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Based on document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

C-2406: Applicability of Provisions of this Section (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph (b) of this section, the hospital must-(i) 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 or not an emergency medical condition exists. Based on document review and interviews, the facility failed to ensure a patient who presented to the emergency department received a medical screening exam to determine the presence of an emergent medical condition in one of four patients reviewed who presented with psychiatric symptoms. (Patient #11)


C-2407: (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. Based on document review and interviews, the facility failed to ensure a patient received stabilizing treatment within the facility's capabilities prior to discharge in one of two patients reviewed who had multiple visits within two days. (Patient #11)

Based on document review and interviews, the facility failed to ensure a patient who presented to the emergency department received an appropriate medical screening exam to determine the presence of an emergent medical condition in one of four patients reviewed who presented with psychiatric symptoms. (Patient #11)

Findings include:

Facility policy:

The EMTALA- Medical Screening Examination and Stabilization Treatment policy read, psychiatric emergencies are situations where a patient is a danger to himself or others by reason of aggressive conduct or inability to perceive or appreciate danger. With regard to a psychiatric emergency, stabilization means protecting the patient and preventing him/her from harming him/herself or others. The medical screening exam (MSE) includes ancillary services routinely available to the hospital along with available personnel in determining whether an emergent medical condition (EMC) exists.

1. The facility failed to conduct a complete MSE, which included available ancillary services, to determine the presence of an emergent medical condition for a patient who presented to the emergency department (ED) with psychiatric symptoms.

A. Document Review

i. Medical record review revealed Patient #11 presented to the ED on 8/11/23 at 3:59 a.m. with complaints of nausea, vomitting, and diarrhea. According to the History of Present Illness (HPI), Patient #11 was up throughout the night because she was lost and became nauseaus two hours prior to the ED visit. Patient #11 received intravenous (IV) fluids, anti nausea medication, and labs were drawn. Patient #11 was then discharged home at 5:35 a.m.

ii. Medical record review revealed Patient #11 returned to the ED via ambulance on 8/11/23 at 4:01 p.m. with complaints of paranoid delusions. Patient #11 received a physical exam, blood work, and intravenous fluids. The contracted behavioral health team was consulted for a psychiatric evaluation. Provider documentation revealed Patient #11 was not homicidal, suicidal, or gravely disabled (a condition in which a person, as a result of mental illness, is in danger of serious physical harm due to their inability or failure to provide themselves the essential human needs of food, clothing, shelter, and medical care). Provider documentation revealed Patient #11's medical record from the visit at 3:59 a.m. was reviewed and during that visit, the patient was not acting as bizzare at that point. The documentation also revealed Patient #11 was diagnosed with delusional disorder and cannabis use disorder, and did not meet criteria for admission. Patient #11 was discharged with behavioral health follow-up.

iii. Medical record review revealed Patient #11 was brought back to the ED the next morning on 8/12/23 at 10:03 a.m. by park rangers. Provider documentation revealed Patient #11 stated she was playing a game of hide-and-seek with people from the internet all night. Patient #11 complained of dizziness, headache, blurry vision, nausea, and excessive thirst. Medical record review revealed Patient #11 had not taken her Metformin (medication used to decrease blood glucose levels) in two days and had not had any calorie intake for 24 hours. Patient #11 had tripped and fell which resulted in abrasions to both of her knees.

Medical record review revealed a physical exam and a computerized tomography (CT) scan of the brain were performed, Patient #11's knee abrasions were dressed with antibiotic ointment and Band-Aids, and she was given water to drink. There was no evidence of blood work in the medical record. Provider documentation revealed Patient #11 had blood work performed on 8/11/23 and due to this, the provider did not feel any other further evaluation was warranted for the 8/12/23 visit.

Additionally, provider documentation read Patient #11's delusions were similar to the 8/11/23 visit. The provider documented that Patient #11 was not suicidal, homicidal, or gravely disabled and did not meet criteria for an involuntary hold at that time. Patient #11 was discharged with instructions to follow up with her behavioral health provider. There was no evidence of a behavioral health consult in the medical record.

This was in contrast to the EMTALA- Medical Screening Examination and Stabilization Treatment policy which read, psychiatric emergencies were situations where a patient was a danger to himself or others by reason of inability to perceive or appreciate danger. The MSE included ancillary services routinely available to the hospital along with available personnel in determining whether an EMC existed.

iv. Medical record review revealed Patient #11 presented to the ED on 9/7/23 at 10:50 a.m. for increased auditory hallucinations (hearing voices that are not there) and insomnia (difficulty sleeping). Provider documentation revealed Patient #11 had been admitted to a separately certified acute care hospital the day after her last ED visit of 8/12/23. Patient #11 received care at the separately certified acute care hospital from 8/13/23 to 9/1/23, where she was diagnosed with schizoaffective disorder and post-traumatic stress disorder. Patient #11 had also been started on Remeron (an antidepressant medication), Trazodone (an antidepressant and sedative medication), and Paliperidone injections (medication used to treat schizophrenia symptoms).

B. Interviews

i. On 9/12/23 at 3:11 p.m., an interview was conducted with registered nurse (RN) #3. RN #3 stated a gravely disabled patient was one who did not keep themselves clean, eat, take their medications, or function properly in society when they were able to before. RN #3 also stated if a patient was not properly assessed prior to discharge, the patient was at risk to not receive the help they needed, or the patient could become injured.

ii. On 9/13/23 at 8:47 a.m., an interview was conducted with Physician #4, who provided care to Patient #11 during her 8/12/23 ED visit. Physician #4 stated behavioral health had not been consulted to evaluate Patient #11 because she had received a full psychiatric evaluation during her 8/11/23 ED visit. Physician #4 stated based on the previous physician's notes and her assessment, Patient #11 was the same as she had been on the 8/11/23 visit and had not experienced a change in condition.

iii. On 9/13/23 at 12:42 p.m., an interview was conducted with chief medical officer (CMO) #2. CMO #2 stated a patient with no caloric intake for 24 hours, who had not taken their medications, who had presented after playing hide-and-seek in the park with people from the internet all night was expected to receive a behavioral health evaluation to determine if the patient was safe to discharge. Furthermore, CMO #2 stated a patient exhibiting this type of behavior was not able to keep themselves safe.

Based on document review and interviews, the facility failed to ensure a patient received stabilizing treatment within the facility's capabilities prior to discharge in one of two patients reviewed who had multiple visits within two days. (Patient #11)

Findings include:

Facility policy:

The EMTALA- Medical Screening Examination and Stabilization Treatment policy read, stabilizing treatment, within the hospital's capabilities, will be provided to all individuals.

1. The facility failed to ensure a patient who presented to the emergency department (ED) for care was provided stabilizing treatment for high blood glucose levels prior to discharge.

A. Document Review

i. Medical record reviews revealed Patient #11 presented to the ED for care three times in a 30-hour period. Patient #11's blood glucose was elevated at each visit with no evidence of stabilizing treatment provided prior to discharge. Examples included:

a. Medical record review revealed Patient #11 presented to the ED on 8/11/23 at 3:59 a.m. with complaints of nausea, vomiting, diarrhea, headache, and hot flashes. Patient #11 had a history of diabetes for which she took Metformin and Glyburide (medications used to lower blood glucose levels). Patient #11's blood work revealed a glucose level of 356 (normal values listed in the medical record are 73-107). Patient #11 was administered Reglan (medication used for nausea) Protonix (medication used to decrease acid in the stomach) and Lactated Ringers (fluids administered intravenously for hydration). There was no evidence in the medical record of medications administered to lower Patient #11's glucose level prior to discharge.

b. Medical record review revealed Patient #11 presented to the ED approximately twelve hours later on 8/11/23 at 4:01 p.m. with paranoid delusions. Patient #11's blood work revealed a glucose level of 336. Patient #11 was administered Normal Saline (fluids administered intravenously for hydration). There was no evidence in the medical record of medications administered to lower Patient #11's glucose level prior to discharge.

c. Medical record review revealed Patient #11 presented to the ED the next morning on 8/12/23 at 10:03 a.m. with dizziness, headache, blurry vision, nausea, and excessive thirst. Medical record review also revealed Patient #11 had not taken her Metformin in two days. Patient #11's fingerstick blood glucose level was 300. Patient #11's discharge diagnoses included poorly controlled diabetes mellitus. There was no evidence in the medical record of medications administered to lower Patient #11's glucose level prior to discharge.

d. Medical record review revealed Patient #11 presented to the ED on 9/7/23 at 10:50 a.m. with increased auditory hallucinations. Provider documentation revealed Patient #11 had been admitted to a separately certified acute care hospital from 8/13/23 to 9/1/23 and had been started on 20 units of insulin glargine (long-acting insulin injections used to lower glucose levels) during her hospital stay. Patient #11's blood glucose level was 260. There was no evidence in the medical record of medications administered to lower Patient #11's glucose level prior to discharge.

These examples were in contrast to the EMTALA- Medical Screening Examination and Stabilization Treatment policy which read, stabilizing treatment would be provided to all individuals within the hospital's capabilities.

B. Interviews

i. On 9/12/23 at 4:28 p.m., an interview was conducted with Physician #1. Physician #1 stated signs and symptoms of high blood glucose levels included dry mouth, increased thirst, blurred vision, and nausea. Physician #1 stated high blood glucose levels required treatment and patients were at risk of diabetic ketoacidosis (DKA) (a life-threatening complication of diabetes) if high glucose levels were left untreated.

ii. On 9/13/23 at 8:47 a.m., an interview was conducted with Physician #4. Physician #4 stated Patient #11 was given water to drink since hydration was part of the treatment for high blood glucose levels. Physician #4 also stated chronic medications, such as Metformin, were not usually administered in the ED.

iii. On 9/13/23 at 12:42 p.m., an interview was conducted with chief medical officer (CMO) #2. CMO #2 stated patients with high blood glucose levels were expected to receive some degree of treatment in the ED. CMO #2 also stated it was expected for patients with high blood glucose levels to receive their Metformin or insulin, as insulin was the most rapid way to decrease glucose levels. Additionally, CMO #2 stated patients were at risk for infection and kidney injury if high blood glucose levels were left untreated.