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Based on a review of hospital medical records, Medical Staff Rules and Regulations, Emergency Services reports, policies and procedures, and staff interviews, it was determined that the hospital failed to ensure that two patients (#21 and #31) of 34 sampled medical records received an appropriate medical screening examination (MSE) that was provided within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine if an emergency medical condition existed.

Refer to findings under A2406.

Based on a review of the facility's policies, procedures, tour of the unit, and staff interviews, the facility failed to have signs posted in the labor and delivery emergency unit waiting room specifying the rights of individuals under special responsibilities of Medicare hospitals in emergency cases and information indicating whether the hospital participates in the Medicaid program.

Findings include:

A review of the facility's policy titled, "Transfer Activities in Accordance with EMTALA Requirements," number 11101630, last approved 1/27/2022, revealed the purpose was to establish guidance for providing appropriate medical screening examinations, stabilizing treatment and appropriate transfer of patients in accordance with the Emergency Medical Treatment and Labor Act (EMTALA), and all regulations promulgated thereunder. Further review revealed the following:

Signage:
A. Signs shall be posted in a place or places likely to be noticed by all individuals entering the Emergency Department as well as those individuals waiting for examination and treatment in areas other than the Emergency Department (entrance, waiting room, admitting area, treatment area).

B. Such signs must:
1. Specify the rights of the individuals with emergency conditions and women in labor who come to the hospital for healthcare services;
2. Indicate whether the facility participates in the Medicaid program; and
3. Be clear and in simple terms and language understandable by the population served by
the hospital.

During a tour of the labor and delivery emergency unit, on 9/25/2024 at 11:11 a.m., EMTALA signage was observed on the wall behind the patient registration desk. EMTALA signage was not observed in a conspicuous location likely to be noticed by all individuals waiting for examination and treatment in the area. That is, there was no EMTALA signage posted in the waiting room. The Director of Women's Services (Dir.) WW was informed of these findings during the tour. Dir. WW acknowledged that there was no EMTALA signage posted in the waiting room and said she could not recall if there had ever been signage posted.

Based on a review of hospital records, policies and procedures, Medical Staff Rules and Regulations, and Emergency Medical Services reports, it was determined the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's Emergency Department (ED), including ancillary services routinely available to the ED to determine whether or not an emergency medical condition (EMC) existed for two patients (#21 and #31) with a complaint of suicidal ideation (SI) of 34 sampled medical records.

Findings include:

1. The facilities "MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS OF PIEDMONT HENRY HOSPITAL, Adopted by the MEC (Medical Executive Committee) on September 13, 2018, Approved by the Board on March 13, 2019, was reviewed. The policy revealed in part, "11. A. GENERAL: Emergency services and care will be provided to any person who comes to the emergency department, as that term is defined in the EMTALA [Emergency Medical Treatment and Labor Act] regulations, whenever there are appropriate facilities and qualified personnel available to provide such services or care. ... 11. B. MEDICAL SCREENING EXAMINATIONS: (1) Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified Medical Personnel ("QMP") who can perform medical screening examinations within applicable Hospital policies and procedures are defined as: (a) Emergency Department: (i) members of the Medical Staff with clinical privileges in Emergency Medicine; (ii) other Active Staff members; and (iii) appropriately credentialed Advanced Practice Professionals. ... 2. The results of the medical screening examination must be documented before the patient leaves the Emergency Department."


2. The facility's Policy titled "Piedmont Henry Hospital Emergency Department Patient Assessment and Reassessment Policy" PolicyStatID 10603466, Origination Date 4/20/2010, Last approved: 10/22/2021, Version Effective Date: 10/22/2021; Last revised 10/22/2021. The policy revealed in part, "Definitions: Assessment- the collection/interpretation of data for the purpose of matching an individual's need with the appropriate setting, care level, or intervention. ... In the ED, an assessment is performed based on the patient's acuity upon arrival and their chief complaint. ... Reassessment- the collection/interpretation of ongoing data to determine the patient's response to care delivery or interventions. Reassessments may be performed at more frequent intervals based on the patient's response to treatment or if there is any significant change in the patient's condition or diagnosis. ... Procedure: Triage: The purpose of triage is to prioritize incoming patients and identify those patients who cannot wait to be seen. Patients who do not require immediate life-saving treatment are sorted based on presenting complaint and/or severity of illness/injury. The Emergency Severity Index (ESI) is used to determine which patient prioritization and determine what resources are necessary in order to determine an ED disposition ...ESI Level 2 Frequency of Reassessments 2 hours ...ESI Level 3 Frequency of Reassessments 4 hours ...*Re-assessments will occur based on ESI level and/or as appropriate for patient condition. Re-assessments completed within 30 mins [minutes] of the designated re-assessment time will be considered compliant with this policy."

3. The facility's policy titled "Care of Behavioral Health Patients Policy" Retired: PolicyStatID 9472000, Origination Date 3/19/2019, last revised 3/19/2019. The policy revealed in part, "Definitions ...At Risk Patient- A patient who does not have an active Form 1013 or Form 2013, but who has a behavioral health history or has exhibited behavior during an admission that may indicate that the patient is at risk of causing harm to him/herself or to others ... Constant Observation- Direct visual monitoring at all times including during procedures located in other areas of the facility... This level may be initiated by nursing staff or medical staff but may only be discontinued by medical staff. ... Constant Observer (Sitter)- Individual designated adult, who is over eighteen (18), and who provides Constant Observation in close proximity to the patient or via video monitoring with, 360 degree viewing, to ensure the safety of a patient. Supervision of Constant Observers will be provided by the primary nurse assigned to the patient. ... Implementation: 1. Suicide Risk Assessment: All patients will be screened at the time of intake to determine risk for suicide and harm to self or others per the suicide assessment tool in the medial record. Scores are automatically calculated in the suicide risk flowsheet. The physician of any patient who is screened as moderate or high risk should be notified. There are three levels of suicide risk: High Risk, Moderate Risk, and Low Risk. The appropriate interventions will be followed according to the patient score/stratification ... Level of Risk: Intervention ... Moderate Risk: Notify MD that psychiatric consult is needed and/or possible 1013 form executed Psychiatric consult and/or 1013 ...Behavioral Health Case Management Referral; Provide Behavioral Health Services Resource List; Reassess every 24 hours. ... Safety Precautions for the Behavioral Health Patient: ...The following behaviors may indicate the patient is an At Risk Patient in need of additional Safety Precautions: Observed or reasonable suspicion of self-injurious behaviors; Observed or reasonable suspicion of self-induced illness (i.e. purging, tampering with equipment, specimens, etc.); Expression of threats of violence to self or others; Exhibiting a level of sedation that is consistently different than the anticipated effect of prescribed medications or staff members have reasonable cause to believe that the patient is self-medicating or using illicit drugs; Observed drug contraband or drug paraphernalia in patient room; or Staff belief that the patient has items in his/her possession that may be dangerous or illegal. If a patient exhibits any of the At Risk Patient behaviors, a physician or a licensed independent practitioner's order is required for a patient to be placed on safety precautions and safety precautions must be noted on the patient's chart. To insure the immediate safety of the patient or others, the primary nurse may place a patient in safety precautions and then immediately contact the physician or licensed independent practitioner and request an order for safety precautions. The physician may order a Constant Observer (sitter) or a belongings search or both if indicated according to the patient's particular behavioral issue. 1. Belongings Search: If a belongings search is deemed necessary to protect the patient, the reason for the search must be recorded in the patient's medical record ...."

4. The facility's policy titled "Leaving Against Medical Advice Policy" Origination date 7/1/2013, Last revised: 1/6/2023, and Last Approved: 11/24/2023 was reviewed. The policy revealed in part, " ... Definitions: Against Medical Advice (AMA)- A mentally competent adult patient leaves the hospital or discharges him/herself despite being advised of possible adverse medical effects by medical personnel. Elopement- An adult patient leaves his/her designated area without permission or knowledge of physician or hospital staff ... 6. Procedures: Leaving Against Medical Advice: 1. If patient informs nursing staff that he/she is leaving, the immediate supervisor and/or immediate nursing leader will be notified of the patient's desire to leave. 2. The immediate supervisor and/or immediate nursing leader, a physician or designee will inform the patient of the risks of leaving as defined by the physician. 3. The physician/nurse informing patients of risks will document the conversation with the patient in the medical record. 4. The patient's nurse should have the patient read and sign from entitled "Leaving Hospital Against Advice." 2. Elopement of Patients with Decision Making Capacity: When it becomes known that a patient is missing from his/her designated room or unit, staff will take the following actions: 1. Notify immediate supervisor, immediate nursing leader, and/or Unit Manager. ... 3. Notify Public Safety immediately. Give a description of the patient. Security will notify officers to begin searching all areas of the facility. 4. Search the unit. 5. Notify the patient's physician when missing status is confirmed. 6. Notify the family or next of kin and request they notify the hospital immediately if they make contact with the patient and/or know patient's location. 7. Document in the medical record time patient noted to be missing, response to search efforts, notifications and times. Elopement of Medically Compromised or Behavioral Health Patients Without Decision Making Capabilities: If the adult patient who elopes has altered mental status, [or] lacks Decision Making Capacity[,] ... additional procedures should be implemented as follows: 1. Nursing staff will notify Nursing Supervisor and initiate a low-key rapid search of the unit searching room-to room, utility rooms, exam rooms, lounges, waiting areas, and adjacent stairwells. 2. Nursing Supervisor will notify local law enforcement and Public Safety that the patient is missing, provide a detailed description, and explain safety-related concerns. ... 4. Time patient noted to be missing, response to all search efforts, notifications and times will be documented in the medical record. ... Leaving the Emergency Department Without Being Seen: 1. If a patient wishes to leave from triage prior to receiving a medical screening, the triage/treatment area nurse will notify the charge nurse and make an attempt to encourage the patient to stay and be seen. 2. The patient will be advised of the risks involved in leaving without having a medical screening performed. 3. If a record has been made, the nurse will document the conversation in the medical record. 4. If the patient has not informed the staff that they are leaving/intend to leave: a. Call the patient's name up to three (3) times. b. Notify the charge nurse or flow coordinator that the patient is missing. c. Perform a low key search of the surrounding area. d. Attempt to contact the patient and emergency contact via the contact information in the chart, if available. e. Document in the medical record time patient noted to be missing, response to search efforts, notifications and times."

5. A review of Patient #21's medical record revealed that he arrived at the hospital on 6/3/2022 at 9:42 p.m., via car. At 10:00 p.m., the Nurse Practitioner ordered the following laboratory tests: Basic Metabolic Panel, Rapid Toxicology Drug Screen Urine; Ethanol level. The Nurse Practitioner documented at 10:01 p.m., "First Provider Evaluation." Further review of the medical record revealed there was no documentation that an appropriate medical screening examination was conducted by a Qualified Medical Professional (QMP). At 10:03 p.m., the patient was admitted to the ED. The patient's arrival complaint was listed as "mental health." The patient's "Chief Complaints Updated" revealed in part, "Suicidal (Pt reports he was here earlier, but left because he wanted to drink, and smoke, because he wasn't feeling well. Pt reports SI [Suicidal Ideation], thought of wanting to slit his wrists. Patient is talking to his hand, denies HI [Homicidal Ideation], but then in a high pitched voice states his hand ... wants to kill everybody here. Pt denies any drug use today, other than alcohol.)" Documentation by the ED triage nurse revealed the patient was triaged as an ESI acuity 2 (Emergent- triage level that requires immediate nursing assessment and rapid treatment). The ED RN documented at 10:03 p.m. that the patient was placed in room ACT-07. On 6/4/2022 at 12:07 a.m., the following abnormal laboratory blood tests results were reported: "Ethyl (B): 212 mg/dL," which is High (hospital reference range: 0-10); at 12:10 a.m., the Sodium was 133, which is low (hospital reference range:136-145); and Anion Gap (Acidosis in the blood) was 16, which is High (hospital reference range: 7-14).

A review of the Suicidal Risk Assessment- Columbia Suicide Severity Rating Scale (C-SSRS- Screens for suicidal ideation and behavior) revealed: 1. Wish to be Dead-(Past 1 month): Y (yes); 3. Active Suicidal Ideation with any methods (Not Plan) without intent to act in past 1 (one) month: Y (yes); 6. Suicidal Behavior (Lifetime): Y (yes) 6 (six) months ago states he drank some antifreeze. 6.Suicidial Behavior (3 months): N (no). Calculated C-SSRS Risk Score: Moderate Risk. The interventions for Suicide Moderate Risk included for staff to: "Notify MD that psychiatric consult is needed and/or possible" and "1013 form executed" (this form is used when someone is considered a risk to themselves or others due to a mental crisis). Continued review of the medical records revealed, as of 6/4/2022, the patient had a past medical history of Bipolar 1 disorder (involves manic episodes that last at least a week, so severe that the individual requires immediate medical care), Schizo affective schizophrenia (Chronic mental health condition, combination of symptoms of schizophrenia and mood disorder), and hypertension (high blood pressure). Patient #21's final diagnoses included: "R45.851 Suicidal ideations" and "Procedure and treatment not carried out due to patient leaving prior to being seen by health care provider."

The "ED Re-evaluation note by ...ED MD, dated 6/4/2022 at 4:28 a.m., revealed in part, Re-evaluation[:] Pt seen walking out. Asked the unit desk sec ... to call Security. Security at front of ED reports that pt has already left. Searches for pt was futile." According to the Updated Chief Complaints, the patient presented to the hospital complaining of homicidal and suicidal ideations/thoughts. The suicidal risk assessment determined the patient to be at moderate risk. There was no documentation in the medical record to indicate the ED physician was notified that a psychiatric consult was needed; that the patient was placed on safety or suicide precautions for his safety and others; that constant observation was initiated or that a belongings search was done to protect the patient and others since he was assessed to be a harm to himself and others, as required by hospital policies. The failure to complete an appropriate MSE after assessing Patient #21 with suicidal and homicidal ideation, and an elevated alcohol level that potentially impairs a person's judgement, failure to assess/reassess the patient on 6/3/2022 between 9:59 p.m. to 4:53 a.m. prior to the patient being discharged, and to fully implement the hospital's policies, "Care of Behavioral Patients Policy", "Piedmont Henry Hospital Emergency Department Patient Assessment and Reassessment Policy" and the "Leaving Against Medical Advice Policy" contributed to the patient not receiving an appropriate MSE to determine that an emergency medical condition exist.

6. A review of the Emergency Medical Service (EMS) ambulance report, dated 1/4/2023, section titled, "Patient Care Narrative" revealed in part, " ...responded .... 41-year-old female having suicidal thoughts. Pt [patient] stated that she has been having these thoughts for a couple weeks. Pt stated that she is a cutter but has not cut in 1.5 years. No cuts were noted on the PT. Pt stated that she wanted to go to the hospital and be seen because she did not like these thoughts."

A review of Patient #31's medical record revealed that she presented to the hospital's ED on 1/4/2023 at 7:06 a.m., via ambulance. The ED Notes dated 1/4/2023 at 7:15 a.m., documented the patient was in bed: ETR-21. At 7:16 a.m., the patient was admitted to the ED. Documentation by the ED RN revealed, "Arrival Complaint ...Suicidal thoughts lobby." Continued review revealed that on 1/4/2023 at 7:17 a.m., "Chief Complaints Updated: Suicidal (Pt presents with suicidal thoughts since last night. Pt denies having a plan. Pt has history of SI and depression does not take meds.)" The patient was triaged by the RN as an ESI acuity 2 (Emergent- requires immediate nursing and rapid treatment). Review of the Flowsheets (ED Patient Care Timeline), dated 1/4/2023 at 7:17 a.m., revealed the patient's heart rate was 112 and elevated.

On 1/4/2023 at 7:18 a.m., the ED RN communicated to the ED MD the following verbal orders with readback mode for Patient #31: Assess and document suicide risk screening; Assess and document social history to include ETOH (alcohol) and drug use; Ensure patient is placed in a safe environment/room; Assess and Document Home Medications; Notify physician immediately of patient's arrival; Blood glucose POCT (Point of Care Testing); Lab - Acetaminophen level; CBC auto differential; Comprehensive metabolic panel; Ethanol level; Salicylate level (test that measures salicylates in the blood ); Pregnancy, urine; Urinalysis complete with reflex culture; Drug Screen Urine, Qualitative Consult - IP (In Patient) consult to psych (Psychiatric) assessment team ... Question: Reason for Consult? Answer: suicidal. The following abnormal laboratory tests for Patient #31 were completed and results were: Ethanol level: 248 mg/dL high (hospital reference range: 0-10 mg/dL); Potassium: 3.0, which is low (hospital reference range: 3.5-5.1 mmol/L); Chloride: 108, which is high (hospital reference range: 98-107 mmol/L); Glucose: 66, which is low (hospital reference range: 74-100 mg/dL); and BUN (Blood Urea Nitrogen)/Creatine: 9, which is low (hospital reference range: 12- 20).

Review of the ED Notes, dated 1/4/2023 at 11:05 a.m., documented "Called for room assignment no answer. Will call again." A note at 11:34 a.m. stated: "Patient called for room assignment, did not answer. Used intercom and physically checked waiting areas. Will attempt to call patient at phone number listed. No answer on phone number listed." Review of the flowsheets, dated 1/4/2023 at 12:02 p.m., documentation by the ED RN, revealed: ED LWBS (left without being seen) and Patient Discharged.

The hospital failed to provide an appropriate medical screening examination to determine if an emergency medical condition existed after assessing Patient #31, with suicidal thoughts and an elevated alcohol level that potentially impairs a person's judgement; implement physician orders to assess the patient and document suicide risk screening; ensure patient is placed in a safe environment/room; ensure that their policies and procedures were followed as evidenced by failing to notify the Charge Nurse, Floor Coordinator, Law Enforcement, and public safety that Patient #31, who presented to the hospital's ED medically compromised (tachycardic pulse of 112, and elevated alcohol level) with behavioral health issues, and without decision making capabilities due to suicidal ideations left the hospital's ED without being seen by a physician and was missing and failed to assess/reassess the patient on 1/4/2023 between 7:06 a.m. to 12:02 p.m. prior to the patient being discharged. These failures contributed to the patient not receiving an appropriate MSE to determine that an emergency medical condition exist.

7. On 10/1/24 at 9:50 am., a telephone interview was conducted with ED Physician's Assistant (PA) PP. She said when assigned the screening shift, she would sit at the computer station in the triage area between 1-2 triage nurses. She said the nurses would lead with the questions and she would ask clarifying questions as needed. She would do a brief examination and order additional testing if applicable. If the patient's signs and symptoms called for the need to be roomed immediately, she would call the charge RN to see if the patient could be placed in a room. She said this would be dependent on the patient's physical look and vital signs. PA PP went on to say that there was no MD oversight while in triage unless you went directly to the physician and that triage was self-driven by the mid-level. She further explained that she typically would not see the patient again after they were triaged and that there were reassessment nurses who retake vital signs and reviewed lab results for patients in the waiting room.

8. An interview was conducted, on 10/1/2024 at 10:48 a.m., in the facility's conference room with ED Nursing Director (Dir.) TT. Dir. TT explained that the triage nurse is an individual who generally has one year of experience or more as a Registered Nurse (RN). Dir. TT explained that all nurses in this role receive training in the triage process and Emergency Severity Index (ESI) levels. Dir. TT explained that during the triage process, there is generally a mid-level provider, i.e., Physician's Assistant (PA) or Nurse Practitioner (NP), also at the screening station. Dir. TT explained that the ESI score is based on the triage nurses' patient assessment. A patient with an ESI of 3 is a patient that generally needs three (3) or more resources, i.e., radiology, laboratory, and a procedure. A patient with an ESI 2 is typically a patient who presents with severe pain or abnormal vital signs.