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Based on policy and procedure review, medical record review and interview, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA Emergency Medical Treatment and Labor Act) requirements. See C2406 for details.

Based on clinical record review, policy review, and interview the facility failed to ensure an appropriate medical screening exam was provided and not delayed for one (# 1) of one patient with suicide attempt received by ambulance to the Emergency Department (ED). This failed practice had the likelihood to affect all suicidal psychiatric patients coming to the ED. Findings follow:

A. Review of the facility Policy "EMTALA GUIDELINES", revised May 2, 2019, showed: "All patients presenting to (Referring hospital) for a non-scheduled visit and seeking care must be accepted and evaluated regardless of the patient's ability to pay. All patients shall receive a medical screening exam that includes providing all necessary testing and services within the capability of the hospital to reach a diagnosis. Federal Law requires that all necessary definitive treatment be given to the patient and only maintenance care can be referred to a physician's office or clinic. Emergency Medical Conditions under EMTALA Law constitute any condition that is a danger to the patient or unborn fetus or could result in a risk of dysfunction or impairment to the smallest body part or organ if the patient is not treated in the near future.
B. Review of the facility policy "EMERGENCY TREATMENT OF MINORS" revised, September 22, 2021, showed, "All attempts will be made to contact the parents or guardian of a non-emancipated minor prior to treatment. If unable to obtain permission from parent or guardian, the Child Protective Agency or the local law enforcement agency will be contacted to assume responsibility. In the event of a life-threatening condition, treatment will not be delayed, the Emergency Department physician will sign for treatment. If phone consent is obtained from parent(s) or legal guardian; two nurses must verify the phone consent and document in nursing documentation. When phone consent has been obtained for treatment of the minor, arrangements should be made to discharge the minor."
C. Review of the facility policy "PSYCHIATRIC PATIENTS" revised, April 2019 showed, "When there are two psychiatric patients admitted to the Emergency Department, this ER (Emergency Room) will be considered at psych(psychiatric) capacity. Emergency Department staff will notify EMS dispatch that this Emergency Department is at psych capacity and cannot accept any known patients needing psychiatric evaluation."
D. Review of the facility policy "TRIAGE" effective, May 2016 showed, "Category of Level 2 acuity: Life/Limb loss is eminent unless intervention is taken and considered unstable. The treatment and assessment should occur between 5-15 minutes."
E. Review of the prehospital care report by Emergency Medical Services (EMS) dated 04/13/24 showed, "unit notified at 11:54 AM, and dispatched Emergent with complaint reported to dispatch of a 14-year-old female with suicidal ideations. Officer was reported to be on scene. EMS arrived at scene at 12:16 PM. Patient was found in back seat of local deputy's patrol car and said she wanted to go for some help. She walked with the deputy to the ambulance, entered the back and lay on the cot. Her primary complaint was suicidal for five (5) days. After EMS evaluation transport required nonemergent transport to a hospital capable of providing adequate care for the chief complaint. EMS transported patient to the (Referring Facility), the closest most appropriate facility capable of providing care for the patient.
F. Review of the EMS Response Times and Mileage dated 03/14/24 showed, "unit dispatched at 11:55 AM, at scene at 12:16 PM, Departed scene at 12:27 PM, and arrived at destination (Referring facility) at 12:45 PM. EMS was back in service at 2:05 PM."
G. Review of the Transfer of Patient Care form dated 04/13/24 showed, the ED Director signed the transfer of patient care form on 04/13/24 at 2:03 PM.
H. Review of the Referring ED Physician Chart showed, "Time to room, assessment, triage, and Physician notification were completed on 04/13/24 at 2:06 PM.
I. Review of the Physician chart dated 03/14/24 at 2:06 PM showed, "Provider treatment notes, Ambulance arrived without report and (named EMS staff) escorted patient into ER (Emergency Room) MD (Medical Doctor) saw patient on arrival and had EMS and patient go to room 2(Psychiatric room). (Named EMS staff) advised all vitals stable, MD verified patient not in distress."
J. Review of the Triage Assessment dated 04/13/2024 at 2:06 PM showed Patient was moved from room 1 with initial vitals at presentation blood pressure (BP 111/68, heart rate (HR) 96, respiratory Rate (RR) 20, Temperature (temp) 98.0 Fahrenheit (F). There was no evidence vital signs were ever repeated. There was no evidence of cardiac monitoring or IV (intravenous fluids) given to the patient in the ED record. At transfer, the record showed, IV status not applicable.
K. Review of the Nursing Chart showed, "Note: date 04/13/24 at 2:55 PM, Patient arrived with EMS and seen by MD (Medical Doctor) upon arrival. EMS told this nurse, grandfather signed for patient to be transported. This nurse in the room with patient as blood being drawn and EKG (electrocardiogram) completed. Patient # 1 told this nurse she had a plan to run away and run into oncoming traffic because she feels worthless because her family is always yelling and cussing at her about dumb things and was mad because she told her grandparents she wanted to live in OK (Oklahoma) with her other grandparents. Patient then told this nurse she tried to OD (overdose) this morning by taking three (3) of her Effexor pills when she woke up around 7:00 AM."
Review of Treatment Notes dated 04/13/24 at 3:05 PM showed, "ED Medical Director notified of patient statement to this nurse about possible OD. At 3:23 PM Called poison control. Patient takes Effexor ER 75 mg. Patient told this nurse she took three pills this morning. Poison control said there is a delayed possible cardiac and seizure effect and patient needs to be observed/admitted for 11-18 hours. At 3:38 PM, Medical Director called Arkansas Children's hospital for transfer at 3:34 PM, patient accepted by Physician at Arkansas Children's hospital, will be going to ED. At 4:48 PM, EMS called for urgent transfer, at 5:57 PM EMS arrived for transfer of patient to Arkansas Children's hospital."
L. Review of patient # 1's clinical record was completed with the ED Manager on 05/02/24 at 8:40 AM. The ED Manager verified patient # 1 arrived at ED at 12:45 PM and time to room, assessment, triage, and Physician notification were completed on 04/13/24 at 2:06 PM.
M. On 05/02/24 at 9:39 AM the Medical Director was asked to review patient # 1's ED record with Surveyor and was asked:
1.What time did this patient arrive in the ED? He said the EMS arrived around 12:45 PM, and walked the patient into the ER, they had not called report in to us. The ER was burning up that day. We were full and the 2 nurses were with some critical patients. I saw patient # 1 come in with EMS and met them at the desk. I did a quick assessment, took a report from EMS, and told them to go to room 2 (a psychiatric room) with the patient. The 2 EMS personnel remained in attendance with Patient #1 until care assumed by ED nurse at 2:06 PM. The Mental Health Screening showed the patient room was assessed for safety, Social Services referral submitted, and Columbia Suicide Severity Scale addressed. The scale was not provided in the ED record.
2.What time does the record show that patient # 1 was placed in a room, triaged, and you were notified? It says 2:06 PM, but there was no delay in assessment or treatment, there was a delay in registration. Patient # 1's Medical Screening exam started at 12:45 PM when EMS walked her through the doors. I saw her, asked her some questions, made sure she was stable and had EMS take her to exam room 2, EMS remained with patient until nursing staff assumed care."