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Based on hospital policy review, document review, medical record review, and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening examination (MSE), monitoring and treatment for 1 of 23 (Patient #1) sampled patients reviewed.

The findings included:

1. Review of the hospital policy titled, "EMTALA [Emergency Medical Treatment and Labor Act] - Definitions and General Requirements" last approved 8/2024 revealed, "...The hospital with an emergency department must provide to any individual, including every infant who is born alive, at any stage of development, who "comes to the emergency department" an appropriate Medical Screening Examination ("MSE") 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 ("EMC") exists..."

Review of the hospital policy titled, "EMTALA [named state] Medical Screening Examination and Stabilization" revised 12/2023 revealed, "...A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the DED [dedicated emergency department]...The medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The psychiatric MSE includes an assessment of suicidal or homicidal thought or gestures that indicates danger to self or others...Psychiatric QMP [Qualified Medical Personnel]. The ED physician shall consult the QMP providing the behavioral assessment for psychiatric purposes but shall remain the primary decision-maker with regard to transfer and discharge of the individual presenting to the DED with psychiatric or behavioral emergencies..."

Review of the hospital policy titled, "Assessment/Reassessment/Plan of Care of Patients" revised 5/2023 revealed, "...Emergency Department...All patients (ESI [Emergency Severity Index] Level Triage 1-3) presenting to the Emergency Department will receive...Rapid Initial Assessment (Rapid Triage) with assigned acuity...Chief Complaint Assessment...Detailed Assessment...Suicide Risk Screening (on all patients > [greater than] 12 years old who are being evaluated for behavioral health conditions as their primary reason for care)...Disposition Assessment...Rapid Initial Assessment is the information-collecting and decision making process to sort ill patients into categories of acuity based on the urgency of medical and psychological needs...Triage Acuity Levels...Level 1 Resuscitation...Level 2 Emergent [patient is considered an emergency and should be seen by a physician promptly]..."

Review of the hospital policy titled, "Suicide Risk Assessment (Non-Behavioral Health)" revised 4/2023 revealed, "Columbia Suicide Severity Rating Scale (C-SSRS): Initial screening tool utilized by the nurse. It will provide an auto-calculated level of no risk, low, moderate or high risk. Suicide Detailed Risk Assessment (suicide DRA)...Any patient with a positive, "at-risk" C-SSRS screening...require a secondary level detailed suicide risk assessment (suicide DRA) to identify activating events, protective factors, and contributing clinical factors to risk of suicide. This would be completed by a licensed or credentialed physician/practitioner. The Provider/Practitioner will use the information collected from the suicide DRA paired with clinical judgement to determine (estimate) the patient's overall risk level (ORL)...The ORL is considered the standard of care for assigning suicide risk level as it is based on consideration of modifiable and protective risk factors..."

2. Review of the hospital document titled, "Medical Staff Rules and Regulations" revised 2/9/2023 revealed, "...Medical Screening Exam a. Federal and State laws and regulations provide that any individual who comes to the Hospital property or premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination (MSE) performed by individuals qualified to perform such examination to determine whether or not an emergency medical condition exists. An appropriate MSE includes routinely available ancillary services...The MSE is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred...It is the policy of the hospital that the MSE is done by the emergency Physician, Quality Medical Personnel (QMP), attending physician or on-call Physician...In addition to Physicians, Physician Assistants, and Nurse Practitioners, QMP for Psychiatric Screening includes the Non-physician Community Assistance Program (CAPS) Staff meeting educational and experience qualifications are approved to perform the initial medical screening examination and consultation for patients with psychiatric care needs..."

3. Review of the hospital's ED log revealed Patient #1, a 25 year old male, presented via walk in on 8/8/2024 at 5:26 PM with chief complaint of "Suicidal Thoughts."

Medical record review revealed Patient #1 was evaluated by Registered Nurse (RN) #1 at 5:26 PM. RN #1 documented Patient #1 reported having suicidal thoughts, was very anxious, agitated and verbally aggressive upon arrival. The nursing documentation further showed Patient #1's blood pressure and heart rate were elevated, and the patient was very tearful and requested medications to help him calm down and to treat his pain. Patient #1 reported he had 5 previous suicide attempts and had just moved to the area from out of state. The C-SSRS assessment revealed Patient #1 was "high risk" for self-harming behaviors.

Patient #1 was seen by ED Provider #1 initially on 8/8/2024 at 5:33 PM, and ED Provider #1 documented Patient #1 had a history of borderline personality disorder, denied suicidal and/or homicidal ideations and was anxious and agitated and stated he needed to relax. ED Provider #1 further documented the patient had no primary care provider. ED Provider #1 documented he spoke with Patient #1's parents, and they didn't think Patient #1 was suicidal. ED Provider #1 documented Patient #1 calmed down and was stable for discharge home. There were no physician orders for laboratory work, medications, and/or psychiatric or behavioral health consults.

Patient #1 left the ED unaccompanied on 8/8/2024 at 6:25 PM with no follow-up appointment scheduled, no new prescriptions for medications to address his anxiety, and no documented safety plan.

There was no documentation Patient #1 was assessed for physiologic causes of his psychiatric condition. There was no blood work or toxicology testing completed. There was no documentation a psychiatric evaluation was completed. There was no documentation Patient #1 received treatment for his acute anxiety while at the hospital's ED. The hospital failed to ensure Patient #1 received an appropriate and on-going medical screening examination, monitoring and treatment to determine if an EMC existed.

Refer to A2406.

Based on hospital policy review, document review, medical record review, and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening examination (MSE), monitoring and treatment for 1 of 23 (Patient #1) sampled patients reviewed.

The findings included:

1. Review of the hospital policy titled, "EMTALA [Emergency Medical Treatment and Labor Act] - Definitions and General Requirements" last approved 8/2024 revealed, "...The hospital with an emergency department must provide to any individual, including every infant who is born alive, at any stage of development, who "comes to the emergency department" an appropriate Medical Screening Examination ("MSE") 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 ("EMC") exists..."

Review of the hospital policy titled, "EMTALA [named state hospital located] Medical Screening Examination and Stabilization" revised 12/2023 revealed, "...A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the DED [dedicated emergency department], including ancillary services routinely available to the DED, to determine whether or not an EMC exists: to...an individual who has such a request made on his or her behalf; or...an individual whom a prudent layperson observer would conclude from the individual's appearance or behaviors needs an MSE. An MSE shall be provided to determine whether or not the individual is experiencing an EMC...An MSE is required when...The individual comes to a DED of a hospital and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition, including where: i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition...Extent of the MSE...The hospital must perform an MSE to determine if an EMC exists...Triage entails the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual will be screened by a physician or other QMP [qualified medical person]...An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not...The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital...The individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC, and if he or she does until he or she is stabilized or appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer...The extent of the necessary examination to determine whether an EMC exists is generally within the judgement and discretion of the physician or other QMP performing the examination function according to algorithms or protocols established and approved by the medical staff and governing board...Individuals with psychiatric or behavioral symptoms: The medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The psychiatric MSE includes an assessment of suicidal or homicidal thought or gestures that indicates danger to self or others...Psychiatric QMP. The ED physician shall consult the QMP providing the behavioral assessment for psychiatric purposes but shall remain the primary decision-maker with regard to transfer and discharge of the individual presenting to the DED with psychiatric or behavioral emergencies..."

Review of the hospital policy titled, "Assessment/Reassessment/Plan of Care of Patients" revised 5/2023 revealed, "...Emergency Department...All patients (ESI [Emergency Severity Index] Level Triage 1-3) presenting to the Emergency Department will receive...Rapid Initial Assessment (Rapid Triage) with assigned acuity...Chief Complaint Assessment...Detailed Assessment...Suicide Risk Screening (on all patients > [greater than] 12 years old who are being evaluated for behavioral health conditions as their primary reason for care)...Disposition Assessment...Rapid Initial Assessment is the information-collecting and decision making process to sort ill patients into categories of acuity based on the urgency of medical and psychological needs...Triage Acuity Levels...Level 1 Resuscitation...Level 2 Emergent [patient is considered an emergency and should be seen by a physician promptly]..."

Review of the hospital policy titled, "Suicide Risk Assessment (Non-Behavioral Health)" revised 4/2023 revealed, "Columbia Suicide Severity Rating Scale (C-SSRS): Initial screening tool utilized by the nurse. It will provide an auto-calculated level of no risk, low, moderate or high risk. Suicide Detailed Risk Assessment (suicide DRA): Subsequent assessment completed by the Provider/practitioner. The Suicide DRA must be completed for any patient with a positive C-SSRS screen. Overall Risk Level (ORL): Determined by the provider/practitioner's clinical judgement and suicide DRA. The provider/practitioner will assign a level of no risk, low, moderate, or high risk. This will take precedence over the C-SSRS, if the risk level differs...Patients who are at an increased risk for suicide or self-harming behaviors require intensive support, close observation, and frequent reassessment for their emotional and physical well-being...Patients in non-psychiatric areas (e.g. Emergency Room (ER) patients, and non-BH [behavioral health] inpatient units, age 12 years and older, who are being evaluated or treated for behavioral health...conditions as their primary reason for care should be screened using the C-SSRS...The Provider/Practitioner will be notified of positive screens (i.e. [such as], at risk patients)...The nursing assessment will include current, recent, and past thoughts of suicide, plans, means and/or intents, as well as recent or past history of suicide attempts within their lifetime for patients age twelve and above being admitted to emergency rooms...who are being evaluated for treatment for behavioral health (BH) conditions. The C-SSRS is the initial screening tool utilized by the nurse...it is intended to differentiate "at-risks" patients from patients without identified risk...Any patient with a positive, "at-risk" C-SSRS screening...require a secondary level detailed suicide risk assessment (suicide DRA) to identify activating events, protective factors, and contributing clinical factors to risk of suicide. This would be completed by a licensed or credentialed physician/practitioner. The Provider/Practitioner will use the information collected from the suicide DRA paired with clinical judgement to determine (estimate) the patient's overall risk level (ORL)...The ORL is considered the standard of care for assigning suicide risk level as it is based on consideration of modifiable and protective risk factors..."

2. Review of the hospital document titled, "Medical Staff Rules and Regulations" revised 2/9/2023 revealed, "...Medical Screening Exam a. Federal and State laws and regulations provide that any individual who comes to the Hospital property or premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination (MSE) performed by individuals qualified to perform such examination to determine whether or not an emergency medical condition exists. An appropriate MSE includes routinely available ancillary services...The MSE is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred...It is the policy of the hospital that the MSE is done by the emergency Physician, Quality Medical Personnel (QMP), attending physician or on-call Physician...QMP or Personnel...In addition to Physicians, Physician Assistants, and Nurse Practitioners, QMP for Psychiatric Screening includes the Non-physician Community Assistance Program (CAPS) Staff meeting educational and experience qualifications are approved to perform the initial medical screening examination and consultation for patients with psychiatric care needs..."

3. Review of the hospital's ED log revealed Patient #1, a 25 year-old male, presented via walk in on 8/8/2024 at 5:26 PM with chief complaint of "Suicidal Thoughts."

Medical record review revealed a triage assessment was completed by Registered Nurse (RN) #1 on 8/8/2024 at 5:26 PM and revealed, "...Stated Complaint: Suicidal Thought...Pt [patient] reports having suicidal thoughts but does not want to be admitted. Pt [patient] state he just wants a 'sedative and something for pain and to go home.'... Objective assessment...A&OX4 [alert and oriented to person, place, time, and situation], tearful and verbally aggressive/uncooperative...Hypertensive..." The patient's presenting vital signs were Respiratory Rate (RR) 18, Pulse (P) 119, Blood Pressure (BP) 197/102, and oxygen saturation (O2 sat) of 99 percent (%) on room air. Patient #1 was assigned an ESI level 2, Emergent (patient is considered an emergency and should be seen by a physician promptly). The nursing documentation further revealed RN #1 completed the C-SSRS assessment and Patient #1 was found to be a High Risk for suicide. RN #1 documented, "Upon bringing pt back for triage, Pt was tearful but agitated/uncooperative/verbally aggressive and immediately stated 'I am not being admitted to the hospital. I will sign out AMA [against medical advice].' This RN told Pt about the psych [psychiatric] eval [evaluation] process and that we needed more information from him to be able to figure out best way to help him. Pt states he has had 5 SI [suicide] attempts in the past and that he just wanted a sedative and something for pain and to go home. Pt refused to answer if he recently attempted SI but stated 'I know better than to answer that question with a camera pointed at me. I am not going to be trapped in a hospital.' Pt stated that this RN...were 'trying to trick him'."

Patient #1 was seen by ED Provider #1 at 5:33 PM. The Provider documented, "...The patient reportedly has a history of borderline personality disorder and bipolar disorder. The patient presents to the emergency department feeling anxious and feeling that he needed to relax. I spoke with the patient's parents...who states that the patient just recently moved to this area...10 days ago. He states that the patient was going to depression/bipolar support [DBS] groups regularly...and went to a DBS group meeting locally 6 days ago. The patient's dad states that he was tricked out of some money while at the mall her [here] today and this triggered him...Chief Complaint: Anxious...Reports Anxiety. Denies: Agitation, Anorexia, Delusions, Depression, Illicit drug use...Paranoia, Violence. Exacerbated by Recent stress Relieved by Nothing...Detailed Suicide Risk...Pos [positive] Nur [nursing] Sui [suicide] Risk Screen? No Overall level suicide risk: no risk Risk Stratification...Suicide - Adult Risk factors reviewed, Prior psych admission...Stated Complaint Suicidal Thoughts..." The Provider further documented that he reviewed the Nursing triage notes as well as the Patient's home medication list. ED Provider #1 documented, "...Focused PE [Physical Exam]...Awake, alert, No acute distress...Oriented x 3, Speech NL [normal limits], No motor deficits...Psychiatric Not suicidal, Not homicidal...Agitated...Anxious...Both the patient's parents who spoke with him while he was in emergency department state that they feel that the patient is state [safe]. They states [state] that they did not feel that the patient has any suicidal ideations." At 6:21 PM, ED Provider #1 documented, "Re-Eval Status Improved, The patient appears very agitated and anxious initially, but is now very calm. The patient states he would just like some resources for local psychiatric services...Condition Stable, Improved...Primary Impression: Anxiety Secondary Impressions :Hx [history] of borderline personality disorder...Discharged to Home...Counseled Regarding Diagnosis, Need for follow-up, When to return to ED...Resource Referral: [named mental health facility]...Follow-Up: Call ASAP [as soon as possible] to arrange..."

The Discharge Assessment completed by RN #1 at 6:25 PM revealed the Patient's vital signs were P 99, RR 17, BP 170/86, and O2 sat 100%. The assessment further revealed, "...Behavioral Health Related--Patient condition assessment: No change..."

Patient #1 left the ED unaccompanied on 8/8/2024 at 6:25 PM with no follow-up appointment scheduled, no new prescriptions for his anxiety, and no safety plan.

There was no documentation Patient #1 was assessed for physiologic causes of his psychiatric condition. No blood work or toxicology testing was completed. There was no documentation a psychiatric evaluation was completed. There was no documentation Patient #1 received treatment for his acute anxiety while at the hospital's ED. The hospital failed to ensure Patient #1 received an appropriate and on-going medical screening examination, monitoring and treatment to determine if an EMC existed.

4. During an interview on 9/17/2024 at 12:20 PM, the ED Medical Director (EDMD) was asked to describe the standard of care for patients presenting to the ED with psychiatric complaints. The EDMD stated the hospital had no "standing orders" for psychiatric patients. The EDMD continued and stated when patients presented to the ED with psychiatric complaints, they would first make sure the patient was "medically stable" and do "routine lab workup" to rule out any medical etiology." The EDMD stated once the patient had been cleared medically, they would consult CAPS for a behavioral health evaluation, then review their recommendations on whether the patient required inpatient services, outpatient services, or if they were deemed stable for discharge home. The EDMD stated that if the behavioral health evaluation indicated the patient required inpatient hospitalization, a psychiatrist would be consulted for a second evaluation and then begin searching for an available bed. The EDMD was asked if there were times when CAPS would not be consulted to complete a behavioral health assessment. The EDMD stated, "Yes. Some patients are here frequently, and we know their history..." The EDMD continued and stated when dealing with pediatric patients, he would rely heavily on the patient's parents to see if they wanted to have a psychiatric evaluation completed. The EDMD stated, "A lot of patients have counselors available and might reach out to their counselors for the first available appointment."

The EDMD was provided the opportunity to review Patient #1's ED record and was asked if any lab work or psychiatric evaluation should have been completed. The EDMD stated, "Just reviewing the record it's hard to tell without interacting with the patient myself. It's hard to tell. It looks like he [ED Provider #1] did talk to his parents. I think these cases are so hard to determine. The interaction with the patient is vital to determine whether or not further work up is necessary. We rely a lot on outsider's information." The EDMD was asked if he recognized Patient #1's name. The EDMD stated, "No, it says he just moved here."

During an interview on 9/17/2024 at 12:30 PM, the Director of Emergency Medicine (DEM) was asked to describe the standard of care for nursing when dealing with patients who presented with psychiatric complaints. The DEM stated nurses would assess the patient's symptoms and complaints such as anxiety, suicidal ideations, or homicidal ideations. The DEM continued and stated if the nurse feels there is a safety issue with the patient, the patient's belongings would be removed along with any items that would present a safety risk and the patient would be asked to remove their clothes and provided a paper gown. The DEM stated once the patient was safe, the ED Provider would complete the MSE.

During an interview on 9/17/2024 at 2:24 PM, RN #1 was asked to describe the nursing role when caring for patients who presented to the ED with psychiatric complaints. The RN stated the patient would be taken to room 10 or 11 (ED rooms designated for psychiatric patients), and a triage assessment would be completed including a risk assessment. RN #1 stated they would follow the protocol based on the risk assessment, such as collecting the patient's belongings. The RN stated a Crisis Prevention Intervention (CPI) trained person would remain with the patient until the Provider did the assessment. RN #1 continued and stated, the ED Provider would put in orders for a psychiatric consult via telehealth and then they would follow the recommendations accordingly. RN #1 confirmed she recalled Patient #1 and.stated, "He had just moved here from out of state I believe. He came in by himself. He was extremely agitated, belligerent and wouldn't answer questions. I asked him 'what brought you in?' He said I was looking at him judgmentally. He said he wanted some medication and wanted to go home." RN #1 was asked if she completed a suicide risk assessment or aggression risk assessment on the Patient. The RN stated, "He said he wasn't suicidal at the time, but has had thoughts (suicidal); it was more along the lines of he was tired and wanted meds [medications]." RN #1 continued and stated the patient was informed of the hospital's process and that the ED Provider would have to evaluate him to determine what his needs were and what needed to be done to help him. The RN stated Patient #1 "didn't like that and said he wasn't going to be hospitalized. RN #1 was asked if she was present when ED Provider #1 assessed the Patient. The RN stated, she met the ED Provider as he was entering and she was exiting the Patient's room, but she did not stay in the room for the exam. RN #1 was asked if she told the Patient he couldn't leave the ED against medical advice. The RN stated, "No, we said he would have to wait until the doctor sees him. He was very agitated and aggressive." The RN was asked if any lab work was collected or any medications were given to Patient #1, or if a psychiatric consult was completed. RN #1 stated, "I didn't see any. I don't recall." RN #1 continued and stated, the "ED Provider puts in the order for a psychiatric consult." RN #1 was asked if psychiatric consults were usually ordered for patients who presented with psychiatric complaints. The RN stated, "Yes."

During an interview on 9/17/2024 at 2:36 PM, the Director of Quality (DOQ) stated there was an algorithm model in the electronic charting. The DOQ stated, "Not all psych patients are suicidal or homicidal. The may just be having a panic attack or something." The DOQ continued and stated for all behavioral health patients, the nurse does a risk assessment and if the assessment is positive, the ED Provider is notified, and he does his own risk assessment. If the ED Provider determines the patient is at risk, the Provider will order a psychiatric or behavioral health evaluation."

During a telephone interview on 9/17/2024 at 2:45 PM, ED Provider #1 was asked to describe the standard of care for patients who presented to the ED with psychiatric complaints. The ED Provider stated, "It depends on the complaint." The ED Provider continued and stated if there were complaints concerning for danger, the patient would be assessed and taken to a safe place and obtain a full history on what was going on. The ED Provider continued and stated, the patient would be "medically cleared and we would consult a mental health provider." ED Provider #1 was asked if he could recall Patient #1. The Provider stated, "This person just had anxiety and he came to me for something for anxiety." ED Provider #1 continued and stated Patient #1 was not suicidal, "I talked to him, and his parents confirmed he was not suicidal, just borderline personality." When asked if he ordered any lab tests on Patient #1, the ED Provider stated, "Labs are for clearance, not for anxiety." ED Provider #1 was asked if Patient #1 was given any medication for his anxiety. The ED Provider stated, "I think he was offered some medications, but he declined it prior to leaving."

During an interview on 9/17/2024 at 2:52 PM, the DEM verified there was no documentation in Patient #1's medical record to indicate the Patient was offered medications to treat his anxiety. The DEM then confirmed there were no medications ordered or prescribed for Patient #1.

During a telephone interview on 9/17/2024 at 3:29 PM, Patient #1 stated, he was "very much in distress" when he presented to the ED. The Patient continued and stated, "As soon as I stepped in the facility things went downhill from there. I've been admitted to a psych [psychiatric] floor twice, and the 3rd time, I signed out AMA. I made a promise to myself that I wasn't going back. I made it clear to them as well. I had mentioned AMA after [Named ED Provider #1] said he was recommending something I will not like. I ended up feeling like I got brushed off by him." Patient #1 was asked if anything was done to address his condition. The Patient verified he was not offered any medications; no lab work was collected and no psychiatric or behavioral health assessment and/or consults were completed. Patient #1 continued and stated, "I went in because I was wanting some relief...my hands were shaking, and I couldn't breathe..." Patient #1 stated he had been on the phone with his parents while in the ED. The Patient continued and stated, "I put him [ED Provider #1] on the phone with my parents. He wasn't very helpful at all. I couldn't see his last name on his lab coat, so I call him Dr. [ED Provider #1's first name]. He said, 'we're not friends, you can call me Dr. [ED Provider #1's last name].' I didn't feel safe at all, and then I wasn't allowed to leave."