HospitalInspections.org

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Based on medical record (MR) review, document review and interview, the hospital failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA).

This failure potentially placed psychiatric patients at increased risk of adverse outcomes.

Findings:

The hospital failed to provide appropriate medical screening exams (MSE) within their capability and capacity, for six (6) of nine (9) psychiatric patients presenting to the Emergency Department (ED).

(See Tag A-2406)

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Based on medical record (MR) review, document review, and interview, in six (6) of nine (9) MRs, the hospital failed to provide psychiatric patients with an appropriate medical screening exam (MSE) within its capability and capacity. Specifically, no physical examinations were conducted for Patients #1, #2, #3, #4, #5 and #7.

This lapse in physical examinations potentially placed all psychiatric patients at increased risk for adverse events, including Emergency Medical Conditions (EMCs) potentially going unrecognized and/or untreated.

Findings:

The Hospital Medical Staff Bylaws dated 02/08/2023 stated, "All Medical Staff members are required to comply with their obligations under the Emergency Medical Treatment and Labor Act and its corresponding regulations. The purpose of this requirement is to assure that all patients are screened and stabilized within the capability of this Hospital, as required by law. All physician and dentist members of the Medical Staff are authorized to conduct appropriate medical screening examinations."

The facility policy and procedure (P&P) titled, "Emergency Medical Treatment & Labor Act Requirements & Compliance," effective 07/06/2021, stated, "An EMTALA obligation is triggered when an individual comes by him or herself or with another person to the Hospital's Emergency Department and a request is made by the individual or on the individual's behalf, or a prudent layperson observer would conclude from the individual's appearance or behavior there is a need for a medical examination or treatment of a medical condition. In such case the Hospital has incurred an obligation to provide an appropriate medical screening examination for the individual and stabilizing treatment or an appropriate transfer."

The facility P&P titled, "Medical Records Patient Specific Data and Information," last reviewed 09/16/2020 stated, "The medical record content shall be pertinent, current, legible, and complete. It shall include identification data; ...chief complaint; and history and physical examination."

Review of Patient #1's MR identified the following: This 14-year-old presented to the ED via Emergency Medical Services (EMS) on 03/10/2023 at 11:18AM for a "Mental health evaluation after aggressive and threatening behaviors, including homicidal ideation towards her school psychologist." Patient #1 had a psychiatric history of Bulimia Nervosa and Anxiety. Patient #1 was triaged at 11:37AM and an Emergency Severity Index (ESI - a tool used to categorize ED patients by acuity and resource needs) Level 3 was assigned. Patient #1 was evaluated by a psychiatrist at 1:53PM. There was no documented evidence a physical examination was performed. On 03/14/2023, four (4) days after discharge, Patient #1 returned to the ED with escalating violent behaviors that included physical assault towards her mother. A physical examination was performed for Patient #1 during the second ED encounter (visit), but not during the first encounter on 03/10/2023.

During interview of Staff G (Chief Executive Officer) on 04/25/2023 at 2:20PM, Staff G confirmed that although the MRs contained a section titled, "Past Medical History/ROS [Review of Systems] and Physical Exam," no physical examination findings were found for Patient #1's first encounter to the ED.

Review of Patient #2's MR identified the following: This 13-year-old presented to the ED via EMS on 03/09/2023 at 4:02PM for a "Mental health evaluation after an angry outburst with mom and expressing homicidal ideation towards her mother." Patient #2 denied medical or psychiatric history. Patient #2 was triaged at 4:06PM and an ESI Level 3 assigned. Patient #2 was evaluated by a psychiatrist at 6:00PM. There was no documented evidence a physical examination was performed.

Review of Patient #3's MR identified the following: This 7-year-old presented to the ED via EMS on 03/10/2023 at 10:07PM for a "Mental health evaluation as patient verbalized suicidal ideation after a tantrum." Patient #3 had a medical history of Asthma and denied a psychiatric history. Patient #3 was triaged at 10:16PM and assigned an ESI Level 2. Patient #3 was evaluated by a psychiatrist on 03/10/2023 at 11:13PM. There was no documented evidence a physical examination was performed.

Similar findings were identified for Patients #4, #5 and #7, where no documented evidence that psychiatric MSEs included a physical examination were found. Specifically, Patient #4 arrived at Triage on 4/24/2023 at 9:43AM and was discharged home on 4/24/2023 at 11:04AM. Patient #5 arrived at Triage on 3/7/2023 at 3:36PM and was admitted inpatient on 3/8/2023 at 12:42PM. Patient #7 arrived at Triage on 4/24/2023 at 9:47AM and was discharged home on 4/24/2023 at 3:38PM.

During interview of Staff G (Chief Executive Officer) on 04/25/2023 at 2:20PM, Staff G confirmed that all ED physicians should perform physical examinations on all patients entering the ED.

The facility failed to ensure physical examinations were provided to Patients #1, #2, #3, #4, #5 and Patient #7.