HospitalInspections.org

Based on interview, record review, review of Facility #1's policies, review of Facility #1's Investigation Report, review of videos (from the facility and the police body camera), and review of Patient #1's medical record from Facility #2, it was determined the facility failed to comply with 42 CFR 489.24 related to not providing an appropriate medical screening examination (MSE) and stabilizing treatment to a patient with an Emergency Medical Condition (EMC), for one (1) of twenty (20) sampled patients, Patient #1.

Refer to the findings in A-2406.

Based on interview, record review, review of Facility #1's policies, review of Facility #1's Investigation Report, review of videos (from the facility and the police body camera), and review of Patient #1's medical record from Facility #2, it was determined the facility failed to comply with 42 CFR 489.24 related to not providing an appropriate medical screening examination (MSE) to a patient with an Emergency Medical Condition (EMC), for one (1) of twenty (20) sampled patients, Patient #1.

Review of the distance between the Facility #1 and #2, using www.mapquest.com, revealed a distance of nine (9) miles and a drive time of sixteen (16) minutes.

The findings included:

Review of Facility #1's policy #3771.9, titled "EMTALA Emergency Care and Transfers", dated July 31, 2020, revealed an Emergency Medical Condition (EMC) specifically included psychiatric disturbances. The policy also defined Medical Screening Examination (MSE) as the process required to determine with reasonable clinical confidence whether an Emergency Medical Condition existed. Per the policy "comes to the hospital's emergency department" meant an individual was considered to have "come to the hospital's emergency department" where the individual presented to the emergency department and a request was made on his or her behalf for an examination or treatment for any medical condition, or a person observing the individual's appearance or behavior would reasonably believe the individual needed examination or treatment for a medical condition. Per the policy, all individuals who "come to the hospital's emergency department" seeking examination or treatment were provided a Medical Screening Examination (MSE) within the capabilities of the hospital and the ancillary services routinely available to the emergency services of the hospital, including examination, testing, treatment, and the services of an appropriate on-call physician where necessary. The policy stated all individuals would be treated similarly to other individuals who came to the hospital's emergency department seeking treatment and/or examination and would be offered an appropriate MSE in line with hospital policies, rules, and regulations.

Review of Facility #1's policy #3770.6, titled "Care of Prisoners, (Forensic Patients)", dated April 18, 2023, revealed the policy was designed to ensure that patients who were in custody of law enforcement officials remained in a secure environment while at Facility #1 and that appropriate measures were taken to ensure the safety of employees, patients, and visitors. Continued review revealed Law Enforcement Responsibilities at Facility #1 included that prior to arrival, the Law Enforcement Officer (LEO) was to contact the facility to inform them of their estimated arrival time. Further review revealed that upon arrival at the emergency room or designated location, the LEO was not to unload the patient (prisoner) at that time. The LEO was to call the hospital security dispatch to request escort assistance and designated parking location. Continued review of the policy revealed that upon arrival at the emergency room or designated location, the patient was to be logged into the security dispatch log and receive a forensic patient general information handout. Additional review revealed Facility Security was to transport the forensic patient via wheelchair to the designated location, and the LEO needed to walk alongside the wheelchair with their weapon located on the opposite side of the patient.

Review of an email notification, dated 11/28/2023 at 3:21 PM, revealed Facility #2 notified Facility #1 they had received notification that Patient #1 had initially been brought to Facility #1 on 11/27/2023 by local law enforcement officer (LEO) #1 for suicidal ideation (SI). It was reported LEO #1 stated Patient #1 was refused treatment at Facility #1 because they did not take voluntary SI patients and therefore, Patient #1 was transported to Facility #2 for treatment. Continued review revealed Facility #2 requested Facility #1 to review the situation to determine the reason Patient #1 was was not provided medical stabilizing treatment prior to transport to Facility #2.

Review of Facility #1's Review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, dated 11/30/2023, revealed Facility #1 might have failed to provide a Medical Screening Exam (MSE) to an individual brought in by a local law enforcement officer (LEO), with a potentially unstable medical condition. Further review revealed Triage Registered Nurse (RN) #1 interpreted LEO #1's question of "could you do this", as meaning could the Emergency Department (ED) do a blood draw to check the blood alcohol content level of Patient #1. Further review of the document revealed Facility #1 had contacted LEO #1 for a statement, and LEO #1 stated he had relayed to RN #1 that Patient #1 was requesting voluntary mental health assistance. Additional review of the document revealed Facility #1 had stated that they did review the video (no audio) of the interaction between RN #1 and LEO #1. The document stated that the interaction between RN #1 and LEO #1 lasted for no more than twenty-two (22) seconds and that LEO #1 and Patient #1 were in the ED waiting room less than a minute. Continued review of the document revealed Patient #1 was not wearing handcuffs and did not appear in any distress. Further review of Facility #1's self-report document indicated Facility #1 felt that there might have been some miscommunication between RN #1 and LEO #1.

Review of Facility #1's Central Log, dated 11/01/2023 through 12/18/2023, revealed Patient #1 was not documented as having presented to Facility #1's Emergency Department (ED) on 11/27/2023. In addition, there was no documented evidence Patient #1 had a medical record generated at Facility #1 on 11/27/2023.

Review of the video provided by Facility #1 revealed that on 11/27/2023, at 10:53:11 PM, Law Enforcement Officer (LEO) #1 and Patient #1 entered camera view. LEO #1 was casually entering the waiting room, with his hands in his pockets and Patient #1 was several steps behind, with a backpack, almost as if he/she was a separate individual, waiting to be checked in. Patient #1 was not in handcuffs. There were no observations of Patient #1 exhibiting any untoward behaviors. At 10:53:24 PM, LEO #1 and Patient #1 walked to the desk as Registered Nurse (RN) #1 was seating another patient for Triage. Review at 10:53:34 PM, showed RN #1 observed LEO #1 and Patient #1. There was no audio, but body language suggested there was a short conversation between RN #1 and LEO #1. At 10:53:39 PM, both the Triage Patient and Significant Other were watching the exchange between RN #1 and LEO #1. Between 10:53:47 PM and 10:53:56 PM, RN #1 retrieved a blood pressure cuff and applied it to the Triage Patient. Further review of the video revealed that at 10:53:59 PM, RN #1 continued with the Triage Patient, and LEO #1 and Patient #1 were observed turned toward the exit. Additional review revealed at 22:54:05 PM, Patient #1 turned back to the waiting room to retrieve his/her backpack. Between 22:54:18 PM and 22:54:23 PM, LEO #1 and Patient #1 were observed to walk toward the exit and disappear from camera view.

Review of the Body Camera (Cam) footage from LEO #1 revealed LEO #1 and Patient #1 entered the ED at 9:48 minutes into the video, or time of 22:52:59 (10:52 PM). Continued review revealed they walked to the desk at 10:18 minutes into the video, or time of 22:53:29 (10:53 PM), and it sounded like LEO #1 told the nurse "voluntary consumer, do you need paperwork from me?" Additional review revealed RN #1 could be heard telling LEO #1 "we don't deal in" then inaudible, at 10:25 minutes into the video, or time of 22:53:36 (10:53 PM). After this, there was some discussion of where the patient wanted to go between Patient #1 and LEO #1, and both left the ED.

Review of Facility #1's Investigation Report, dated 11/28/2023, revealed on 11/29/2023, facility video footage was reviewed, and RN #1 was identified as the Triage Nurse on 11/27/2023. RN #1 was interviewed and reported that she did not remember Law Enforcement Officer (LEO) #1 telling her that Patient #1 was having suicidal ideation (SI). It was further documented in the investigation that all she remembered was LEO #1 asking if they "do this", as meaning could the Emergency Department (ED) do a blood draw to check the blood alcohol content level of Patient #1. RN #1 was reported to have said that at no time did LEO #1 express to her that Patient #1 was having SI. Continued review of Facility #1's investigation revealed LEO #1 was interviewed on 11/29/2023. It was documented that he asked RN #1 if they (Facility #1) handled voluntary patients that were having suicidal thoughts, and RN #1 told him no, so he transported Patient #1 to Facility #2.

Review of Patient #1's medical record from Facility #2 revealed, on 11/27/2023 at 11:50 PM, Patient #1 was admitted to the ED, with the Chief Complaint (CC) of suicidal ideation (SI). Continued review revealed that an appropriate medical screening exam (MSE) was completed, and Patient #1 also received a Psychiatric evaluation. The Psychiatric evaluation eventually recommended an in-patient stay, and a bed was obtained at Facility #3, a Psychiatric hospital.

Request for records from Facility #3 revealed Patient #1 did not have an admission on 11/27/2023 or 11/28/2023.

On 12/19/2023 at 9:29 AM, and 12/21/2023 at 11:22 AM, voicemails were left for law enforcement officer (LEO) #1, but no return phone call was received.

While interviewing Registered Nurse (RN) #1 on 12/20/2023 at 12:47 PM, she stated she had been an employee of Facility #1 for a total of three and one-half (3.5) years, two and one-half (2.5) years as a facility employee and one (1) year as Agency. She stated she had been caring for another patient at the Triage desk when LEO #1 walked in with Patient #1. She stated Patient #1 was not in acute distress, and he/she did not display any outward signs or symptoms of anxiety, such as crying, trembling, or a flat affect. She stated Patient #1 was calm and without disruptive behaviors. She stated Patient #1 was standing several steps behind LEO #1, smiling, without handcuffs and with a casual behavior. RN #1 stated that if she had observed any signs or symptoms of abnormal behaviors, she would have inquired further into the needs of Patient #1. RN #1 stated that all she remembered LEO #1 asking was how she was doing, and there was no indication of what Patient #1's needs were. Additionally, RN #1 stated that she assumed LEO #1 brought Patient #1 in for a "chain of custody" blood draw to check for the amount of alcohol in Patient #1's systems. She stated she remembered telling LEO #1 they did not do chain of custody blood draws at the facility if law enforcement did not bring the kit, but thought another local facility did do them.

During an interview with the ED Educator (EDE) on 12/21/2023 at 9:15 AM, she stated that the Triage area in the waiting room was called First Watch, that was because the staff were the eyes of the waiting room. In addition to triaging patients, they would keep watch on the waiting room to assess if there was a change in an individual's condition that might require emergent attention. The EDE stated clinical staff had replaced non-clinical staff as registrars for constant visualization of the waiting room for any change in individuals' conditions, whether they had already been checked or were waiting to be checked in. She stated First Watch education was presented annually and was ongoing.

During interviews with Registered Nurse (RN) #2 and RN #3 on 12/22/2023 at 10:49 AM, they both stated part of the responsibility of the First Watch (Triage) nurse was to complete across the room assessments of the individuals in the waiting room, both the ones waiting to be seen and the ones waiting on a bed if applicable. RN #1 and RN #2 stated they would observe for any changes in individuals in the waiting room and respond accordingly. While continuing the interviews with RN #2 and RN #3, both stated that the usual process any time a law enforcement officer (LEO) brought an individual into the emergency department (ED) for evaluation and treatment, was they usually came in through the ambulance bays and not the front door. RN #3 stated she could not remember the last time a LEO brought someone in the front door, and most of the LEOs were aware of the process.

While interviewing the Director of the Emergency Department (DED) on 12/22/2023 at 1:09 PM, she stated she had been notified by the Director of Care Coordination (DCC) on 11/28/2023 of the possible EMTALA event. The DED stated she had reviewed the video to ascertain who the RN was working First Watch at that time, and she was able to identify RN #1. Continuing the interview, the DED stated she had RN #1 share her recollection of the encounter. The DED stated that RN #1 was adamant that law enforcement officer (LEO) #1 never stated the purpose of the visit. RN #1 stated all she remembered of the conversation with LEO #1 was him asking, "do you do this?" The DED stated RN #1 told her that RN #1 had not been able to ascertain that Patient #1 was even with LEO #1 until she observed Patient #1 following LEO #1 toward the exit. The DED stated RN #1 told her she had looked toward the door when LEO #1 was casually entering the waiting room, with his hands in his pockets, and Patient #1 was several steps behind, with a backpack. Patient #1 was not in handcuffs. While further interviewing the DED, she stated RN #1 expressed to her that even as LEO #1 was walking toward the desk, Patient #1 remained several steps behind him, almost as if he/she was a separate individual, waiting to be checked in. The DED stated RN #1 told her about the conversation, RN #1 assumed LEO #1 was talking about chain of custody blood draws, and RN #1 told LEO #1 the facility did not do those (Facility #1 did not have a Forensics Lab for chain of custody). The DED stated RN #1 told her as LEO #1 turned to exit, still with his hands in his pockets, Patient #1 followed him out, still several steps behind. The DED stated RN #1 told her, in hind sight, RN #1 should have asked more questions. The DED stated she had provided RN #1 with verbal real time education that included do not assume: ask every patient the purpose of the visit, all patients were screened, and regarding chain of custody blood draws, the facility could still do the blood draw for alcohol blood level. However, she stated the results would not hold up in court, and the LEO and patient needed to be educated about that because Facility #1 did not have a Forensics Lab.

Additionally, the DED shared these concerns with the State Survey Agency (SSA) Surveyor via an email, dated 12/27/2023, which stated: "I wanted to share some concerns I have after watching the 11/27/23 video of a LMPD [Louisville Metro Police Department] officer walking a person in and then leaving with the person. My first concern was that the officer brought a SI person in the front ED lobby. Most of these type of patients are brought in the EMS bay. This keeps our lobby safe with patients and families waiting. When police brings in a SI patient through the EMS doors this also is near our behavioral health rooms. The officer was also walking in front of the person with his arms in his coat almost the entire time he was in the lobby. The person had two personal bags, which he placed in waiting chairs prior to approaching the nurse's station. We do not know if the bags had been searched; their contents could pose danger to the officer, the person with the officer, and everyone in the lobby. From watching the interaction with the officer and the nurse, he spoke a very brief time with the nurse who was with another patient the majority of their interaction. He did not sign the person in or wait for his turn. Their interaction of speaking was less than 15 seconds which is a very short time to give a report of why you were called and why the person is here. If he would have signed the person in and waited, this could have been done with no interruptions and a clear and concise report would have be given. There would also have been no possibility of breaking [Health Insurance Portability and Accountability Act] HIPAA as he was talking about the person he brought in right in front of a patient waiting to be checked in. After the officer spoke to the nurse, the officer did not seem concerned about what was said by the nurse or that he questioned the validity. His expression did not change and he appeared to speak briefly to the person without facing the person again with his hands in his coat. The officer walked out toward the exit with the person behind him and did not see initially that the person went back in to get his belongings that he left in a chair. Officer then turned around to see where person went and walked back to the person. Next they both walked out of the emergency department with the officer in front with his back to the person. Again not the usual close observation of someone who is suicidal. I can see how my nurse would have thought this person was not here for behavioral health concerns but an alcohol screening."

Facility #1 alleged the following actions were completed prior to the survey entrance date:

1. A. Facility #1 alleged they had self-reported the possible Emergency Medical Treatment and Labor Act (EMTALA) event on 11/27/2023 to the State Survey Agency (SSA) and the Centers for Medicare and Medicaid (CMS).

B. Review of Facility #1's Review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, dated 11/30/2023, revealed Facility #1 self reported a Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation to the Centers for Medicare and Medicaid (CMS), Region IV office in Atlanta, Georgia.

2. A. Facility #1 alleged Leadership met via a ZOOM meeting, discussed the event, and devised a corrective Action Plan prior to the State Survey Agency (SSA) Surveyor's entry on 12/18/2023. Facility #1 alleged the ZOOM Leadership meeting discussed the investigation, devising a corrective Action Plan, and proposed training with Emergency Department staff at the facility. Facility #1 alleged the Action Plan had components added to the annual EMTALA education that would address that staff must observe for signs and symptoms of mental illness and ask clarifying questions as to the purpose of an individual's visit to the Emergency Department (ED).

B. Review of Facility #1's Investigation Report, dated 11/28/2023 revealed a ZOOM Leadership meeting took place on 12/01/2023, at 12:30 PM. Participants were the Chief Nursing Officer, Director of Emergency Department/Patient Care, Risk Director, Compliance Director, Quality Director, Emergency Department Educator and the Emergency Department Manager. The meeting detailed the investigation and response of review of completed training records as well as proposed training with Emergency Department staff at Facility #1.

Review of the Action Plan revealed components were added to the annual EMTALA education that would address staff observing for signs and symptoms of mental illness and asking clarifying questions as to purpose of an individual's visit to the emergency department (ED) in slides #25 and #53.

Review of training records for the revised EMTALA education revealed an employee roster was utilized to ensure all staff were educated in the emergency department (ED). Additional review revealed the training was completed by 12/08/2023, with disciplinary action for staff who did the complete the education timely.

Review of RN #1's employee file did not reveal any disciplinary actions, she was up-to-date on competencies, including EMTALA, and she had completed the Pilot Education on 12/05/2023.

Review of an email, dated 12/08/2023 at 7:07 AM, sent from the Emergency Department Educator, to the 12/01/2023 ZOOM meeting participants, outlined the remediation education that had been presented to Facility #1 ED staff, that included Traveling Nurses.

During an interview with Patient #2, on 12/18/2023 at 4:47 PM, the patient stated he/she had presented to the Emergency Department (ED) for suicidal ideation (SI). Patient #2 stated that during this time, he/she did not have any concerns and felt care was being delivered in a professional manner.

During continued interview with the ED Educator (EDE) on 12/21/2023 at 9:15 AM, she stated she had been present at the ZOOM meeting on 12/01/2023. She stated that during the meeting, the investigation into the event of 11/27/2023 was discussed and a remediation Action Plan was formulated. The Action Plan included "Pilot Education", which was additional education added to the Emergency Medical Treatment and Active Labor Act (EMTALA) education that was already in place. The added education dealt with making sure staff asked enough questions to ascertain an individual's concern for presenting to the ED. She continued the interview by stating that notification to staff was across multiple communications media, notifying them of the education and test and the deadline date of 12/08/2023. She stated that a Master Grid for the ED was utilized to ensure all staff completed the education and post-test. She stated she ran a report on 12/08/2023 and sent to Leadership for review. Compliance was 100%.

While interviewing the Compliance Director on 12/21/2023 at 2:24 PM, he stated the Pilot Education for ED staff was a direct result of the identified miscommunication between RN #1 and law enforcement officer (LEO) #1, on 11/27/2023. The Compliance Director further stated the Pilot Education was part of the Action Plan instituted by Facility #1.

During an interview on 12/21/2023 at 2:28 PM with the Quality Director, she verified she had been a participant in the ZOOM meeting on 12/01/2023. The topic of discussion was the possible EMTALA event on 11/27/2023. She stated an Action Plan was devised to present the Pilot Education to all Emergency Department (ED) staff with a 12/08/2023 compliance date.

During an interview on 12/21/2023 at 3:48 PM with the Emergency Department (ED) Manager, she stated she was present at the ZOOM meeting on 12/01/2023. She stated the purpose of the meeting was to review the possible EMTALA event of 11/27/2023. The ED Manager stated it was determined what education (Pilot Education) was needed, and a deadline date was decided to be 12/08/2023. She stated the Pilot Education contained slides (#25 and #53) that went over recognizing mental health issues and to ask clarifying questions and not just going by perceptions. She also stated that the education sparked additional discussion in the ED.

While interviewing Emergency Room Technician (ERT) #1 and ERT #2 on 12/22/2023 at 10:18 AM, both stated they had received the new EMTALA education and had passed the post-test.

In an interview with the Director of Care Coordination (DCC) on 12/22/2023 at 12:57 PM, she stated she had attended the ZOOM meeting on 12/01/2023. She stated the meeting included going over the possible EMTALA event of 11/27/2023 and devising an Action Plan that included the Pilot Education.

During an additional interview with the Compliance Director on 12/27/2023 at 1:48 PM, he stated that the Pilot Education was slated to be rolled out system-wide on 01/08/2024. However, he stated, given the possible EMTALA event on 11/27/2023, the education was piloted at Facility #1 as part of the remediation process. He continued the interview by stating that the plan would be to monitor the new education, system-wide, on an on-going basis.

While interviewing the Director of Accreditation and Medical Staff Services on 12/27/2023 at 2:02 PM, she stated she had shared, in general conversation last week (12/18/2023 to 12/22/2023) with the State Survey Agency (SSA) Surveyor, about Facility #1's Quality Management System (QMS) escalation process. The Director of Accreditation continued by stating, that in the case of the possible EMTALA event of 11/27/2023, the Chief Nursing Officer (CNO) had pulled the Leadership team (ZOOM participants of 12/01/2023) together to identify the root cause analysis (RCA) (miscommunication), and develop a corrective Action Plan. She stated the Action Plan included the Pilot Education, so named because of the on-going assessment of the test results and adjusting the remediation process as part of the process of improving the efficacy of the education. She stated QMS supported management of concerns at the local level and would escalate up the ladder to the CNO or Executive sponsor. She stated QMS provided the opportunity to solve concerns and replicate solutions across the System.

In an interview with the Director of Risk Management (DRM) on 12/27/2023 at 2:30 PM, she verified she was present at the ZOOM meeting on 12/01/2023. The DRM stated that in addition to the discussion about the Pilot Education program and process for presenting the education and monitoring efficacy of the education, there was also discussion of the two (2) different perceptions of RN #1 and LEO #1.
Continuing the interview, the DRM stated she sent a weekly Standards publication (Zero-gram) via email to Department Leaders for pertinent discussion of content with their staff.

Review of the weekly Zero-gram, dated 12/07/2023 at 11:00 AM, revealed a discussion of clear, concise communication regarding patient safety strategies to prevent errors and miscommunication.

Per interview on 12/27/2023 at 2:57 PM with the Quality Director, the Director stated the Root Cause Analysis (RCA) was determined to be miscommunication of the involved parties.

While interviewing Registered Nurse (RN) #1, #2, #3, #4, #5, #6, and Emergency Room Technician (ERT) #1 on 12/27/2023 at 3:02 PM, they verified they had received the updated EMTALA education and passed a post-test.

While continuing the interviews with RN #7, #8, #9, #10, #11, #12, and ERT #2 on 12/27/2023 at 3:11 PM, they stated they had received the new EMTALA education with a post-test.

During interviews on 12/27/2023 at 3:21 PM with RN #13, #14, #15, #16, and ERT #3, they verified they had received the updated EMTALA education and passed a post-test.

On 12/27/2023 at 3:37 PM during interviews with Physician #1 and Physician #2, they both stated they were employees of Facility #1 and had received the updated EMTALA training.

In additional interviews on 12/27/2023 at 3:52 PM with Advanced Practice Registered Nurse (APRN)#1, Physician's Assistant (PA) #1, and PA #2, they stated they were employees of Facility #1 and had received the updated EMTALA training.