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Based on document review, policy review, medical record review, and interview, the facility did not comply with all of the provisions of EMTALA, including documenting all patients on the central log, providing necessary stabilizing treatment, and providing an appropriate transfer for Patient #1.

Reference findings under the following Tags:

A 2405- Central Log
A 2407- Necessary Stabilizing Treatment for Emergency Medical Conditions
A 2409- Appropriate Transfer

Based on policy review, interview, and medical record review, the facility does not ensure that all patients who present to the emergency department (ED) are entered on the ED central log, specifically for Patient #1. The ED central log is required to track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition.

Findings Include:

Review of policy "Emergency Medical Treatment and Active Labor Act (EMTALA)," last revised 02/2023 indicates that each individual who presents to the ED is entered into the central log.

Interview on 05/22/23 at 02:11 PM, Staff (J) Registration Clerk (RC) revealed the entire incident happened very fast, and Patient #1 was not in the ED long enough for registering to occur.

Interview on 05/23/23 at 03:00 PM with Staff (B), Registered Nurse (RN) Quality Director revealed while conducting daily ED log and transfer form audits on 05/01/23, it was determined that Patient #1 was not registered on the ED log for 04/30/23, and there was no medical record. Registration was contacted and confirmed that Patient #1 was not registered on the ED log for 04/30/23. Registration staff made a late entry on 05/01/23 to document Patient #1's presentation to the ED on 04/30/23.

Review on 05/23/23 of the ED record for Patient #1 revealed late entries entered on 05/01/23 and 05/02/23 for Patient #1's presentation with Police Officers to the ED on 04/30/23 at 09:00 PM, for aggressive behavior, homicidal ideation, and possible alcohol intoxication.

Based on policy review, interview, and medical record review, the facility did not provide an appropriate medical screening examination (MSE) for Patient #1 within the capability of the hospital's emergency department (ED).

Findings Include:

Review of policy "Emergency Medical Treatment and Active Labor Act (EMTALA)," last revised 02/2023 indicates that for psychiatric conditions, the patient is considered to be stable when they are protected and prevented from injuring them self or others. If the licensed health care provider believes a patient to be at immediate risk of harming themselves or others, reasonable efforts must be made to keep the patient until a psychiatric evaluation can be performed. If the medical screening examination indicated that an emergency medical condition exists, the facility shall either provide treatment to stabilize the patient or, appropriately transfer the patient to another facility. The treatment provided to stabilize the patient must be considered with general acceptable standards of care. For persons who appear under the influence of drugs or alcohol and who refuse consent or treatment, refer to policy "Management of Behavioral Health Patients".

Review of policy "Management of Behavioral Health Patient," last revised 06/2022 indicates that providers must rule out any medical condition(s) as a cause of the presenting behavior prior to behavioral health evaluation. Medical clearance must be documented.

Interview on 05/23/23 at 03:00 PM with Staff (B), Registered Nurse (RN) Quality Director revealed while conducting daily ED log and transfer form audits on 05/01/23, it was determined that there was no medical record for Patient #1 on 04/30/23. Staff (M), ED Medical Director, was made aware. Staff (D), PA was contacted and informed that documentation needed to be entered into Patient #'1 medical record regarding the attempt to conduct a medical screen.

Review on 05/23/23 of the Ira Davenport Memorial Hospital (IDMH) emergency department (ED) record for Patient #1 revealed a late entry was documented on 05/02/23 by Staff (D), Physician Assistant (PA) for Patient #1's presentation to the ED on 04/30/23. The late entry indicates Patient #1 presented to the ED on 04/30/23 at 09:00 PM in police custody for aggressive behavior, homicidal ideation, and possible alcohol intoxication. Patient #1 was handcuffed and actively struggling with police during provider attempt at an MSE. Patient repeatedly yelling "I will expletive kill you," "let me go," "get off of me," "I will expletive kill you." Patient #1 was lunging forward when the provider attempted to get close enough for a physical exam. Staff (D), PA advised the officers that the ED did not have adequate facilities or staff to evaluate Patient #1 as they were at high risk of harming themselves and/or staff. Staff (D), PA recommended Patient #1 be taken to another hospital ED where they are better equipped to evaluate Patient #1 if they (the officers) felt a medical issue needed evaluation. At 06:59 AM, Staff (D), PA documented that due to severe aggression, was unable to adequately perform an MSE, though there did not appear to be a medical emergency. With severe medical physical aggression, Patient #1 was an immediate threat to themselves and staff. The ED does not have a secure or safe psychiatric holding room, and only one unarmed security guard. Therefore, Staff (D) PA made the decision to recommend to the officers to pursue evaluation of Patient #1 at another hospital ED, where they have more security and psychiatric resources, if they felt a medical exam was necessary. Patient #1 will be discharged. At 07:07 AM, a physical exam documented by Staff (D) indicates that Patient #1's head is normocephalic (normal sized head), eye exam normal, nose exam normal, no nasal deformity, no respiratory distress, movement of chest symmetrical, chest expansion equal, and speech normal.

Review on 05/24/23 of the ED record (another hospital) for Patient #1 dated 04/30/23 revealed at 10:29 PM, Patient #1 was brought in by law enforcement for a "Welfare Check". Police Officers stated Patient #1 was acting bizarre, tried to fight with police. Zyprexa 1mg intramuscular (IM) injection given for everyone's safety. Unable to get vital signs at this time, Patient #1 violent toward staff and police. Seems to be highly intoxicated. At 11:57 PM, Patient #1 is calmer. The physical exam was normal, drug versus alcohol versus agitation. Assessment and Plan is for a sober re-evaluation.

Telephone interview on 05/23/23 at 08:05 AM with Staff (D), PA revealed that on 04/30/23, Staff (D) went out to the ED waiting room as two Officers were bringing Patient #1 in. The Officers were struggling to control Patient #1, who was in handcuffs, and were basically dragging Patient #1 in kicking, swearing, and yelling "I'll kill you." Staff (D) approached Patient #1 in an attempt to do a medical screening exam (MSE). Patient #1 was very combative and aggressive, attempting to headbutt and bite Staff (D) when trying to listen to Patient #1's lungs. Staff (D) asked the Officers if they could remain with Patient #1 for the safety of Patient #1 as well as other patients and ED staff. The Officers stated they could not. Based on Patient #1's presentation, Staff (D) determined Patient #1 was not having a medical emergency and suggested that the Officers take Patient #1 to another hospital ED that is better equipped to handle a patient like Patient #1.

Based on policy review, medical record review, and interview, the facility did not ensure Patient #1 received appropriate transfer to a receiving facility.

Findings Include:

Review on 05/23/23 of policy "Emergency Medical Treatment and Active Labor Act (EMTALA)," last revised 02/2023, the medical screening examination indicated that an emergency medical condition exists, the facility shall either: provide treatment to stabilize the patient or, appropriately transfer the patient to another facility, The treatment provided to stabilize the patient must be considered with general acceptable standards of care. Condition for Transfer: prior to transferring a patient, the hospital must provide medical treatment within its capacity, the receiving facility must have agreed to accept the patient and provide treatment.

Review on 05/23/23 of the Ira Davenport Memorial Hospital (IDMH) emergency department (ED) record for Patient #1 revealed a late entry dated 05/02/23 was documented by Staff (D), Physician Assistant (PA) for Patient #1's presentation to the ED on 04/30/23. The late entry indicates Patient #1 presented to the ED on 04/30/23 at 09:00 PM in police custody for aggressive behavior, homicidal ideation, and possible alcohol intoxication. Patient #1 was handcuffed and actively struggling with police during provider attempt at an MSE. Staff (D), PA advised the officers that the ED did not have adequate facilities or staff to evaluate Patient #1 as they were at high risk of harming themselves and/or staff. Staff (D), PA recommended Patient #1 be taken to another hospital ED where they are better equipped to evaluate Patient #1 if they (the officers) felt a medical issue needed evaluation. At 06:59 AM, Staff (D), PA documented that due to severe aggression, was unable to adequately perform an MSE, though there did not appear to be a medical emergency. With severe medical physical aggression, Patient #1 was an immediate threat to themselves and staff. The ED does not have a secure or safe psychiatric holding room, and only one unarmed security guard. Therefore, Staff (D) PA made the decision to recommend to the officers to pursue evaluation of Patient #1 at another hospital ED, where they have more security and psychiatric resources, if they felt a medical exam was necessary. Patient #1 will be discharged. No transfer documentation and/or notification of transfer to the receiving hospital was found in the medical record.

Review on 05/24/23 of the other hospital ED medical record from 04/30/23 to 05/01/23 revealed on 04/30/23 at 10:29 PM, Patient #1 presented to the ED with Law Enforcement. No transfer documentation and/or notification of the transfer by the originating facility was found in the medical record.

Telephone Interview on 05/23/23 at 08:05 AM with Staff (D), PA revealed that on 04/30/23, an attempt to contact the other hospital ED was made to inform them Patient #1 was being brought in by Police, but the number was busy, and was not able to record a message.