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Based on interview, review of the Emergency Department (ED) Central Log for all ED patients (patient name, arrival time, chief complaint, diagnosis, etc.), and review of Hospital 1's policy and procedures, Hospital 1 failed to maintain an accurate Central log for 1 of 25 Sampled Patients (Patient 100) when Patient 100 presented to the ED on 5/7/2023, accompanied by her mother, seeking care for suicidal ideation (SI: thinking about or planning suicide). Facility staff did not register Patient 100 as an ED patient and did not enter her name and other pertinent information into the Central Log. Rather, security staff directed Patient 100 and her mother to seek care at Facility 2 (an independent facility located within Hospital 1's campus that provides psychiatric assessments, nursing assessments, and drug and alcohol screening to individuals experiencing a mental health crisis, such as suicidal depression or psychotic behavior).

This failure resulted in Hospital 1's inability to accurately track the frequency of Patient 100's ED visits within a four-day timeframe, potentially impaired Hospital 1 from accurately tracking the care provided to Patient 100 when she came to the ED seeking help for an emergency medical condition (suicidal ideation) on three occasions, and potentially prevented Hospital 1 from tracking the care of other patients who presented to the ED seeking care for psychiatric emergencies.

(Central log - record reflecting the names and disposition of individuals presenting to the dedicated Emergency Department seeking or in need of examination or treatment for an emergency medical condition. When ED staff register a patient in the computer, the patient is entered on the central log.)

Findings:

On 5/12/23, the Department received an anonymous complaint that a mother and her 14-year-old daughter had presented at the hospital's ED on 5/7/23 at 10:30 p.m. due to suicidal ideation with a plan for self-harm. They were stopped at the door, asked what the presenting problem was and, upon learning it was mental health related, were told, "We can't help you here, you need to go to the [Facility 2]."

During an observation and concurrent interview on 6/5/23 at 10:44 a.m., Hospital 1's ED entrance had a security officer seated at a reception desk in the breezeway between two sets of sliding doors. A sign was placed in front of the reception desk that indicated "Check In Here" with an arrow pointing at the security officer. Security Officer U verified the sign was there so that everyone who entered the ED checked in with security. Security Officer U stated it was his role to greet everyone who entered, find out why they were there, and if the person was a visitor, give them a visitor's badge. Security Officer U stated if a patient came in and mentioned they were having a mental health issue, he would direct them to the registration desk. The second set of sliding doors beyond the reception desk led to the ED waiting room with a registration desk approximately 10 feet inside the sliding doors.

During a record review on 6/6/23 at 11:45 a.m., Patient 100's medical record indicated she was seen in the ED on 5/5/23 at 11:55 p.m. (two days prior to being turned away from the ED). Patient 100's triage notes for the 5/5/23 visit indicated she was suicidal and considering cutting herself. Patient 100 had a medical screening exam performed by a physician's assistant and was seen by a licensed clinical social worker (LCSW). Patient 100 was cleared for discharge home with her mother with a plan for Patient 100 to follow up with her psychiatrist in the next 24 to 48 hours. Patient 100 was discharged home at 2:23 a.m. on 5/6/23.

Continuing the record review, Patient 100's next documented visit to the ED was on 5/8/23 at 2:57 p.m. Patient 100's triage note on 5/8/23 indicated Patient 100 was having thoughts of hurting herself, overdosing on pills, and "went to [Facility 2] last night and sent home..." Patient 100 received a medical screening exam, was seen by a LCSW, and placed on a 5150 hold (5150 is the number of the section of the Welfare and Institutions Code, which allows a person experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric hospitalization). Patient 100's physician note indicated that on 5/9/23 Patient 100 was transferred to another hospital for inpatient psychiatric care.

During an interview on 6/8/23 at 12:56 p.m., Family Member (FM) stated she took Patient 100 to the Hospital 1 ED on the night of 5/7/23. FM stated she spoke to a girl at the check-in counter, and the girl at the registration desk, and they told FM that "they couldn't see us." FM stated they told her Facility 2 was the right place for Patient 100 to go. FM stated the girl at the registration desk told the girl at the check-in desk to give FM a map to Facility 2. FM stated she was upset that Hospital 1 ED would not see Patient 100. FM stated when Patient 100 came back to Hospital 1's ED the next day (5/8/23), she got the help she needed.

During an interview on 6/8/23 at 1:30 p.m., Security Officer L stated her role when posted at the ED entrance was to greet patients and visitors and escort visitors where they needed to go. When asked how she responded when someone approached her with a mental health issue, Security Officer L stated she would direct them to the registration desk or if directed by the charge nurse, escort them to Facility 2. Security Officer L verified she remembered a mother and her daughter, who was suicidal, came to the ED on the night of 5/7/23. Security Officer L stated when the mother and daughter approached her, she told them to go to the registration clerk, and then the registration clerk told Security Officer L to give the mother directions to Facility 2. Security Officer L stated she was often instructed to direct people with mental health issues to go to Facility 2. Security Officer L stated, "One minute they tell us to send psych (psychiatric) patients to Facility 2, then they tell us to stop." When asked who was instructing her to do this, Security Officer L stated it was the registration clerk or the triage nurse.

During an interview on 6/8/23 at 2:20 p.m., Medical Director A was informed a patient had been turned away at the ED entrance on 5/7/23 and redirected to Facility 2 by the registration clerk and the security officer. Medical Director A stated it was his understanding that they (Hospital 1 ED) saw everyone who came to the ED, and he was not aware this was happening. Medical Director A verified the process should have been to register the patient at the registration desk (which enters them on the Central Log), triage the patient, perform a medical screening exam in a patient room with a sitter (staff assigned to one-to-one continuous supervision of a patient at risk for self-harm), perform a psychiatric evaluation, and seek placement if needed.

During an interview on 6/8/23 at 2:55 p.m., Supervisor I and Director J stated they had oversight of the registration staff in the ED. Supervisor I and Director J stated it was their expectation that the registration staff in the ED lobby registered anyone who walked through the doors [seeking care] whether it was day or night. Supervisor I and Director J stated a person seeking care for a mental health issue should be registered the same as anyone else and be seen by a provider.

During an interview on 6/8/23 at 4 p.m., Staff V stated she recalled Patient 100 and her mother coming to Facility 2 on the night of 5/7/23. Staff V stated when they arrived, Patient 100's mother broke down crying while she described how they were turned away at the Hospital 1 ED entrance.

During an interview on 6/9/23 at 9:55 a.m., Director F stated he had oversight of the security officers. Director F stated it was his expectation that the security officer at the ED entrance greet people, find out what direction they need to go and point them in that direction. Director F stated if care was needed, the security officer should direct them to the clerk (for registration).

During an interview on 6/9/23 at 11:30 a.m., Director B was informed Patient 100 had been turned away at the ED entrance on 5/7/23 and redirected to Facility 2 by the registration clerk and the security officer. Director B stated that should not have happened and it was disheartening. Director B stated that if a patient presents with suicidal ideation, the triage nurse should be notified immediately. Director B confirmed Patient 100 had not been registered and entered onto the ED Central Log on 5/7/2023.

Review of hospital policy "EMTALA/COBRA - Provision of Emergency Services And Care Prior To Patient Transfer," subtitled, "Policy," (last revised 06/2022) revealed, "C. All patients presenting to (Hospital 1) must be accepted and evaluated..." Under subtitle, "III General Information," the policy indicated, "B. Application 1. Medical Screening Exams (MSEs) shall include at a minimum the following: a. Emergency Department Log entry, including disposition of patient..."

Based on interview and record review, the hospital (Hospital 1) failed to provide a medical screening exam to one of 25 sampled patients (Patient 100) who presented to the emergency department (ED) seeking care for suicidal ideation. Patient 100 was instead redirected to Facility 2 (an onsite psychiatric stabilization unit that is not part of the hospital system, open 24 hours/day, seven days/week). This failure had the potential to result in Patient 100 carrying out her plan to take her own life, and potentially delayed her placement and treatment at an inpatient psychiatric facility.

Findings:

On 5/12/23, the Department received an anonymous complaint that a mother and her 14-year-old daughter had presented at the hospital's ED on 5/7/23 at 10:30 p.m. due to suicidal ideation with a plan for self-harm. They were stopped at the door, asked what the presenting problem was and, upon learning it was mental health related, were told, "We can't help you here, you need to go to the [Facility 2]."

During an observation and concurrent interview on 6/5/23 at 10:44 a.m., the Hospital 1 ED entrance had a security officer seated at a reception desk in the breezeway between two sets of sliding doors. A sign was placed in front of the reception desk that indicated "Check In Here" with an arrow pointing at the security officer. Security Officer U verified the sign was there so that everyone who entered the ED checked in with security. Security Officer U stated it was his role to greet everyone who entered, find out why they were here, and if the person was a visitor, give them a visitor's badge. Security Officer U stated if a patient came in and mentioned they were having a mental health issue, he would direct them to the registration desk. The second set of sliding doors beyond the reception desk led to the ED waiting room with a registration desk approximately 10 feet inside the sliding doors.

During a record review on 6/6/23 at 11:45 a.m., Patient 100's medical record indicated she was seen in the ED on 5/5/23 at 11:55 p.m. Patient 100's triage note for the 5/5/23 visit indicated she was suicidal and considering cutting herself. Patient 100 had a medical screening exam performed by a physician's assistant and was seen by a licensed clinical social worker (LCSW). Patient 100 was cleared for discharge home with her mother with a plan for Patient 100 to follow up with her psychiatrist in the next 24 to 48 hours. Patient 100 was discharged home at 2:23 a.m. on 5/6/23.

Continuing the record review, Patient 100's next documented visit to the ED was on 5/8/23 at 2:57 p.m. Patient 100's triage note on 5/8/23 indicated Patient 100 was having thoughts of hurting herself, overdosing on pills, and "went to [Facility 2] last night and sent home . . . ." Patient 100 received a medical screening exam, was seen by a LCSW, and placed on a 5150 hold (5150 is the number of the section of the Welfare and Institutions Code, which allows a person experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric hospitalization). Patient 100's physician note indicated that on 5/9/23 Patient 100 was transferred to another hospital for inpatient psychiatric care.

During an observation on 6/7/23 at 10:53 a.m., the survey team walked from the ED entrance to Facility 2. The walk through the Hospital 1 parking lot and up the hill to the behavioral health building took seven minutes. Outside the building there was no clear signage indicating how to access Facility 2 after hours when the front door was locked. On entering the building, there was no clear signage indicating Facility 2 was on the second floor.

During an interview on 6/7/23 at 2:30 p.m., Supervisor P stated that when he was posted at the ED entrance, sometimes he would offer Facility 2 to people seeking care for a psychiatric issue if it looked like the wait in the ED was going to be long and the person seeking care looked like they were not doing well.

During an interview on 6/8/23 at 12:56 p.m., Family Member (FM) stated she took Patient 100 to the Hospital 1 ED on the night of 5/7/23. FM stated she spoke to girl at the check-in counter and the girl at the registration desk and they told FM that "they couldn't see us." FM stated they told her Facility 2 was the right place for Patient 100 to go. FM stated the girl at the registration desk told the girl at the check-in desk to give FM a map to Facility 2. FM stated she was upset that Hospital 1 ED would not see Patient 100. FM stated she would have preferred to be seen in the ED because it would have been easier on Patient 100 to not have to go back and forth (from the ED to Facility 2 and back again). FM stated she got lost trying to find Facility 2, and when she got there the front door was locked and had a sign that indicated it was closed. A security guard helped her and directed her upstairs (to Facility 2). FM stated when Patient 100 came back to Hospital 1 ED the next day (5/8/23) she got the help she needed.

During an interview on 6/8/23 at 1:30 p.m., Security Officer L stated her role when posted at the ED entrance was to greet patients and visitors and escort visitors where they needed to go. When asked how she responded when someone approached her with a mental health issue, Security Officer L stated she would direct them to the registration desk or if directed by the charge nurse, escort them to Facility 2. Security Officer L verified she remembered a mother and her daughter, who was suicidal, came to the ED on the night of 5/7/23. Security Officer L stated when the mother and daughter approached her, she told them to go to the registration clerk, and then the registration clerk told Security Officer L to give the mother directions to Facility 2. Later when she was on patrol, Security Officer L saw the mother and her daughter in their car. They told her the front door to Facility 2 was locked and Security Officer L told them they had to go around to the back gate to get in. Security Officer L stated she was often instructed to direct people with mental health issues to go to Facility 2. Security Officer L stated, "One minute they tell us to send psych (psychiatric) patients to Facility 2, then they tell us to stop." When asked who was instructing her to do this, Security Officer L stated it was the registration clerk or the triage nurse.

During an interview on 6/8/23 at 2:20 p.m., Medical Director A was informed a patient had been turned away at the ED entrance on 5/7/23 and redirected to Facility 2 by the registration clerk and the security officer. Medical Director A stated he was angry to hear that happened, and stated it was "scary" because a registration clerk has no medical training. Medical Director A stated it was his understanding that they (Hospital 1 ED) saw everyone who came to the ED, and he was not aware this was happening. Medical Director A verified the process should have been to register the patient at the registration desk, triage the patient, perform a medical screening exam in a patient room with a sitter (staff assigned to one-to-one continuous supervision of a patient at risk for self-harm), perform a psychiatric evaluation, and seek placement if needed.

During an interview on 6/8/23 at 2:55 p.m., Supervisor I and Director J stated they had oversight of the registration staff in the ED. Supervisor I and Director J stated it was their expectation that the registration staff in the ED lobby registered anyone who walked through the doors (seeking care) whether it was day or night. Supervisor I and Director J stated a person seeking care for a mental health issue should be registered the same as anyone else and be seen by a provider. Supervisor I and Director J stated they were not aware registration staff in the ED lobby were directing people to go to Facility 2 for help with mental health issues.

During an interview on 6/8/23 at 4 p.m., Staff V stated she recalled Patient 100 and her mother coming to Facility 2 on the night of 5/7/23. Staff V stated when they arrived, Patient 100's mother broke down crying while she described how they were turned away at the Hospital 1 ED entrance and then got lost trying to find Facility 2. The mother told Staff V that she was asked why they were there at the ED, and when she told them her daughter was suicidal, the ED staff said, "If that's the case you need to go to [Facility 2]."

During an interview on 6/9/23 at 9:10 a.m., Staff W stated she recalled Patient 100 and her mother coming to Facility 2 on the night of 5/7/23. Staff W stated Patient 100 and her mother came to the back gate and she went to meet them. Staff W stated the mother told her they had gone to the Hospital 1 ED seeking care because her daughter was suicidal, but when they got to the door of the ED and told the ED staff her daughter was suicidal, they were told to leave and go to Facility 2. Staff W stated the mother was very distressed. Staff W stated the mother told her she did not understand why they could not be seen when they were just seen there two nights ago. Staff W stated the mother also told her they got lost in the parking lot, security found them and helped them find their way. Staff W stated Patient 100 and her mother had never been to Facility 2 before. Staff W stated when a teen or adult in psychiatric distress were turned away at the ED, there was no guarantee they will make it to another facility. It increased the risk the patient will feel unworthy of help and they might go home, and Patient 100 could have taken her life. Staff W stated that risk was enormous and did not understand why a psychiatric emergency would be treated differently than any other concern.

During an interview on 6/9/23 at 9:55 a.m., Director F stated he had oversight of the security officers. Director F stated the role of the security officer at the ED entrance was "pretty much visitors management." Director F stated it was his expectation that the security officer greet people, find out what direction they need to go and point them in that direction. Director F stated if care was needed, the security officer should direct them to the clerk. Director F stated the security officers were not instructed to ask the nature of a person's reason for seeking care. Director F stated no one else had authority to change the security officers' directive on who they allowed into the ED. Director F stated he was not aware of anyone directing officers to divert psychiatric patients to Facility 2. Director F stated he had reviewed the personnel files of the three sampled security officers, and they had not been trained on EMTALA (Emergency Medical Treatment and Labor Act, federal regulations that pertain to emergency services provided at hospitals that participate in the Medicare program).

During an interview on 6/9/23 at 10:30 a.m., Supervisor I stated ED registration staff received EMTALA training upon hire and at annual performance reviews. Supervisor I stated the EMTALA training was verbal and was not able to provide documentation that staff had completed the training when requested. When asked about her expectation regarding the ED log (the log used to track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition), Supervisor I stated she did not know what the ED log was and would reach out to ask her boss.

During an interview on 6/9/23 at 11:30 a.m., Director B was informed Patient 100 had been turned away at the ED entrance on 5/7/23 and redirected to Facility 2 by the registration clerk and the security officer. Director B stated that should not have happened and it was disheartening. Director B stated that if a patient presents with suicidal ideation, the triage nurse should be notified immediately. Director B verified that sending people in a mental health crisis to find the back gate of Facility 2 in the dark of night was a safety issue. When asked about the lack of EMTALA training or documentation of training for the security officers and registration staff, Director B stated those staff will be trained on EMTALA.

Review of hospital policy "Emergency Initial Assessment/Triage," last revised 10/2021, revealed, "All Patients who present in the Emergency Department (ED) will receive a complete Medical Screening Exam (MSE). The rapid, initial, and comprehensive assessment will be done by a qualified Emergency Department Nurse and a final Medical Screening Exam done by a Physician or Mid-Level Care Provider."