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Based on observation, interview and policy review, the hospital failed to post required Emergency Medical Treatment and Labor Act (EMTALA) signage that would likely be seen by patients in the ambulance entrances (A-2402), failed to track the care of one patient who presented to the psychiatric emergency service seeking care for an emergency medical condition in the emergency room log (A-2405), and failed to ensure staff performed an appropriate medical screening exam for a patient that presented to the emergency department requesting treatment of a medical condition (A-2406). This affected one (Patient #3) of 20 patients reviewed.

Based on observation and interview, the hospital failed to post Emergency Medical Treatment and Labor Act (EMTALA) signage at ambulance entrances so that patients would likely see them. This had the potential to affect all patients entering the emergency departments through the ambulance entrance.

Findings include:

The facility's main ED, called Center for Emergency Care (CEC), was toured on 03/13/23 at 11:25 AM. Patients with their family members were observed sitting in chairs in the lobby. A large Emergency Medical Treatment and Labor Act (EMTALA) sign, approximately 45 inches in width by 30 inches in height, was affixed to a wall to the right of an information desk in the waiting area. The sign was visible for patients and visitors to see. Each pod making up the 62 bed ED was toured. Upon entrance to the building at the ambulance entrance, there was no EMTALA signage. Staff B was asked the whereabouts of the EMTALA sign. Staff B pointed to a small EMTALA sign enclosed in a 8.5 inch by 11 inch frame. The framed sign was affixed to a wall at approximately six feet just inside the doors of the ambulance entrance. It was confirmed with Staff B and Staff C during the tour that given the small size and the height the EMTALA sign was posted at the ambulance entrance, patients entering the ED by stretcher would likely not see the sign.

The facility's 15 bed Psychiatric Emergency Service (PES) was toured on 03/14/23 at 12:00 PM. A large EMTALA sign was observed in the waiting area. At the ambulance entrance there was no EMTALA signage posted. The absence of the required EMTALA signage was confirmed with Staff B, Staff I, and Staff J during tour on 03/14/23.

Based on record review, staff interview, and review of the Psychiatric Emergency Services (PES) emergency room log, the facility failed to track the care of one patient who presented to the PES seeking care for an emergency medical condition. This affected one (Patient #3) of 20 patients. The facility's total census was 476.

Findings include:

Review of the medical record of Patient #3 revealed the patient arrived to the CEC on 2/9/23 at 12:59 AM with complaints of bilateral foot pain for two weeks. According to a triage note, the patient stated: "I have been walking a lot." The patient had a past medical history of psychosis. The patient reported being exposed to persistent low temperatures due to his homelessness and believed there was a high probability of frostbite. The patient also complained of left knee pain. Review of the ED Course revealed the patient's toes were examined and there was no sign of necrosis. The patient was medicated with Toradol (medication used in the treatment of moderate to severe pain) to treat his complaints of pain. An x-ray of the knee was completed which showed no acute abnormality. The patient was provided with social work resources due to his homelessness and was given follow-up information with orthopedics to be completed on an outpatient basis for his knee. The emergency physician stated the following in a progress note: "At this time, the patient is hemodynamically stable, and I do not see any evidence of any emergency medical condition requiring emergent stabilization. A nurse's note at 12:55 PM stated the patient became agitated, "punching air," and was verbally aggressive. The patient was escorted out by security prior to being provided discharge instructions. The patient was discharged from the facility at 12:59 PM.

The patient presented to CEC the next day on, 2/10/23 at 3:25 AM. The patient again, complained of bilateral foot pain. The patient reported walking more than 20 miles in a typical day due to his homelessness. An assessment of the patient's feet by an emergency physician revealed no redness or warmth and the patient denied any trauma to his feet. A note stated that the patient was also interested in talking to a social worker about additional resources that may be available. A note composed by a social worker stated the patient requested a "Greyhound bus pass, a place to go right now, and psych services." The social worker informed the patient she was unable to provide a Greyhound bus pass. The patient requested that he "wanted to talk to psych services now." The medical social worker notified the psych social worker of the patient's request to speak with him. A progress note by a behavioral health social worker at 5:00 AM stated he briefly met with the patient to "assess for psychiatric needs." The patient requested to see a "psychiatrist or psychologist" for some counseling. The social worker noted the patient "was just here in CEC recently and was given referrals by psych social work at that time." The patient denied suicidal or homicidal ideations but "would maybe like some medications to get himself back on track." The social worker suggested that the patient contact a community agency for "referrals and assistance during regular business hours." When the patient stated that these services would be limited, the social worker informed the patient he could "go to PES on his own" if he desired. The patient was discharged at 5:03 AM.

Staff L was interviewed on 3/15/23 at 9:35 AM. According to Staff L, she was informed by Staff I and Staff J that Patient #3 was escorted by police to PES the morning of 2/10/23 at which time it was "very busy." A charge nurse admitted that she told the patient it would be awhile before being seen and he may be seen quicker if he went somewhere else. Staff L stated the nurse "genuinely thought this was the best thing for the patient."

The medical record from an outside hospital for Patient #3 was reviewed on 3/15/23 at 2:00 PM. An emergency physician's progress note at 11:06 AM on 2/10/23 stated the following: "Patient presents emergency room via University of Cincinnati police with complaints of agitation and combative behavior. Patient was acutely agitated and aggressive with staff and myself. Unfortunately the patient needed to be chemically and mechanically restrained." According to a nurse's note, it required three security guards and several staff members at the bedside to assist in order to administer intramuscular (IM) medication. The patient was medicated with Geodon (a psychotropic medication used to treat symptoms of schizophrenia and acute manic or mixed episodes associated with bipolar disorder) 20 milligrams (mg) IM.

The patient was admitted to the psychiatric unit on 2/10/23 at 2:45 PM for further evaluation and psychiatric management. The patient was discharged home on 2/11/23 at 3:16 PM.

The PES emergency room log from 1/1/23 through 2/15/23 was reviewed on 3/14/23 at 2:45. Patient #3's name and medical number were missing from the emergency log on 2/10/23.

Staff A and Staff B were interviewed on 3/15/23 at 2:50 PM. It was confirmed that the PES emergency room log lacked evidence that care of Patient #3, a patient that presented to this dedicated emergency department seeking care for an emergency medical condition, was tracked as required.

Based on record review, facility policy review, and staff interview, the facility failed to ensure staff followed the current facility policy related to performance of an appropriate medical screening exam for one patient that presented to the emergency department requesting treatment of a medical condition. This affected one (Patient #3) of 20 sampled patients.

Findings include:

Review of the medical record of Patient #3 revealed the patient arrived to the CEC on 2/9/23 at 12:59 AM with complaints of bilateral foot pain for two weeks. According to a triage note, the patient stated: "I have been walking a lot." The patient had a past medical history of psychosis. The patient reported being exposed to persistent low temperatures due to his homelessness and believed there was a high probability of frostbite. The patient also complained of left knee pain. Review of the ED Course revealed the patient's toes were examined and there was no sign of necrosis. The patient was medicated with Toradol (medication used in the treatment of moderate to severe pain) to treat his complaints of pain. An x-ray of the knee was completed which showed no acute abnormality. The patient was provided with social work resources due to his homelessness and was given follow-up information with orthopedics to be completed on an outpatient basis for his knee. The emergency physician stated the following in a progress note: "At this time, the patient is hemodynamically stable, and I do not see any evidence of any emergency medical condition requiring emergent stabilization. A nurse's note at 12:55 PM stated the patient became agitated, "punching air," and was verbally aggressive. The patient was escorted out by security prior to being provided discharge instructions. The patient was discharged from the facility at 12:59 PM.

The patient presented to CEC the next day on, 2/10/23 at 3:25 AM. The patient again, complained of bilateral foot pain. The patient reported walking more than 20 miles in a typical day due to his homelessness. An assessment of the patient's feet by an emergency physician revealed no redness or warmth and the patient denied any trauma to his feet. A note stated that the patient was also interested in talking to a social worker about additional resources that may be available. A note composed by a social worker stated the patient requested a "Greyhound bus pass, a place to go right now, and psych services." The social worker informed the patient she was unable to provide a Greyhound bus pass. The patient requested that he "wanted to talk to psych services now." The medical social worker notified the psych social worker of the patient's request to speak with him. A progress note by a behavioral health social worker at 5:00 AM stated he briefly met with the patient to "assess for psychiatric needs." The patient requested to see a "psychiatrist or psychologist" for some counseling. The social worker noted the patient "was just here in CEC recently and was given referrals by psych social work at that time." The patient denied suicidal or homicidal ideations but "would maybe like some medications to get himself back on track." The social worker suggested that the patient contact a community agency for "referrals and assistance during regular business hours." When the patient stated that these services would be limited, the social worker informed the patient he could "go to PES on his own" if he desired. The patient was discharged at 5:03 AM. The medical record lacked documentation that the patient was transported to PES via the mobile care shuttle.

Staff L was interviewed on 3/15/23 at 9:35 AM. According to Staff L, she was informed by Staff I and Staff J that Patient #3 was escorted by police to PES the morning of 2/10/23 at which time it was "very busy." A charge nurse admitted that she told the patient it would be awhile before being seen and he may be seen quicker if he went somewhere else. Staff L stated the nurse "genuinely thought this was the best thing for the patient."

The medical record from the outside hospital for Patient #3 was reviewed on 3/15/23 at 2:00 PM. An emergency physician's progress note at 11:06 AM on 2/10/23 stated the following: "Patient presents emergency room via University of Cincinnati police with complaints of agitation and combative behavior. Patient was acutely agitated and aggressive with staff and myself. Unfortunately the patient needed to be chemically and mechanically restrained." According to a nurse's note, it required three security guards and several staff members at the bedside to assist in order to administer intramuscular (IM) medication. The patient was medicated with Geodon (a psychotropic medication used to treat symptoms of schizophrenia and acute manic or mixed episodes associated with bipolar disorder) 20 mg IM.

The patient was admitted to the psychiatric unit on 2/10/23 at 2:45 PM for further evaluation and psychiatric management. The patient was discharged home on 2/11/23 at 3:16 PM.

The facility policy titled Emergency Medical Treatment and Labor Act, last reviewed/revised on 11/30/21, was reviewed on 3/15/23. According to the policy facilities that have a dedicated emergency department must comply with the EMTALA. The facilities that are subject to EMTALA will provide an appropriate medical screening examination for all individuals (including children) presenting to the dedicated emergency department requesting examination or treatment of a medical condition. All individuals who come to the emergency department and all individuals who present on hospital property requesting examination or treatment of an emergency medical condition or who reasonably appear to need examination or treatment for an emergency medical condition shall receive an appropriate medical screening examination by qualified medical personnel. Transfers of patients from the facility to other facilities will be done in a medically appropriate manner.

Staff A and Staff B were interviewed on 3/15/23 at 2:50 PM. It was confirmed that the medical record of Patient #3 lacked documentation a medical screening exam was performed after the patient presented to a dedicated emergency department for medical treatment.