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Based on hospital policy review, medical record review, provider interview, and staff interview the hospital failed to provide an appropriate medical screening examination and stabilize a patient within the capability of the hospital's dedicated emergency department (DED), for 1 of 22 patients that presented to the DED for evaluation and treatment. Additionally, the hospital is not in compliance with 42 CFR §489.20 and §489.24.

Findings included:

1. The hospital's Dedicated Emergency Department (DED) failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, for 1 of 22 patient's who presented to the DED for evaluation and treatment (Patient #17).

Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A2406.

2, The hospital's DED failed to provide further medical examination and treatment to stabilize a patient within the capability of the hospital's DED, for 1 of 22 patient's who presented to the DED for evaluation and treatment (Patient #17).

Cross refer to §489.24(d) Necessary Stabilizing Treatment - Tag A2407.

Based on hospital policy review, medical record review, provider interview, and staff interview the hospital's Dedicated Emergency Department (DED) failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists for 1 of 22 patient's who presented to the DED for evaluation and treatment (Patient #17).


The findings were:

Review on 08/14/2019 of the "EMTALA - Emergency Medical Treatment and Labor Act" last revised 04/2017 revealed "...A. Medical screening examination 1. Individuals (including minors) entitled to a medical screening examination a) Individuals in the dedicated emergency department (ED) seeking medical care - When an individual comes to the dedicated emergency department of the hospital, and a request is made on the individual's behalf for a medical examination or treatment, the hospital shall provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition exists..."

DED record review, on 08/14-15/2019, revealed Patient #17 arrived to the DED by private vehicle on 05/16/2019 at 0039 with a chief complaint of "SI (suicidal ideations), throwing up blood." Triage notes, performed 05/16/2019 at 0041, stated the patient complained of "Abdominal Pain (with blood in emesis, blood in stool) Suicidal." The triage assessment note revealed Patient #17 had a positive suicide screening. Vital signs were recorded as Temperature (T) 98.5, Pulse (P) 74, Respirations (R) 20, Blood Pressure (BP) 121/78, and SpO2 100% on room air. A pain score of 9 (on a scale of 1-10, with 10 being worst pain) was documented, with pain location noted as "abdomen." The patient was triaged as level 2 emergent. Patient #17 was roomed at 0050 and seen by a provider at 0053. Review of the Nurse Practitioner (NP #1) documentation at 0102, revealed " ...(Patient #17) is 39 y.o ....with PMH of COPD (past medical history chronic obstructive pulmonary disease), stomach ulcers, bipolar disorder, antisocial personality disorder, asthma, depression and anxiety presents with abdominal pain, vomiting blood, blood in stool and suicidal thoughts. He reports that his SI started this morning. He reports that he had some intermittent vomiting for the last 2 days with some blood in it. He reports that it was red. He reports decreased intake. He reports that this morning he saw red blood in his stool as well ....He reports abdominal pain for the last 2 days ..... Abdominal Pain Associated symptoms: nausea and vomiting Suicidal Presenting symptoms: suicidal thoughts Associated symptoms: abdominal pain and appetite change .... Physical Exam ....Constitutional: Vitals signs normal He appears well-developed and well-nourished. He is active and cooperative .... Abdominal: Soft. Bowel sounds are normal. Rectal: Fecal occult blood test negative .... Neurological: he is alert and oriented to person, place, and time. Moves all extremities equally. Gait normal. He has normal speech .... Psychiatric: He has a normal mood and affect. His speech is normal. His behavior is normal. He expresses suicidal ideation .... On chart review via care everywhere he was seen yesterday afternoon for the same that (as written) and had CT scan done there which was negative Will obtain labs, xr (xray) of abd (abdomen) Hemoocult is negative UDS: cannabinoid +, opiates + UA: cloudy, sg>1.030, 30 protein, small bilirubin, 6RBCs, rare bacteria, many mucous Labs without gross abnormalities XR of abd without acute findings Consulted BH...(BH assessor) has seen patient and recommends staying will reassess in the morning BH (behavioral health) orders placed and results discussed with patient..." Review of the nursing assessment on 05/16/2019 at 0100 revealed "Patient Reports: Nausea; Vomiting; Loss of appetite (Patient states that he has been vomiting blood. Patient denies swallowing any objects. Patient is not currently vomiting here in ED) ...Patient Behaviors/Mood/Affect: Calm; Cooperative; Appropriate for situation; SUICIDAL ..." Review revealed Patient #17 at 0100 was searched and changed into paper scrubs and his belongings were collected. Review of the "Columbia-Suicide Severity Rating Scale" at 0100 revealed Patient #17 resulted as high risk for suicide. Review of the Social Worker note at 0222 revealed "39 yo male significant for antisocial/borderline DO presents to ED with increasing SI. Pt has hx of swallowing razors/sharps and cutting (sic). Most recent attempted while incarcerated in March. He has multiple presentations at (Hospital Name) for same- last one yesterday. He also has hx of drug seeking and generally does not avail himself of outpatient resources. He reports decrease in sleep and appetite and is not able to contract for safety at this time. Further evaluation recommended to assess risk of self-harm at this time and reviewed w (NP #1) Med rec requested." Review of the "Lifetime/Recent Suicide Screening" at 0229 by SW #1 revealed " ...5. Have you had any active suicidal ideation with specific plan and intent?: No ...BH Access Recommendations: BH Access Suicide Risk Recommendations: Moderate risk Environmental Restrictions: remove objects that may be swallowed ...continue SI protocol ..." Review of the abdominal x-ray, resulted at 0230 revealed "...XR ABDOMEN ACUTE SERIES ....IMPRESSION: No acute findings in the chest or abdomen. ..." Review of a nursing note at 0309 revealed "Attempted to call report to ED BH, states that they will look at his stuff and will call back ..." Review revealed at 0359 Patient #17 was transferred to the Behavioral Health ED Holding Area. Review of a nursing note at 0422 revealed "Pt walked up to the nurse's station and said 'You might want to send me downstairs to the ED, I just swallowed the batteries in my TV remote.' On inspection, the batteries were missing. Pt's ED Provider was notified. Said she'll put in an order for an Xray." Review revealed an order for an abdominal x-ray was placed by NP #1 at 0425. Review revealed Patient #17 was transferred back to the main ER at 0453 and an abdominal x-ray resulted at 0455. Review of the abdominal x-ray revealed "...INDICATION: Swallowed battery.... FINDINGS: ....6.3 cm radiopaque foreign body is projecting overlying midline of the abdomen at L4-L5 level ....IMPRESSION: 1. Radiopaque foreign body projecting overlying mid abdomen. 2. Nonobstructive bowel gas pattern. 3. Lungs are clear. ..." Further review of Nurse Practitioner Notes revealed "...Discussed results with patient Consulted GI, Discussed case with Dr. (name), reviewed HPI, PMH and results of work up here Patient will return to EDBH 550am: called to patient's room as he was throwing the wheelchair and refusing to go back upstairs to EDBH. He reports that he needs these batteries out right now and that we are not doing anything for him. Discussed again with him that I had spoken with the GI doctor who will be seeing him tomorrow that he does not emergently need to go to surgery. He told me that he was just going to leave and go somewhere that would take the batteries out now. I discussed his suicidal ideations that mentioned upon arrival again with him, he reports that he only said he was suicidal so that we would do more testing for his stomach pain. I discussed with him that I would have worked him up for stomach pain the same as whether he told me he had suicidal ideations or not. He has denied any suicidal ideations at this time and continues to say that he only told us that he was having suicidal thoughts so that we would see him for his abdominal pain. Discussed with patient the recommendation of him staying to be evaluated by GI in the morning as well as psychiatry but he continues to refuse and will be leave AGAINST MEDICAL ADVICE..." Review of the nursing notes at 0606 revealed "Patient refusing to go back up to behavioral health and denies being suicidal. Patient continues to state that he only said that he wanted to hurt himself so that he would be seen for his stomach. Patient ripped his IV catheter out and threw it across the room. Security already at bedside, as they were called to escort patient with sitter back up to behavioral health. Patient given his belongings per provider and patient refused to wait for AMA form and discharge papers. Patient escorted out by security. Patient refused to have vital signs checked." Review of the Patient Care Timeline "Refusal of Care-Patient Choice" at 0609 by NP #1 revealed "Patient Choices/Refusals To be hospitalized ...Refused ...The benefits of the recommended care are::Evaluation by GI, psychiatric help ...The risks of declining the recommended care are:: Continuing abdominal pain, inability to pass foreign body ...The patient stated the decision not to have the recommend care is because:: Other ...'I want the batteries out now.'" Review of the "Refusal of Care - Patient Choice" Form, revealed a handwritten note on the signature line "Pt refused to sign" and was dated 05/16/2019 at 0613. Review revealed Patient #17 left Hospital A at 0610. Review of SW #1's notes at 0610 revealed "Consulted w ED provider concerning pt requesting d/c after returning to ED from EDBH. Pt denying any SI and states he only said that to get in hospital for stomach pain. Confirmed with provider that pt never endorsed any plan or intent at assessment and was low risk for suicide ..."

Interview with SW #1, on 08/14/2019 at 1930 revealed Patient #17 recanted all suicidal ideation before leaving the ED. Interview revealed the patient swallowed items, but the SW saw it as more of a "compulsive" behavior than suicidal.

Interview on 08/14/2019 at 1745 with NP #1 revealed she did not recall Patient #17. Interview revealed after reviewing her notes she was called by the behavioral health RN and told Patient #17 had swallowed batteries. Interview revealed NP #1 placed an order for an abdominal x-ray. Interview revealed Patient #17 had swallowed batteries and NP #1 consulted gastroenterology who said they would see him in the morning and Patient #17 did not need emergency surgery. Interview revealed NP #1 discussed with Patient #17 why he wanted to leave, and she thought it was "fine" Patient #17 wanted to leave AMA, NP #1 "didn't think (he was) suicidal."

In summary, Patient #17 arrived to the Emergency Department with complaints of suicidal ideation and abdominal pain. The patient was seen by the ED provider. At 0100 Patient #17 was noted by suicide risk screen to be high risk and and at 0222 it was noted the patient could not contract for safety and needed further evaluation. Patient #17 was medically cleared and moved from the main ED to the ED Behavioral Health Unit for care. While in the BHU, Patient #17 swallowed batteries, was sent back down to the main ED and had xrays which showed an abdominal foreign body. Gastroenterology (GI) was consulted and stated the patient did not need emergency removal at that time and a GI physician would see the patient in the AM. Patient #17 demanded the batteries be removed immediately or leave and after review of risks and benefits the patient was allowed to leave AMA. Patient #17 was originally determined to need to stay for further evaluation, then swallowed batteries, then later stated he only voiced suicidal ideation to get abdominal pain evaluated, demanded to leave or immediate battery removal, threw a wheelchair and pulled out an IV. The medical screening examination was not completed. With some claims and risk of suicidal ideation, swallowing a foreign body, and irrational behavior it is difficult to determine that Patient #17 was no longer a danger to himself and had the capacity to sign out against medical advice.

Based on hospital policy review, medical record review, provider interview, and staff interview the hospital's DED failed to provide further medical examination and treatment to stabilize a patient within the capability of the staff and facilities available at the hospital's DED as required, for 1 of 22 patient's who presented to the DED for evaluation a and treatment (Patient #17).

Review on 08/14/2019 of the "EMTALA - Emergency Medical Treatment and Labor Act" policy last revised 04/2017 revealed "...C. Stabilization of individuals in the dedicated emergency department who have an emergency medical condition 1. General standards - Individuals in the dedicated emergency department who have an emergency medical condition shall receive necessary stabilizing treatment or an appropriate transfer to another medical facility...5. Individuals with psychiatric conditions...the individual is considered to be stable when he or she is protected and prevented from injuring himself or herself or others. For purposes of discharging an individual with a psychiatric condition, the individual is considered to be stable when the individual is not longer considered to be a threat to himself or herself or others...3. Voluntary withdrawals - If an individual chooses to withdraw his or her request for examination or treatment, the hospital shall: a. Offer the individual further medical examination and treatment within the capabilities of the Team Members and facilities available at the hospital as may be required to identify and stabilize an emergency medical condition..."

DED record review, on 08/14-15/2019, revealed Patient #17 arrived to the DED by private vehicle on 05/16/2019 at 0039 with a chief complaint of "SI, throwing up blood." Triage notes, performed 05/16/2019 at 0041, stated the patient complained of "Abdominal Pain (with blood in emesis, blood in stool) Suicidal." The triage assessment note revealed Patient #17 had a positive suicide screening. Vital signs were recorded as Temperature (T) 98.5, Pulse (P) 74, Respirations (R) 20, Blood Pressure (BP) 121/78, and SpO2 100% on room air. A pain score of 9 (on scale of 1-10, with 10 being worst pain) was documented, with pain location noted as "abdomen." The patient was triaged as level 2 emergent. Patient #17 was roomed at 0050 and seen by a provider at 0053. Review of the Nurse Practitioner (NP #1) documentation at 0102, revealed " ...(Patient #12) is 39 y.o ....with PMH of COPD, stomach ulcers, bipolar disorder, antisocial personality disorder, asthma, depression and anxiety presents with abdominal pain, vomiting blood, blood in stool and suicidal thoughts. He reports that his SI started this morning. He reports that he had some intermittent vomiting for the last 2 days with some blood in it. He reports that it was red. He reports decreased intake. He reports that this morning he saw red blood in his stool as well ....He reports abdominal pain for the last 2 days ..... Abdominal Pain Associated symptoms: nausea and vomiting Suicidal Presenting symptoms: suicidal thoughts Associated symptoms: abdominal pain and appetite change .... Physical Exam ....Constitutional: Vitals signs normal He appears well-developed and well-nourished. He is active and cooperative .... Abdominal: Soft. Bowel sounds are normal. Rectal: Fecal occult blood test negative .... Neurological: he is alert and oriented to person, place, and time. Moves all extremities equally. Gait normal. He has normal speech .... Psychiatric: He has a normal mood and affect. His speech is normal. His behavior is normal. He expresses suicidal ideation .... On chart review via care everywhere he was seen yesterday afternoon for the same that (as written) and had CT scan done there which was negative Will obtain labs, xr (xray) of abd (abdomen) Hemoocult is negative UDS: cannabinoid +, opiates + UA: cloudy, sg>1.030, 30 protein, small bilirubin, 6RBCs, rare bacteria, many mucous Labs without gross abnormalities XR of abd without acute findings Consulted BH...(BH assessor) has seen patient and recommends staying will reassess in the morning BH orders placed and results discussed with patient..." Review of the nursing assessment on 05/16/2019 at 0100 revealed "Patient Reports: Nausea; Vomiting; Loss of appetite (Patient states that he has been vomiting blood. Patient denies swallowing any objects. Patient is not currently vomiting here in ED) ...Patient Behaviors/Mood/Affect: Calm; Cooperative; Appropriate for situation; SUICIDAL ..." Review revealed Patient #17 at 0100 was searched and changed into paper scrubs and his belongings were collected. Review of the "Columbia-Suicide Severity Rating Scale" at 0100 revealed Patient #17 resulted as high risk for suicide. Review of the Social Worker note at 0222 revealed "39 yo male significant for antisocial/borderline Disorder(DO) (A mental condition in which a person consistently show no regard for right and wrong, & violates the law) presents to ED with increasing SI. Pt has hx of swallowing razors/sharps and cutiing (sic). Most recent attempted while incarcerated in March. He has multiple presentations at (Hospital Name) for same- last one yesterday. He also has hx of drug seeking and generally does not avail himself of outpatient resources. He reports decrease in sleep and appetite and is not able to contract for safety at this time. Further evaluation recommended to assess risk of self-harm at this time and reviewed w (NP #1) Med rec requested." Review of the "Lifetime/Recent Suicide Screening" at 0229 by SW #1 revealed " ...5. Have you had any active suicidal ideation with specific plan and intent?: No ...BH Access Recommendations: BH Access Suicide Risk Recommendations: Moderate risk Environmental Restrictions: remove objects that may be swallowed ...continue SI protocol ..." Review of the abdominal x-ray, resulted at 0230 revealed "...XR ABDOMEN ACUTE SERIES ....IMPRESSION: No acute findings in the chest or abdomen. ..." Review of a nursing note at 0309 revealed "Attempted to call report to ED BH, states that they will look at his stuff and will call back ..." Review revealed at 0359 Patient #17 was transferred to the Behavioral Health ED Holding Area. Review of a nursing note at 0422 revealed "Pt walked up to the nurse's station and said 'You might want to send me downstairs to the ED, I just swallowed the batteries in my TV remote.' On inspection, the batteries were missing. Pt's ED Provider was notified. Said she'll put in an order for an Xray." Review revealed an order for an abdominal x-ray was placed by NP #1 at 0425. Review revealed Patient #17 was transferred to the main ER at 0453 and an abdominal x-ray resulted at 0455. Review of the abdominal x-ray revealed "...INDICATION: Swallowed battery .... FINDINGS: ....6.3 cm radiopaque foreign body is projecting overlying midline of the abdomen at L4-L5 level ....IMPRESSION: 1. Radiopaque foreign body projecting overlying mid abdomen. 2. Nonobstructive bowel gas pattern. 3. Lungs are clear. ..." Further review of Nurse Practitioner Notes revealed "...Discussed results with patient Consulted GI, Discussed case with Dr. (name), reviewed HPI, PMH and results of work up here Patient will return to EDBH 550am: called to patient's room as he was throwing the wheelchair and refusing to go back upstairs to EDBH. He reports that he needs these batteries out right now and that we are not doing anything for him. Discussed again with him that I had spoken with the GI doctor who will be seeing him tomorrow that he does not emergently need to go to surgery. He told me that he was just going to leave and go somewhere that would take the batteries out now. I discussed his suicidal ideations that mentioned upon arrival again with him, he reports that he only said he was suicidal so that we would do more testing for his stomach pain. I discussed with him that I would have worked him up for stomach pain the same as whether he told me he had suicidal ideations or not. He has denied any suicidal ideations at this time and continues to say that he only told us that he was having suicidal thoughts so that we would see him for his abdominal pain. Discussed with patient the recommendation of him staying to be evaluated by GI in the morning as well as psychiatry but he continues to refuse and will be leave AGAINST MEDICAL ADVICE(AMA)..." Review of the nursing notes at 0606 revealed "Patient refusing to go back up to behavioral health and denies being suicidal. Patient continues to state that he only said that he wanted to hurt himself so that he would be seen for his stomach. Patient ripped his IV catheter out and threw it across the room. Security already at bedside, as they were called to escort patient with sitter back up to behavioral health. Patient given his belongings per provider and patient refused to wait for AMA form and discharge papers. Patient escorted out by security. Patient refused to have vital signs checked." Review of the Patient Care Timeline "Refusal of Care-Patient Choice" at 0609 by NP #1 revealed "Patient Choices/Refusals To be hospitalized ...Refused ...The benefits of the recommended care are::Evaluation by GI, psychiatric help ...The risks of declining the recommended care are:: Continuing abdominal pain, inability to pass foreign body ...The patient stated the decision not to have the recommend care is because:: Other ...'I want the batteries out now.'" Review of the "Refusal of Care - Patient Choice" Form, revealed a handwritten note on the signature line "Pt refused to sign" and was dated 05/16/2019 at 0613. Review revealed Patient #17 left Hospital A at 0610. Review of SW #1's notes at 0610 revealed "Consulted w ED provider concerning pt requesting d/c after returning to ED from EDBH. Pt denying any SI and states he only said that to get in hospital for stomach pain. Confirmed with provider that pt never endorsed any plan or intent at assessment and was low risk for suicide ..."

Interview with SW #1, on 08/14/2019 at 1930 revealed Patient #17 recanted all suicidal ideation before leaving the ED. Interview revealed the patient swallowed items, but the SW saw it as more of a "compulsive" behavior than suicidal.

Interview on 08/14/2019 at 1745 with NP #1 revealed she did not recall Patient #17. Interview revealed after reviewing her notes she was called by the behavioral health RN and told Patient #17 had swallowed batteries. Interview revealed NP #1 placed an order for an abdominal x-ray. Interview revealed Patient #17 had swallowed batteries and NP #1 consulted gastroenterology who said they would see him in the morning and Patient #17 did not need emergency surgery. Interview revealed NP #1 discussed with Patient #17 why he wanted to leave, and she thought it was "fine" Patient #17 wanted to leave AMA, NP #1 "didn't think (he was) suicidal."

In summary, there was delay in stabilization when Patient #17, who earlier in the visit voiced suicidal ideation and was determined to be moderate - high risk of suicide, swallowed batteries, stated he only voiced suicidal ideation to get abdominal pain evaluated, refused to return to the BHU, and was allowed to leave without determining if the patient had the capacity to sign out AMA.