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The facility failed to meet the following requirements under the EMTALA regulation:

Tag C2406 - Medical Screening Exam Until Individual Is Stabilized

Based on interviews and record review, the facility failed to comply with the Medicare provider agreement as defined in §489.24 related to the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. Specifically, the facility failed to provide a medical screening exam for 1 (#14) of 25 sampled patients presenting to the emergency department. (Refer to C-2406)






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Based on interviews and record review, facility staff failed to provide an appropriate Medical Screening Exam (MSE) to a patient that presented to the Emergency Department (ED) to determine if an Emergency Medical Condition (EMC) existed for 1 (#14) of 25 sampled patients. Findings include:

During a tour of the ED on 2/24/20 at 12:43 p.m., staff member B stated the ED did not have a dedicated triage nurse assigned for this task. Staff member B stated all ED nurses were required to triage patients when they registered with the ED clerk. Staff member B stated the patient would be given an ESI/EMC status, and the patient would receive a MSE by the physician on staff.

A review of the Hospital's ED Activity Log showed patient #14 presented to the ED with his mother on 1/22/20 at 1:08 p.m. The Reason For Visit read, "MHE." Patient #14's Discharge Disposition read, "Left Without Being Seen" at 1:40 p.m.

A review of Progress Notes, in patient #14's medical record, dated 1/22/20 at 1:40 p.m., read, "Pt [sic] here after event last night where pt held a knife to his own neck and put blanket over mothers [sic] face. Pt states he was angry at his dad. Prior to arrival, pt mother was advised to go to [other Hospital's name] due to resources per [NF1] prior to arrival. Mom did say she called someone at [other Hospital's name] and they told her not to come. Pt could be transferred if he did need to stay as an in-patient. It would not be known until seen by [NF1] if he would stay in-patient or be seen as a [sic] outpatient. I discussed that I could not advise on their decisions and that they needed to make the decision on where to go. That remained up to them. They stated that they would go to [other Hospital's name] per the recommendations of [NF1]. Family was advised not to leave child alone for any amount of time and to take him directly to [other Hospital's name] ED department. They all stated understanding. grandpa [sic] thanked me and stated "Nice triage." The medical record lacked a triage assessment, with an EMC, and MSE by the ED physician.

During an interview on 2/25/20 at 8:01 a.m., staff member H stated all patients presenting to the ED should be triaged by the nursing staff to establish an EMC. All patients triaged by nursing staff would receive a MSE by the physician working in the ED. If a patient decided to leave the ED, prior to receiving a MSE or Against Medical Advice, a member of the ED would review the Risks versus Benefits and other options. Those patients would be asked to sign an AMA Form stating they understood their options and the risks associated with leaving without a MSE. If a patient refused to sign the AMA Form, ED staff would document the patient left the ED without signing the AMA documentation. The AMA would be filed into the patient's medical record.

During an interview on 2/25/20 at 8:17 a.m., staff member E stated patients presenting to the ED would be provided a MSE, with stabilizing treatment, and the patient would be safely discharged home, admitted to the hospital, or transferred for a higher tertiary of care when needed. Staff member E stated patients were triaged by nursing staff, assessed with an EMC level, and evaluated with a MSE by the physician or a mental health professional. Staff member E stated patients with the chief complaint of Suicidal Ideation (SI) would need to receive a MSE and mental health evaluation prior to being discharged from the ED. Staff member E stated, depending on the situation, if a patient wanted to leave AMA, the police department would be contacted to ensure patient was safe to be discharged.

During an interview and record review on 2/25/20 at 10:20 a.m., staff member B stated all patients presenting to the ED would be triaged by the nursing staff and the patient would receive an ESI. Staff member B stated the ESI served as the Emergency Medical Condition status; ESI Level 1 through Level 5. Review of the ESI documentation read, "ESI- Level 1: Immediate life-saving intervention required...Level 2: High risk situation is a patient you would put in your last open bed... Level 3: count the number of different types of resources, not the individual tests or x-rays...Level 4: Requires 1 resource. Level 5."

During an interview on 2/25/20 at 10:59 a.m., staff member B stated patient #14 presented to the ED with his mother and the patient was not triaged by ED staff. Staff member B stated ED staff spoke with patient #14's mother and informed the parent a Mental Health Professional would be assessing patient #14 in the ED. Patient #14's mother did not want to see the Mental Health Professional on-call. Staff member B stated patient #14 was not triaged by ED nursing staff, nor did the patient receive a MSE. Staff member B stated the hospital was on "divert" but that did not include the ED.

During an interview on 2/25/20 at 12:10 p.m., staff member C stated patient #14's mother should have been seen by the ED provider on the day they presented to the ED. Staff member C stated the hospital was obligated to see and offer all patients registering to the ED with a triage to check an ESI/EMC and MSE.

During an interview on 2/25/20 at 1:33 p.m., staff member E stated patient #14's mother had been told by the mental health professional to go to [other Hospital]. Staff member E stated patient #14 did not get triaged by the ED nursing staff and therefore did not receive a MSE. Staff member E stated all patients presenting to the ED with Suicidal Ideation or for a Mental Health Exam would be evaluated by the on-call MHP. Staff member E stated no other options are provided, except to be evaluated by the on-call MHP, even if the patient refuses those services.

During an interview on 2/25/20 at 2:49 p.m., staff member D stated she remembered patient #14 presenting to the ED on 1/22/20. Staff member D stated patient #14's mother registered the patient with the ED clerk, and patient #14's medical record labels printed on the ED printer at the desk where the physician(s) and nurses sat. Staff member D stated patient #14's information "popped" up on the ED Cerner screen and the physician asked staff member D to inquire if patient #14 was going to be seen by the mental health provider, or go to the other hospital. Staff member D stated she interviewed patient #14, his mother, and grandfather in the waiting room, and the patient's mother did not want to be evaluated by on-call mental health provider, and was not happy with previous interactions with this provider. Staff member D stated patient #14's mother "did not know what to do, so she sat and contemplated" her options. Staff member D stated the only options given to patient #14's mother were to be seen by the on-call mental health provider or drive to the next community and be seen at that hospital. Staff member D stated the physician working in the ED on 1/22/20 knew patient #14 and his family had presented to the ED. Staff member D stated patient #14 was not triaged by ED nursing staff, did not receive a MSE by the physician, and left the ED. Staff member D stated no other options were provided to the patient and his family, "he would have to see whoever [MHP] is on call." Staff member D stated an AMA was not documented, since the patient had not been triaged or assessed by the physician with an MSE. Staff member D stated she had "a little bit of EMTALA training, but needed to have more." Staff member D stated in the future, she would properly triage anyone presenting to the ED, ensure they did not have a true EMC, and have the physician provide a MSE to ensure the patient was safe. Staff member D stated patient #14 was in no apparent distress upon exiting from the ED.

A review of the Hospital's policy, EMTALA Guidelines, read, "It is the policy of [Hospital name] that all patients who present to the ED for treatment or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay. In the absence of an actual request for services, if a 'prudent layperson' observer would believe, based on the individual's appearance or behavior that the individual needs an examination or treatment for a medical condition, EMTALA still applies and the person must be accepted and evaluated for treatment...1.0- All patients shall receive a medical screening exam that includes providing all necessary testing and on call services within the capability of the hospital to reach and diagnosis."

A review of the Hospital's policy, Leaving Hospital Against Advice, read, "This is to certify that I am leaving the hospital against the advice of the attending physician and hospital administration. I acknowledge that I have been informed of the risk involved and hereby release the attending physician and the hospital from all responsibility and any ill effects which may result from this action..."