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Based on surveyor review of records and staff interviews, the facility failed to provide an appropriate Medical Screening Exam (MSE) for the assessment of every patient based on the individuals' presenting signs and symptoms, as well as the capability and capacity of the hospital. The findings include:

On 7/22/22 patient #1 was brought to the facility's emergency department [ED] by a mental health officer for bizarre behavior, command hallucinations, and paranoia.

Per the police officer's report, patient #1 believe he was being followed by an unknown individual; This belief resulted in patient #1 driving greater than 100 miles per hour on a highway and maneuvering through highway traffic attempting to evade police.


The complainant stated, "I brought the patient [patient #1] into the ER [emergency room], the doctor entered into the room and said, 'He doesn't meet inpatient criteria. It is not enough.' The doctor was in the room for 30 seconds. He was discharged before I could finish my emergency detention paperwork. I couldn't hold him on any charges. I had to let him go. We were there less than 10 minutes."

Surveyor review of patient #1's visit length revealed a length of stay of 10 minutes.

The ER provider medical decision making note dated 7/22/2022 at 0115 am reads in part, "Patient here complaining of hallucination, has history of schizophrenia and substance abuse, denies SI/HI/ AVH [suicidal ideation/ homicidal ideation/audio-visual hallucinations . . . Patient does not meet any acute inpatient psychiatric criteria, does not present a danger to self, others, will discharge. . . Patient well known to this department, this is his 5th visit in past week for similar complaint. Patient denies SI/HI, states that he feels like people are after him, command hallucination."

On 7/22/2022 01:32 am staff #16 documented, "Patient has been assessed by attending MD [medical doctor]. He states that patient does not meet criteria for acute psychiatric IPT [inpatient treatment] . . . A BH [behavioral health] assessment is reportedly not needed at this time. Return precautions discussed with patient by MD and understood by patient."

The Centers for Medicare and Medicaid Services State Operations Manual [SOM] states, "The MSE must be the same MSE that the hospital would perform on any individual coming to the hospital's dedicated emergency department with those signs and symptoms, regardless of the individual's ability to pay for medical care." SOM - Appendix V (cms.gov)

Surveyor review of an additional 14 randomly sampled behavioral health patient medical records revealed 14/14 received a MD MSE and behavioral health evaluation by the intake social worker. This suggests patient #1's medical screening exam and lack of behavioral health evaluation for the visit on 7/22/2022 was conducted in a disparate fashion.

Findings validated by staff #17. During a phone interview on 8/22/2022 at 1500 in the facility's conference room, staff #17 stated, "Our policy and the standard at this facility is to treat each patient, each visit like a new episode. It is not okay to immediately release a patient with an assessment because they are MVPs [multi visit patients]."