at a Behavioral Health Unit (BHU). The APRN discussed mental health concerns with Patient #1 and family members (aunt and father). Patient #1 expressed the desire to receive treatment for his/her mental health.

Review of Hospital #1's Documentation Of Transfer, dated 05/02/18 at 6:00 PM, revealed there was documented evidence of contact with the BHU who agreed to accept the patient. Additionally, there was no documented evidence of the patient's medical condition/diagnoses, reason for transfer, or the medical risks involved with the transfer on the Transfer Document. Review of the Course Of Care revealed Patient #1's aunt requested to transport him/her to the BHU by private vehicle, because she felt the patient would do better if he/she spoke with his/her father during transport.

Interview with Patient #1's Aunt, on 06/27/18 at 10:58 AM, revealed she transported Patient #1 to Hospital #1's ED on 05/02/18. Interview revealed Patient #1 was "psychologically unstable" as well as having medical problems; however, the patient did not verbalize he/she was suicidal or express a plan of intent to harm self. She revealed Patient #1's medical issues were assessed at the ED, and medically cleared. She revealed Patient #1 wanted inpatient treatment for his/her mental health and agreed to a voluntary admission to the BHU. Patient #1's aunt revealed the Hospital offered to provide the patient transportation by law enforcement or ambulance, but said she declined. Patient #1's aunt stated, "I offered to transport my [family member], I strongly encouraged the Nurse Practitioner to allow me to because I felt it would be best. I did feel he/she (Patient #1) could be suicidal, but I just did not feel it was to that extreme to jump out of a moving car, it was totally sporadic. He/she was sitting in the front seat, I know he took his/her seat belt off because he/she had mentioned his/her side was hurting, so when I heard the seat belt buzzer go off, I asked if he/she was still hurting, but he/she never said a word. The Aunt stated Patient #1 "just opened the car door and proceeded to jump out. I was driving down the interstate at 70 mph, and thankfully I was traveling in the right hand lane". Further interview revealed when the patient's aunt realized what happened, she grabbed Patient #1 by his/her shirt in an attempt to prevent him/her from jumping out of the car; however, the patient was successful, and sustained multiple injuries. Interview revealed Emergency Medical Services (EMS) was called to the scene and the patient was transported back to Hospital #1's ED.

Review of Patient #1's Nurses Clinical Report at Hospital #1 revealed the patient arrived back to the facility at 7:30 PM by EMS. Review revealed the patient had been discharged from Hospital #1's ED to go to a BHU thirty-eight (38) miles away. While enroute, the patient reportedly jumped out of the car going at approximately fifty (50) mph. The chief complaint identified was abrasions to face, forehead, multiple large skin abrasions to both arms, chest, trunk, back, both legs, and loss of consciousness. Further review of the Nurses Clinical Report revealed Patient #1 had psychotic behavior, suicidal thoughts, and had conceived a plan.

Review of Patient #1's Physician's Clinical Report, dated 05/02/18 at 7:52 PM, revealed a MSE was performed consisting of CT of the following areas: C-Spine, Head, Chest, Abdomen, and Pelvis. Clinical Impression was acute hysterical psychosis, suicide attempt, closed, nondisplaced left iliac wing fracture, acetabulum fracture involving the anterior wall, multiple deep abrasions to the scalp, head, left flank, right shoulder, right/left hand, and right/left knee. It was determined an EMC existed, and the patient required a higher level of care. The hospital facilitated the transfer to the receiving facility (Hospital #2), which was ninety-five (95) miles away.

Review of the Documentation Of Transfer, dated 05/02/18 at 8:50 PM, revealed contact was made with Hospital #2's attending ED Physician, which agreed to accept transfer. Report was given to the receiving nurse at 9:12 PM. Further review of the Documentation Of Transfer revealed Patient #1 left the facility to be transported to Hospital #2 by EMS at 10:45 PM.

Review of Hospital #1's Department of Emergency Services meeting, dated 05/17/18 at 3:00 PM, revealed "Transfers: BHU transfers will not include an option for private vehicle transport any longer. Transfers to BHU continue to be an issue. Call EMS if constable is not available for the transport. The EMTALA policy is being reviewed to edit BHU transfers with adjusted requirements for transport".

Review of Patient #1's ED note at Hospital #2 revealed arrival by EMS on 05/03/18 at 1:43 AM (Eastern Time). Review of an assessment revealed a scalp laceration approximately three (3) centimeters (cm), with superficial surrounding abrasion approximately forty (40) cm, road rash to the left chest wall, a laceration approximately three (3) centimeters (cm) to the right shoulder, and scattered superficial abrasions to the left buttock, both knees, both feet, and a left acetabulum fracture was identified on CT imaging from Hospital #1. Orthopedics Department was consulted, weight bearing as tolerated recommended, without surgical intervention. The laceration to the frontal scalp was repaired, all other wounds were cleaned and dressed, and no other lacerations required suturing. Patient #1 was admitted to Hospital #2's Behavioral Health Unit (BHU) for safety and stabilization.

Interview with the APRN, on 06/27/18 at 11:50 AM, revealed she was the attending medical professional who cared for Patient #1 in Hospital #1's ED, on 05/02/18 at 1:37 PM. She revealed Patient #1 was catatonic, quiet, withdrawn, made no eye contact, and revealed no previous history of mental illness. She stated, "the patient's aunt and father were present, and the aunt provided information about the patient". Further interview revealed Patient #1 voluntarily agreed to inpatient treatment at the BHU; however, Patient #1 was not evaluated by a Qualified Mental Health Professional (QMHP) while in the ED. The APRN stated, "if a patient with psychiatric symptoms was seeking treatment, the patient did not have to be evaluated/assessed by a QMHP, even if it was determined inpatient treatment was recommended and agreed upon. I did not feel the patient was in an acute crisis or a harm to self; however, I felt Patient #1 needed mental health treatment, and the patient and family agreed". She revealed she discussed Patient #1's condition with the attending ED Physician; although, she was not certain if the Physician assessed the patient.

Interview with the Clinical Director of Emergency Services, on 06/28/18 at 1:05 PM, revealed Patient #1 was treated in Hospital #1's ED on 05/02/18. Interview revealed a MSE was completed, and it was determined an EMC did not exist, the patient was medically cleared, and he/she was treated for symptoms that led to the ED visit. Interview revealed the patient volunteered to be transferred to a BHU for inpatient mental health treatment. Further interview revealed treatment at an inpatient BHU was recommended, the patient agreed, and arrangements were made. The Clinical Director of Emergency Services revealed a patient did not necessarily have to be assessed/screened by a mental health professional, if the patient voluntarily agreed to behavioral health treatment.

Review of the discharge summary from Hospital #2 revealed Patient #1 was discharged on 05/10/18. Patient #1 was calm and cooperative on the day of discharge. The patient denied any thoughts of harming self and/or others and expressed readiness to continue therapy as an outpatient. Follow-up care for behavior health was established by Hospital #2 prior to discharge.