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Based on record review and interview, the hospital failed to ensure compliance with 42 CFR §489.20 (l) of the provider's agreement which requires that hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by:

Failing to provide an appropriate medical screening examination to determine whether or not an emergency medical condition exists for an individual who presented to the hospital's dedicated emergency department with an emergent psychiatric medical condition. This was noted for 1 (Patient #2) of 20 sampled patients. (see findings in A2406)

Based on record review and interview, the hospital failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition exists for an individual who presented to the hospital's dedicated emergency department with an emergent psychiatric medical condition. This was noted for 1 (Patient #2) of 20 sampled patients.
Findings:

Review of the medical record for Patient #2 revealed he was a 35 year old male who presented to the ED (Emergency Department) on 07/09/15 at 10:12 a.m. with a chief complaint of high blood pressure (172/120). Documentation revealed that Patient #2 was transported to the ED by the local law enforcement agency (Agency A) where he was in custody for being a "violent offender who was arrested for murder". Patient #2 was assessed by S8RN (Registered Nurse) and assigned a triage status of "3" which indicates "urgent".

Review of the Emergency Physician Record revealed an examination was conducted by S4MD (Medical Doctor) at 10:21 a.m. S4MD indicated Patient #2's chief complaint was high blood pressure with onset today (07/09/15) and denied chest pain and shortness of breath. Past history included- Anxiety, medication- Lisinopril, Psychiatric- oriented x 4, mood/affect nml (normal) and memory intact. ER Progress notes (no time) revealed the following: "Agency "A" noted pt. (as written) became paranoid while in custody. "Discussed care with S12Social Worker and Director of Critical Care Services who are concerned about patient placement." Clinical Impression: 1) Hypertension 2) Psychosis. A note written (5:35 p.m.) at the bottom of the page read: " Repeat MSE (Medical Screening Examination) (as written) - pt. clearly psychotic" (not signed).

Further review of the medical record revealed Patient #2 was placed on a PEC (Physician Emergency Certificate) on 07/09/15 (signed at 11:40 a.m.) by S4MD. Documentation on the PEC revealed that Patient #2 was Dangerous to Self, Unwilling, Unable to seek voluntary admission and Gravely Disabled.

Further review of the medical record revealed documentation written by S5MD which read: "By police report, this gentlemen is a violent offender who was arrested for murder. In the jail his blood pressure was elevated and he was sent here for evaluation. Once here he began to exhibit bizarre behavior and, by description from my colleague, S4MD, frankly psychotic ideation. He is alert and appropriate at my exam. He does relate a history of schizophrenia; however this may have contributed to his initial behavior. S4MD wrote a PEC on the patient; no doubt he does need psychiatric evaluation. However our psychiatrist in the hospital does not consult on ER (Emergency Room) psychiatric patients and the chances of him being placed at an outpatient facility, given the charges against him, are zero, there would be no benefit in holding him here in the ER for three days. If he were to receive inpatient psychiatric evaluation it should be arranged by the jail's medical staff and at a facility that has people to handle potentially violent patients. On another note, I question the wisdom of holding such a patient in the ER where he will pose a serious and legitimate threat to the safety of the staff for his entire stay ..... It is my considered opinion that the patient should be remanded to the jail where his captors may take appropriate measures for his security and theirs. I discussed this with S17Officer for Agency "A". He related to me that they do have the facilities to handle this gentlemen." Documentation at 10:00 p.m. written by S5MD read: "At my exam I find a healthy-appearing young man who's (as written) AAOx3 (as written) and cooperative. he (as written) exhibits no psychotic ideation at my exam. His affect is flat, however and he is a vague historian.

Documentation at 11:13 p.m. by S9RN read: "Orders for D/C to prison. CO (Correctional Officer) (as written) from Sheriff (as written) Office that has been here with pt. called the facility with report." Documentation at 11:42 p.m. written by S9RN read: "______ Parish Correction Officer arrived for transport of prisoner back to their facility. No distress noted."

Further review of the medical record revealed documentation indicating that discharge instructions were provided for High Blood Pressure and Psychosis. Additional Instructions indicated that the patient was to "Follow up with the jail medical staff as soon as possible."

Review of the medical record revealed no documentation to indicate that Patient #2 was being discharged to a facility that was capable of providing acute care psychiatric services.

Review of the hospital's policy & procedure titled "Care of the Behavioral Health Patient in the Emergency Department" presented by S14Regional Compliance Director, being current (04/15) read in part: Purpose: To delineate a process for delivering appropriate care to the psychiatric/behavioral health patient and ensuring that care is provided with regard to dignity, respect and safety of the patient and others. Procedure: The patient will be evaluated by the ED physician and medically cleared. If the patient meets criteria for PEC, the ED physician will complete the PEC form. The Behavioral Health Unit Liaison and Social Services (available on site Monday-Friday, Social Services available as needed on weekends) should be notified of PEC/CEC status, the need for psychiatric inpatient placement, and to participate in care and discharge planning as needed. The ED manager, director, and /or charge nurse will work collaboratively with the Behavioral Unit staff and Social Services to facilitate timely inpatient placement. Documentation: Transfer forms and documentation should be completed as described.

In an interview on 08/11/15 at 2:45 p.m., S12Social Worker indicated that one of her roles in the ED is to assist with the placement of psychiatric patients who have been placed on a PEC and/or CEC once that have been medically cleared for placement. S12Social Worker indicated to the best of her knowledge Patient #2 did not qualify for placement (prisoner). S12Social Worker indicated that she had always been informed that the process for psychiatric prisoners was to discharge the patient back to the facility with psychiatric follow-up care, to notify the guards of discharge instructions, to have the Prison Social Worker or Case Manager make the follow up appointment. S12Social Worker indicated that no inpatient facility (hospital) within the state of Louisiana. would admit a prisoner for inpatient psychiatric care. S12Social Worker indicated S4MD was notified that Patient #2 would not qualify for inpatient psychiatric care. S12Social Worker indicated social services was not consulted for Patient #2. When asked if there was any documentation to indicate that no hospital's would provide inpatient psychiatric care to prisoners within the state of Louisiana, S12Social Worker replied no.

In a telephone interview on 08/11/15 at 3:10 p.m., S3ED Medical Director indicated that S4MD had contacted him by phone on 07/09/15 for a recommendation relative to the coordination of care for Patient #2. S3ED Medical Director indicated that he consulted with S1Chief Medical Director and the following was agreed upon: Patient #2 would remain in the ED until 07/10/15 and S4 would make contact with the Medical Director at the prison to find out about resources available for prisoners. S3ED Medical Director indicated he was not aware that Patient #2 had been discharged back to the prison on 07/09/15.

In a telephone interview on 08/12/15 at 9:30 a.m., S9 RN indicated she was the night nurse (7 p.m.-7 a.m.) who was assigned to care for Patient #2. S9 RN indicated Patient #2 was placed on a PEC. S9 RN indicated Patient #2 was discharged back to the prison with discharge instructions relative to high blood pressure and psychosis. S9 RN indicated that discharge instructions (Hypertension & Psychosis) were directed to Patient #2 with the officer present in the room. S9 RN indicated she was not sure if the prison provided acute care psychiatric services.

In a telephone interview on 08/12/15 at 10:20 a.m., S5MD indicated Patient #2 was placed on a PEC by S4MD. S5MD indicated that Patient #2 had a zero chance of receiving psychiatric treatment in the hospital's ED. S5MD indicated the Hospital's staff psychiatrist did not see psychiatric patients in the ED and that prisoners (Patient #2) could not be admitted to the Hospital Behavioral Unit. S5MD indicated that based on his examination of Patient #2 on 07/09/15 at 9:39 p.m., Patient #2 was noted to be medically stable and seemed normal and reasonable and at that time he did not feel Patient #2 was in need of emergent psychiatric care. S5MD indicated that he called Agency "A" and spoke to the Warden in Charge (unable to recall name) who informed him that Patient #2 would be provided adequate and safe care through direct observation at the prison. S5MD indicated that Patient #2 "had a history of Schizophrenia so it was okay for him to return back to the jail so he could eventually be placed back on his medication." S5MD indicated Patient #2 had a history of violent behavior and he could pose a threat to the staff. S5MD indicated he discharged Patient #2 back to the prison. When asked if psychiatric care was provided at the prison, S5MD indicated that they should have "a Jail Doctor, NP (Nurse Practitioner) or PA (Physician Assistant) that would evaluate treat psychiatric prisoners." When asked about the PEC that Patient #2 was placed on, S5MD did not answer.

In a telephone interview on 08/12/15 at 11:00 a.m., S11Prison Medical Director indicated Agency "A" did not have a psychiatric unit or staff to provide psychiatric services. S11Prison Medical Director indicated prisoners with mental health issues sometimes are managed at the facility and are referred for outpatient Mental Health services to local State Mental Health Clinic. S11Prison Medical Director indicated prisoners that require intensive psychiatric care are transferred to a higher level facility within the prison system for psychiatric treatment.

In a telephone interview on 08/12/15 at 11:05 a.m., S16RN Agency"A" indicated that Patient #2 was discharged back to the prison and placed on suicide watch. S16 indicated that the hospital discharged Patient #2 back to Agency"A" without psychiatric follow-up care.

In a telephone interview on 08/12/15 at 11:15 a.m., S4MD indicated that Patient #2 was placed on a PEC for Psychotic Behavior and was in need of psychiatric care. S4MD indicated that Patient #2 was re-evaluated by him at approximately 5:30 p.m. on 07/09/15 and again between the hours of 7:30 p.m. & 8:30 p.m. S4 indicated at both times Patient #2 remained psychotic. S4MD confirmed he consulted S3ED Medical Director for guidance and recommendation. S4MD indicated it was concluded that Patient #2 was to remain in the ED overnight and S4MD would contact (07/10/15) Agency "A's" Medical Director for assistance for Psychiatric Care for Patient #2. S4MD indicated upon return on 07/10/15, Patient #2 had been discharged back to Agency "A".