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Based on document review and interview,it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure that for a patient presenting to the ED, a complete medical screening examination (MSE) was provided. See deficiency at A-2406 A.

2. The Hospital failed to ensure that the Hospital's Bylaws and the Rules and Regulations of the Medical Staff included the responsible person to perform a medical screening exam. See deficiency at A-2406 B.

3. The Hospital failed to ensure that for a patient presenting to the ED, an appropriate transfer was provided. See deficiency at A-2409.

A. Based on document review and interview, it was determined that for 1 of 20 (Pt. #1) patients that presented to the ED, the Hospital failed to ensure a complete medical screening examination (MSE) was provided.

Findings include:

1. On 5/21/19 at approximately 11:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 48 year old female who presented to the Emergency Department (ED) on 5/10/19 with complaints of anxiety and situational crisis:

- The Hospital's Emergency Room Triage Report dated 5/10/19 included, " ... Arrival Time: 9:08 AM ... Mode of arrival: automobile, accompanied by: Police, Informant: Police ... (Pt. #1) ran away from group home today ..."

- A Petition for Involuntary Admission/Judicial Admission completed by Chicago Police Department (CPD), dated 5/10/19 included, "... (Pt. #1) who is asserted to be a person subject to involuntary in-patient admission ... a person with mental illness who: because of his or her illness is reasonably expected, unless treated on an inpatient basis ... in need of immediate hospitalization for the prevention of such harm ... above listed ran away from group home ... danger to self because she's running away... 4A. If you are subject to involuntary admission (mentally ill) you must be examined within 24 hours ... by a psychiatrist ..."

- The History and Physical Notes of MD #1 (ED Medical Doctor) dated 5/10/19 at 9:55 AM included, " ... (Pt. #1) was sent to group home 2 days ago from (the Hospital.) (T)his morning (Pt. #1) ran away ...states they do not let her come out of her room ... (History) obtained from (Pt. #1) ... Past Medical History ... Mental Retardation ... Final Disposition: OBS (observation) ... referred to HRDI (Human Resource Developmental Institute/Crisis Worker)/Psych (Psychiatry), Final Diagnosis: Schizoaffective (disorder) - social problems ..."

- The Assessment Notes of E #5 (ED Registered Nurse) on 5/10/19 at 10:36 AM and at 10:51 AM included, "...Patient reported problems: aggressive behavior... Coping skills inadequate ... agitation ..." At 11:08 AM, E #5 documented, " ... HRDI on unit...to evaluate (Pt. #1) ... (MD #2/Psychiatrist) advised to discharge back to the group home ..."

- The clinical record lacked the crisis worker's and psychiatrist's documentation that a psychiatric examination or evaluation was performed.

2. On 5/21/19 at approximately 11:45 AM, the Hospital's Emergency Department Log dated 5/10/19 included, "... Discharged ... (Pt. #1) ..."

3. On 5/21/19 at approximately 1:00 PM, the Hospital's policy titled, "ED (Emergency Department) Duties for Behavioral Medicine and Medical Stabilization and Medical Stabilization Patients" (effective 2008) was reviewed and included, " ... All patients who present to the (Hospital) emergency department will go through the following process to ensure their safety ... and to safeguard patient rights ... 4. If the patient is brought by the Chicago Police Department (CPD) ask the police to fill out a petition for the patient ... 10. Notify crises triage (HRDI) to see patient immediately for (psychiatric) evaluation ... 13. Obtain report from crisis triage worker and contact the Psychiatrist about the patient ... Definitions ... Involuntary Petition: Form to be completed that serves as a request for a patient's admission to the behavioral medicine unit ..."

4. On 5/21/19 at approximately 1:30 PM, findings were discussed with E #2 (Vice President for Patient Care) and E #3 (Clinical Director, ED). Both E #2 and E #3 stated that there's no documentation of HRDI's psychiatric evaluation on 5/10/19 in Pt. #1's clinical record. E #2 stated, "There's none."

5. On 5/21/19 between 3:12 PM and 3:28 PM, an interview was conducted with E # 4 (ED Charge Nurse). E #4 stated, " ... (Pt. #1)... ran away from group home ... She (Pt. #1) was sent to 4th floor (Emergency Department extension area for psychiatric patients) for psychiatric assessment (by HRDI and RN) ... HRDI usually sees the patient ... We (nurses) wait for the HRDI assessment before calling the psychiatrist ... Otherwise, there's nothing for us to say ..."

6. On 5/22/19 between 8:59 AM and 9:27 AM, an interview was conducted with MD #2 (Psychiatrist). MD #2 stated, " ... For patients with psychiatric issues, they (patients) are seen by the (crisis worker) for evaluation ...Then, the psychiatrist will be contacted regarding the disposition ... I can't recall the name of the (crisis worker) or the nurse I talked to ... I don't remember if I ordered to discharge (Pt. #1) ... I can't recall who called me about (Pt. #1) ..." If a patient comes to the ED with a petition for involuntary admission, MD #1 stated, " ... Patients should be seen by a psychiatrist as soon as possible or within 24 hours ... I don't recall that she (Pt. #1) had a petition for involuntary admission ... If I see a patient, there should be a documentation of the evaluation ..."

7. On 5/22/19 between 9:37 AM and 9:50 AM, a telephone interview was conducted with MD #3 (Medical Director ED). MD #3 stated, "For patients... with a petition for involuntary admission, patients should be seen by a psychiatrist within 24 hours ... The psychiatrist is the one who can clear for any psychiatric problem ... The goal is for the patient to be safe ..."

B. Based on document review and interview, it was determined that the Hospital failed to ensure that the Hospital's Bylaws and the Rules and Regulations of the Medical Staff included a qualified person to perform a medical screening exam.

Findings include:

1. On 5/21/19 at approximately 11:10 AM, the Hospital's Bylaws (amended 5/2017) and the Rules and Regulations of the Medical Staff (amended 8/2017) was reviewed. The Bylaws and the Rules and Regulations of the Medical Staff failed to include who had been deemed appropriate to perform medical screening exam in the Emergency Department.

2. On 5/21/19 at approximately 11:15 AM, findings were discussed with E #2 (Vice President for Patient Care). E # 2 stated that she (E #2) could not find the qualified medical professional deemed appropriate to perform medical screening exam specified in the Hospital's Bylaws and the Rules and Regulations of the Medical Staff.

3. On 5/21/19 at approximately 12:15 PM, findings were discussed with E # 1(Vice President, Quality and Compliance). E #1 stated that, a qualified person to perform medical screening exam is in the policy but not in the Hospital's Bylaws.

Based on document review and interview, it was determined that for 1 of 2 (Pt. #1) patients that presented to the ED, with a petition for involuntary admission, the Hospital failed to ensure that an appropriate transfer was provided.

Findings include:

1. On 5/21/19 at approximately 11:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 48 year old female who presented to the Emergency Department (ED) on 5/10/19 with complaint of anxiety and situational crisis:

- The Hospital's Emergency Room Triage Report dated 5/10/19 included, " ... Arrival Time: 9:08 AM ... Mode of arrival: automobile, accompanied by: Police, Informant: Police ... (Pt. #1) ran away from group home today ..."

- A Petition for Involuntary Admission/Judicial Admission completed by Chicago Police Department (CPD), dated 5/10/19 included, "... (Pt. #1) who is asserted to be a person subject to involuntary in-patient admission ... a person with mental illness who: because of his or her illness is reasonably expected, unless treated on an inpatient basis ... in need of immediate hospitalization for the prevention of such harm ... above listed ran away from group home ... danger to self because she's running away... 4A. If you are subject to involuntary admission (mentally ill) you must be examined within 24 hours ... by a psychiatrist ..."

- The History and Physical Notes of MD #1 (ED Medical Doctor) dated 5/10/19 at 9:55 AM included, " ... (Pt. #1) was sent to group home 2 days ago from (the Hospital.) (T)his morning (Pt. #1) ran away ...states they do not let her come out of her room ... (History) obtained from (Pt. #1) ... Past Medical History ... Mental Retardation ... Final Disposition: OBS (observation) ... referred to HRDI (Human Resource Developmental Institute/Crisis Worker)/Psych (Psychiatry), Final Diagnosis: Schizoaffective (disorder) - social problems ..."

- The Assessment Notes of E #5 (ED Registered Nurse) on 5/10/19 at 10:36 AM and at 10:51 AM included, "...Patient reported problems: aggressive behavior... Coping skills inadequate ... agitation ..." At 11:08 AM, E #5 documented, " ... HRDI on unit...to evaluate (Pt. #1) ... (MD #2/Psychiatrist) advised to discharge back to the group home ..."

- The clinical record lacked HRDI's psychiatric evaluation, psychiatrist's examination and physician's order for discharge.

-The clinical record also lacked documentation of how and where Pt. #1 was transferred to.

2. On 5/21/19 at approximately 11:45 AM, the Hospital's Emergency Department Log dated 5/10/19 included, "... Discharged ... (Pt. #1) ..."

3.. On 5/22/19 at approximately 9:00 AM, findings were discussed with E #1 (Vice President, Quality and Compliance) and E #2 (Vice President for Patient Care). Both E #1 and E #2 stated that the clinical record of Pt. #1 did not include HRDI's psychiatric evaluation, psychiatrist's examination and physician's order for discharge.

4. On 5/22/19 between 8:59 AM and 9:27 AM, an interview was conducted by MD #2 (Psychiatrist). MD #2 stated, " ... For patients with psychiatric issues, they (patients) are seen by the (crisis worker) for evaluation and assessed by the nurse. Then, the psychiatrist will be contacted regarding the disposition (if a patient will be admitted or discharged) ... I can't recall the name of the (crisis worker) or the nurse I talked to ... I don't remember if I ordered to discharge (Pt. #1) ... I can't recall who called me about (Pt. #1) ... " If a patient comes to the ED with a petition for involuntary admission, MD #1 stated, " ... Patients should be seen by a psychiatrist as soon as possible or within 24 hours ... I don't recall that she (Pt. #1) had a petition for involuntary admission ... If I see a patient, there should be a documentation of the evaluation ..."

5. On 5/22/19 between 9:37 AM and 9:50 AM, a telephone interview was conducted with MD #3 (Medical Director, ED). MD #3 stated, "For patients coming in with a petition for involuntary admission, patients should be seen by a psychiatrist within 24 hours ... The psychiatrist is the one who can clear for any psychiatric problem ... The goal is for the patient to be safe ..."

6. On 5/22/19 between 1:03 PM and 1:13 PM, an interview was conducted with E #3 (Clinical Director, ED). E #3 stated, " ... If patients come from a group home, we always call the group home to make sure someone is there to receive the patient ...The charge nurse will make the arrangement ...There needs to be an order to discharge the patient...These should have been documented ... I don't see the documentation in the chart ..."