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Based on record reviews, policy reviews, review of the Security video (audio not recorded), staff interviews and a patient's responsible party interview, the facility failed to ensure 4 of 12 sampled patients (Patient 1, 2, 26 and 28) at the Psychiatric Assessment Center (Lasting Hope Recovery Center -LHRC) received a Medical Screening Examination (MSE) to determine within the hospital's capabilities the presence of an Emergency Medical Condition (EMC) in accordance with the facility policies and Medical Staff by-laws, rule and regulations pertaining to EMTALA (Emergency Medical Treatment and Labor Act). CHI Health Creighton University Medical Center-Bergan Mercy system has 3 Dedicated Emergency Department's (DED); (DED A) is at the main campus, Level 1 trauma center capable of providing all levels of emergency care located 6 miles away from LHRC; (DED B) is an off campus facility which is a full service emergency department staffed with board-certified emergency physicians, located 1.5 miles away from LHRC ; and (DED C) is the Psychiatric Assessment Center (Lasting Hope Recovery Center -LHRC). A total sample of 28 records were reviewed, of patients presenting to the 3 departments for a MSE. This failure placed all emergency patients requesting to be seen at the LHRC to be at risk of harm due to being discharged/transferred with an untreated/unstabilized EMC. The Hospitals 3 DED's saw an average of 5053 emergency patients per month.

Also see A 2406

Findings are:

A) A review of the "Medical Staff by-laws, rules and regulations pertaining to EMTALA" with a board approval date of 7/10/2020, identified:
-A Medical Screening for Existence of Emergency Medical Condition. An Emergency Medical Condition (EMC) is defined as: "A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a) placing the health of the individual in serious jeopardy, or b) serious impairment of bodily functions, or c) serious dysfunction of any bodily organ or part."
-A Medical Screening Examination or MSE is the process required to determine with reasonable clinical confidence whether an EMC does or does not exist. The extent of the MSE may vary depending on the individual's signs and symptoms. An appropriate MSE can include a wide spectrum of actions ranging from a simple process only involving a brief history and physical examination to a complex process that also involves performing ancillary tests and procedures. The extent of the necessary examination to determine whether an EMC exists is within the judgement and discretion of the physician or other QMP performing the examination consistent with Medical Center protocols. With respect to an individual manifesting behavioral or psychiatric symptoms, the MSE consists of both a medical and behavioral/psychiatric screening. Triage is not a MSE.
-The following individuals are Qualified Medical Personnel (QMP) who may initiate and /or complete a MSE within the scope of their license: registered nurses (RNs), nurse practitioners (NPs), physician assistants (PAs), Doctors of Osteopathy (DOs), and Medical Doctors (MDs).
-The MSE for existence of an EMC will be initiated on all Emergency Department patients by the Emergency Nurse where such screening examination can be conducted within the scope of RN practice under state law.
-The Emergency Physician or APC (Advanced Practice Clinician) will review the initial nursing information and will complete the MSE for existence of an EMC.

Medical Screening for Existence of Emergency Medical Condition at LHRC
-Patients arriving in the Assessment Center at LHRC shall have a Medical Screening Examination for the existence of an Emergency Medical Condition performed by the LHRC nurse where such screening examination can be conducted within the scope of registered nurse practice under state law. The examination will include:
1) Complete set of vital signs.
2) Complete nursing assessment using the behavioral health assessment tool which is part of the medical record. The behavioral nurse will notify the On-Call behavioral physician prior to the patient leaving the facility. Discharge and follow-up instruction will be given to the patient as ordered by the On-Call behavioral physician. (If during this evaluation, it is determined that the patient needs additional medical screening, the patient will be transferred to the medical emergency department for a medical evaluation and treatment if necessary.)

B) Review of facility policy titled "Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department - EMTALA - Creighton University Medical Center - Bergan Mercy" last revised 03/2018 revealed the facility will; Provide for an appropriate transfer of the unstabilized individual to another medical facility in accordance with these procedures. The transfer of an unstabilized EMC is permitted only pursuant to individual request, or when a physician, or other QMP in consultation with a physician, certifies that the expected benefits of the transfer outweighs the risks of the transfer.

C) A clarification of LHRC policies for the Assessment Center at LHRC with the Quality Director for LHRC on 8/27/21 at 12:50 PM revealed:
1. Assessment Center performances of laboratory point of care tests (tests nurses can do at the patients bedside/without a laboratory facility) are accucheck blood glucose and urine pregnancy. A breathalyzer is available in the Assessment Center to be used as a screening tool based on presenting symptoms or reported of intoxication.
2. Point of care testing is dictated by laboratory policy and procedure requiring training and competency. Nurses in the Assessment Center receive training on use of the breathalyzer as a screening tool and report results to the provider. The provider will then order a blood alcohol test if indicated.
3. Orders are obtained from the provider to conduct blood glucose, urine pregnancy and blood alcohol.
4. Patients are transferred to a medical facility for care, treatment and services for acute alcohol withdrawal or referred to a Detox Center as directed by the provider.
5. Patient may return to LHRC for psychiatric care following medical stability of acute alcohol withdrawal.

D) A tour of LHRC-Assessment Center on 8/17/21 at 1:15 PM revealed, the Assessment Center has a badge secure area with 8 rooms, an ancillary area where safety searches are performed prior to going to the triage area where vital signs, weight and the Behavioral Mental Status Exam can be completed. The LHRC-Assessment Center has 2 RN's scheduled and the House Supervisor RN will assist as needed. The RN's must have Basic Life Support (BLS) certification, and know how to respond in case of a medical emergency to initiate life saving services until 911 can arrive. The Center has a Psychiatrist On-Call 24 hours a day, there is no medical provider present at the LHRC-Assessment Center.

E) A review of Patient 1's electronic Medical Record (EMR) revealed that Patient 1 arrived at LHRC as an unscheduled walk in patient on 6/26/21 at 4:26 PM and discharged at 4:54 PM. Patient 1's EMR lacked evidence that RN M performed a MSE as required by the hospital's medical staff bylaws or contacted the on-call psychiatrist (Dr.M) for orders. Additionally, the medical record lacked evidence that staff arranged to transport Patient 1 to the hospital's DED B, an off campus full service emergency department staffed with board-certified emergency physicians, located 1.5 miles away, or to its DED A, main campus Level 1 trauma center capable of providing all levels of emergency care located 6 miles away.

F) Review of Patient 2's EMR revealed that Patient 2 arrived at LHRC as an unscheduled walk in patient on 7/13/21 at 7:12 PM and left at 7:53 PM. Patient 2's EMR lacked evidence that RN D performed a MSE as required by the hospital's medical staff by laws or contacted the on-call psychiatrist (Dr S) for orders. Additionally, the medical record lacked evidence that the staff arranged to transport Patient 2 to the hospital's DED B or DED A.

G) Review of Patient 26's EMR revealed that Patient 26 arrived at LHRC as an unscheduled walk in patient on 8/13/21 at 12:43 PM and left at 1:11 PM. Patient 26's EMR lacked evidence that RN G performed a MSE as required by the hospital's medical staff bylaws or contacted the on-call psychiatrist (Dr T) for orders. Additionally, the medical record lacked evidence that the staff arranged to transport Patient 26 to the hospital's DED B or DED A.

H) Review of Patient 28's EMR revealed that Patient 28 arrived at LHRC on 8/13/21 in the custody of law enforcement as an EPC (emergency protective custody-temporary custody due to the threat to harm self or others) at 3:32 AM and was discharged at 4:00 AM. Documentation by law enforcement on the EPC form showed that Patient 28 had injected herself with 20 units of a fast acting insulin, even though she WAS NOT a DIABETIC because she was upset with her husband and "wanted to get his attention." The EMR lacked evidence that RN M performed a MSE as required by the hospital's medical staff bylaws, or made arrangements for patient 28 to receive a MSE at DED A or DED B, located 1.5 miles away prior to calling 911 for transport to Hospital U's ED.

I) An interview on 8/17/21 at 12:10 PM with he Director of Nurses at LHRC verified:
-RN M; RN D and RN G were considered a QMP's.
-The EMR for Patients 1, 2 and 26 lacked an MSE as required by the hospitals medical staff bylaws or consistently notified the on call psychiatrist prior to doing point of care testing (bedside breathalyzer & blood glucose testing) or prior to calling 911 for transport.
-The nurses do not consistently call the on-call psychiatrist for determination of the patient's status for transfer to an accepting community hospital not affiliated with LHRC.

Based on record reviews, review of the Security video (audio not recorded), staff interviews and a patient's escort interview, the facility failed to ensure 4 of 12 sampled patients (Patient 1, 2, 26 and 28) who presented to the Psychiatric Assessment Center (Lasting Hope Recovery Center -LHRC) received a Medical Screening Examination (MSE) within the hospital's capabilities to determine whether or not an Emergency Medical Condition (EMC) existed. CHI Health Creighton University Medical Center-Bergan Mercy system has 3 Dedicated Emergency Department's (DED); (DED A) is at the main campus, a level 1 trauma center capable of providing all levels of emergency care; (DED B) is an off campus facility which is a full service emergency department staffed with board-certified emergency physicians; and (DED C) is the Psychiatric Assessment Center (Lasting Hope Recovery Center -LHRC). The DED A is 6 miles for LHRC and DED B is 1.5 miles from LHRC. A total sample of 28 records were reviewed, of patients presenting to the 3 DEDs for a MSE. This failure placed all emergency patients requesting to be seen at the LHRC to be at risk of harm due to being discharged/transferred with an untreated/unstabilized EMC. The Hospitals 3 DED's saw an average of 5,053 emergency patients per month.

Findings are:

A) Review of Patient 1's electronic Medical Record (EMR) revealed that the patient arrived at LHRC as an unscheduled walk-in patient on 6/26/21 at 1626 (4:26 PM) and was discharged at 1654 (4:54 PM). Register Nurse M (RN M) noted on 6/26/21 at 4:50 PM, Patient was at desk in lobby and was unsteady and had garbled speech. Further documentation showed "Asked patient what all she had taken today and she replied alcohol and gabapentin" (a medication to prevent seizures and relieve pain for certain conditions in the nervous system). "Patient was advised to go to nearest ER. Friend who brought her stated she would take Pt 1 immediately. Patient left before signing correct paperwork."

LHRC staff RN M was identified as a QMP and failed to follow the facility policy by not performing a MSE. Patient 1's EMR lacked evidence of a MSE, consultation or an order from the on call psychiatrist (Dr M), or evidence that staff attempted to arrange for patient 1 to receive further examination at DED A or DED B, located 1.5 miles away.

B) Patient 2 arrived at LHRC on 7/13/21 at 7:08:18 per review of the hospital's Security Video (no audio available). The Security Video revealed:
-7:08:18- Patient 2 entered the lobby of DED C at LHRC accompanied by Soldiers A and B.
-7:08:45- Registrar T (RA T) handed patient 2 the Consent to Treat form.
-7:09:05- Registered Nurse D (RN D) came in the far door from the Assessment Center. RN D appeared to speak to Soldiers A and B. Patient 2 was located approximately 2 feet away.
-7:10:15- Soldier B laid his phone on the desk; Patient 2 and Soldier A walked over to the chairs; RN D picked up the phone and appeared to talk on Soldier B's phone.
-7:13:21- Patient 2, Soldiers A and B went to the Covid Screening Kiosk than sat down.
-7:17:46- Soldier B went outside.
-7:19:30- Soldier B returned to the lobby and sat with Patient 2 and Soldier A.
-7:27:17- RN D passed through the lobby and did not interact with the Patient or Soldiers A or B.
-7:27:58- RA T approached Patient 2 with the hospital identification bracelet.
-7:30:49- Soldier B appeared to be talking on the phone and pacing. RA T was talking with Patient 2.
-7:32:58- Soldier B handed RA T his phone and RA T appeared to be talking to someone on the phone.
-7:34:32- RN D came into the lobby and RA T handed RN D Soldier B's phone.
-7:35:29- RA T grabbed a piece of paper from the lobby desk.
-7:36:34- RN D gave Patient 2 the piece of paper to sign (Refusal of a MSE paper).
-7:37:46- RN D and Soldier B appeared to be talking when they walked out of the video view.
-7:40:42- Patient 2, Soldiers A and B left facility.

A telephone interview with Soldier A on 7/14/21 at 3:15 PM revealed; on 7/13/21 Soldier A and B picked Patient 2 up from the (Military Base Clinic). Soldier A stated that staff at the Military Base Clinic called LHRC and asked if we could bring Patient 2 to the LHRC for evaluation and were told we could. Upon our arrival the receptionist greeted us. We asked if we were in the right place. Soldier A stated that Patient 2's mental status was severely degraded and that she needed assistance. Soldier A stated that RN D came out of the back and asked the receptionist "is that them." RN D said she needed to talk to us and moved us about 2 feet from Patient 2 (close enough for her to hear) and RN D said "we are not a babysitter" then informed us that the facility was full and it was not likely that Patient 2 would be admitted. Soldier A stated that RN D then turned to Patient 2 and asked "are you suicidal" and she said no, then RN D asked Patient 2 "are you homicidal"? She again said she wasn't. Soldier A stated that RN D said "she probably won't be accepted anyway but we'll let the doctor determine that and walked away. Soldier B called our Superior Officer and they called around to assist us in getting Patient 2 to another hospital for treatment. While leaving LHRC lobby, Soldier A stated that RN D came back out and insisted to us that she did not refuse services but said if she was to admit Patient 2, she would be transferring her to (Hospital V ER) anyway. As we were preparing to leave RN D told us that Patient 2 had to sign a release form. Soldier A stated they were not informed of the risks of leaving without treatment prior to being seen. Soldier A indicated they did not get a copy of the release form that Patient 2 signed. Soldier A stated that their primary concern was getting Patient 2 to a location where she would be cared for safely. Soldier A stated they took the patient to (Hospital V) where she was admitted for care. When inquired of Soldier A regarding this interaction, he stated, "This kind of behavior from a Nurse is uncalled for! Certainly from a Behavioral Health Nurse in front of the patient! Like I said Patient 2's mental status was severely degraded and she needed assistance!" "We signed the paper and left, took her to (Hospital V ER) and they assisted us and admitted her."

A telephone interview with the receptionist/registrar (RA T) for LHRC on 8/16/21 at 3:20 PM regarding the events that occurred when Patient 2 was at the facility on 7/13/21. RA T stated, "Yes I remember her, she came in with 2 officers. "RN D knew they were coming because she told me that she wanted to talk to them." On arrival I started the process and registered the patient in and gave the patient a Consent to Treat paper to sign and offered her the hospital hand book. RN D came out from the Assessment Center and "took over the situation" with Patient 2, and I went back to my work. RN D was talking to the 2 officers while Patient 2 signed the paperwork and then RN D returned to the Assessment Center. The patient and the 2 officers went and sat down. RN D came back and told me to register the patient in. I made the wristband and walked over to where the 3 were sitting in the lobby. The head officer (Soldier B) was on the phone off and on while waiting. When I got to them the head officer said they had a bed for the patient at (Hospital V- a community hospital not affiliated with LRHC) and they were going to (Hospital V). The head officer then handed me the phone and the Base Physician told me they contacted (Hospital V) and they would have a bed for her and they were taking her there. RN D came back, I handed her the phone and she talked to the Base Physician. RN D and the head officer went over to the waiting area across from my desk and talked. I could tell the officer was upset when they were talking by his body language. RN D then came and got a paper (the refusal before being seen form) and had (Patient 2) sign it and the 3 left.

Telephone interview with RN D on 8/17/21 at 8:30 AM regarding the events that occurred when Patient 2 was at the facility on 7/13/21. RN D stated, "Yes I remember (Patient 2), she came in just after the shift started. I was the House Supervisor and helping in the Assessment Center doing safety searches." When asked if RN D was aware Patient 2 was coming? RN D stated, "No, I wasn't aware they were coming, maybe the Assessment Center Nurses knew." When asked what RN D recalled about the events with Patient 2, "They were in the building at the front desk. I came out from the assessment center and asked what's going on. They (Soldiers A & B) told me they were looking for a place for Patient 2." I said, "We can do an assessment and see if she meets criteria. We were full at that time. I asked if she was suicidal or homicidal or having auditory or visual hallucinations and Patient 2 said No." They were registered and sat down in the lobby. "I went back to the assessment center again. I then went to a unit downstairs and when I came back upstairs I saw they (the patient and officers) were still sitting in the lobby and I stopped and said it should only be a few more minutes. The officer in charge told me "we are taking her to (Hospital V ER). I said ok, but would be happy to do an assessment and if she meets criteria we can transfer the patient." The lead officer said that "(Hospital V had a bed, and they had talked to them, and that they were taking (Patient 2) there." I told the lead officer that I needed (Patient 2) to sign a paper and she signed it. When inquired who was on the telephone when RA T handed Soldier B's phone to her, "oh that was the (Base Physician) and they told me the patient needed placement and we hung up." When asked if Patient 2 received a MSE, RN D said "No, we were processing other patients in the back. I asked the quick questions related to thoughts of suicide or homicide or hallucinations." When inquired if the patient was seen by, or if the On Call Psychiatrist was notified the patient had arrived, "No we do the full mental health assessment and then notify the provider." "If we need something emergent we contact the On-Call Psychiatrist, for example if a patient had an overdose or multiple wounds and/or felt the patient was not medically stable, or their behavior was out of control and dangerous. If they are medically unstable, like an overdose we stay with them, and check vital signs in the lobby and call 911 and the on-call doctor."

A review of Patient 2's Electronic Medical Record (EMR) at LHRC's ED (Emergency Department) Events timeline revealed, Patient 2's Emergency encounter was created on 7/13/21 at 1912 (7:12 PM) by RA T and RN D identified the patient departed the DED at 1953 (7:53 PM). The timeline identified that Patient 2 was placed in room 2AR08 at 1935 (7:35 PM) and 'trigger for triage start/triage started'. (Verified in the telephone interview with RN D that Patient 2 remained in the lobby the entire time she was at LHRC). ED timeline identified patient discharge/physical depart time was 1953 (7:53 PM). The timeline identified that Dr S (the On Call Psychiatrist) signed the medical record on 7/14/21 at 2007 (8:07 PM).

RN D's ED Note revealed, Patient was brought in by (Individuals A & B) and stated the patient had an overdose in May, and is looking for where she can be placed. While talking to patient denies thoughts of suicide or homicide, but did sign in. Further documentation by RN D showed, "I will do a assessment but cannot say she will be admitted that is up to the Dr." "Explained we do not have any current open beds but will do a assessment and if the Dr thinks she needs to be admitted we can either look for a bed or keep her in the AC (assessment center)." "When this nurse went to get the patient for safety search was told by her first sargent that they called (Hospital V-a community hospital not affiliated with LHRC) who has open beds and they would just take patient to (Hospital V) again offered a assessment but they stated no they were going to (Hospital V) Patient signed refusal of tx (treatment) form." Further documentation in the medical record showed that the patient's "ED Disposition" was LWBS (left without being seen).

LHRC staff RN D was identified as a QMP and failed to follow the facility policy by not performing a MSE. Patient 2's EMR lacked evidence of a MSE, no vital signs were documented, the record lacked consultation or an order from the on call psychiatrist (Dr S). Patient 2's EMR timeline identified that the next day on 7/14/21 at 2007 (8:07 PM) Dr S signed the record as "Charting Complete."

C) Review of Patient 26's electronic Medical Record (EMR) revealed that Patient 26 arrived at LHRC as an unscheduled walk in patient on 8/13/21 at 1243 (12:43 PM) and was discharged at 1311 (1:11 PM). RN G's nurses note dated 8/13/21 at 1:30 PM revealed, "At 12:40 PM patient walked into the lobby at LHRC. Great difficulty walking. Accompanied by (Patient 26's) elderly parents. Slurring speech. Very difficult to understand. Swaying in the chair. Complaints of nausea but never had any emesis. Complaints of seeing rats "all over the place." Stated was seeing them now. Complaints of hearing people tell him to drink himself to death. BAC (Blood Alcohol Concentration) was 222 (A patient presenting without consumption of Alcohol would register as a 0). Appeared to be about ready to pass out. Reminded him to take breaths. 911 called. The flowsheet identified the patient's "Disposition" as an ED transfer; method of transfer-Ambulance; Reason for transfer-Medically unstable and Transfer destination- (Hospital U-a community hospital not affiliated with LHRC)

A review of Pt 26's (EMR) ED (Emergency Department) Events timeline revealed, Pt 26's Emergency encounter was created on 8/13/21 at 1243 (12:43 PM). The ED timeline identified by RN G that at 1249 (12:49 PM) Pt 26 was roomed in 2AR01 and 'trigger for triage start/triage started'. ED timeline identified for transfer to another facility at 1303 (1:03 PM) -1310 (1:10 PM) Pt 26 discharged/physical depart at 1311 (1:13 PM). The timeline identified that Dr T signed the record as charting complete on 8/14/21 at 1554 (3:54 PM).

LHRC staff RN G was identified as a QMP. Patient 26's EMR lacked evidence that RN G performed a MSE, obtained vital signs or documented notifiication or consultation with on-call psychiatrist (Dr. T). The EMR did not contain an order for a BAC check or to arrange for patient 26 to receive further examination at DED A or DED B, located 1.5 miles away prior to RN G calling 911 for transport to Hospital U's ED.

D. Review of Patient 28's EMR revealed that Patient 28 arrived to LHRC on 8/13/21 at 3:32 AM and was discharged at 4:00 AM. Patient 28 arrived in custody of local law enforcement under an emergency protective custody-temporary custody (EPC) due to the threat to harm self or others. The documentation on the EPC form included in the medical record showed that Patient 28 injected herself with 20 units of Novalog (fast acting insulin) when she WAS NOT DIABETIC because she was upset with her husband and "wanted to get his attention." Further documentation on the EPC form showed that Patient 28 is a nurse and knew the potential harm that could occur by using insulin. When she was placed into custody she stated, "I should've done this the right way."

RN M documented in the medical record that the patient stated she felt woozy and unsteady, a bedside POCT (point of care test) for blood sugar was checked and registered 55 (normal range 70-99). The patient was given a glass of juice. The psychiatrist on-call was notified. An order for discharge was received from Dr O. RN M charted "pt will be sent to (Hospital U-ED) to rule out any other ingestion and medical clearance."

LHRC staff RN M was identified as a QMP. Patient 28's EMR lacked evidence of a MSE, no vital signs or update on the patient's status after drinking juice was documented, no repeat blood sugar POCT was obtained, and no arrangements were made for patient 28 to receive further examination at DED A or DED B, located 1.5 miles away prior to RN M calling 911 for transport to Hospital U's ED.

E. An interview on 8/17/21 at 12:10 PM with the Director of Nurses (DON) at LHRC verified:
-RN M (on 6/26/21), RN D (on 7/13/21) and RN G (on 8/13/21) were considered a QMP on the days they were working.
-The medical records for Patients 1, 2 and 26 lacked an MSE; vital signs and physician notification and orders.