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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag C2405 - Emergency Room Log - Based on interview and document review, the facility failed to ensure that all patients who came to the Emergency Department (ED) seeking emergency medical care were documented on the ED central log. This failure created the potential for patients seeking emergency medical treatment and not documented on the facility's central log, to leave the facility's ED remaining in need of treatment or care, and to be unable to be tracked by the facility in order to ensure the safety and well being of these patients.

Tag C2406 - Medical Screening Examination - Based on interviews and document review, the facility failed to provide an appropriate Medical Screen Exam (MSE) in 10 of 10 emergency department patients reviewed who presented with psychiatric emergencies and were not admitted to the hospital (Patients #2, #3, #4,#5, #6, #7, #8, #9,#10 and #11). Specifically, the facility relied on an external mental health provider entity, who had no relationship with the hospital, to conduct psychiatric and behavioral health medical screening examinations for patients with psychiatric emergencies. In addition, the facility failed to ensure every patient who presented to the emergency department received a MSE by Qualified Medical Personnel (QMP) in 1 of 21 telephone triage records reviewed (Patient #18).

Based on interview and document review, the facility failed to ensure that all patients who came to the Emergency Department (ED) seeking emergency medical care were documented on the ED central log.

This failure created the potential for patients seeking emergency medical treatment and not documented on the facility's central log, to leave the facility's ED remaining in need of treatment or care, and to be unable to be tracked by the facility in order to ensure the safety and well being of these patients.

FINDINGS

POLICY

According to the policy, EMTALA (Emergency Medical Treatment and Labor Act) Guidelines, apply to all areas of the hospital and ensure the patient's right to appropriate and timely care. Every patient who presents to the hospital will be documented in the Log (ER Book). A patient has "presented" when they enter onto the premises, campus (and 250 yard zone around the hospital), and remote sites.

According to the policy, Logging of ER Patients in ER Book, an ER book will be used as a ready reference for ER visits and will be kept at the nurse's station. After treatment has been rendered, the ER patient is to be logged in the ER book. All ER admissions are to be logged. The date, time, name, address, age, sex, physician and service, nature of injury, services rendered, and disposition of the case are to be filled in.

The policy, Telephone Triage, defines the process for licensed nursing personnel. The policy provides guidance for nurses when a patient calls the hospital to obtain information regarding care. The "Telephone Triage Protocols for Nursing" is a reference book will be used by all nurses that provide information and/or care over the phone to patient or their family member. The patient will always be offered to come to the Emergency Room or to talk with the Medical Staff member that is on call. If at any time the RN (Registered Nurse) does not feel comfortable in providing the information and feels that directing the call to a member of the Medical Staff is needed, s/he shall do so. All phone calls, requesting phone advice, will be documented on the Telephone Triage form and placed in the Telephone Triage book kept at the nurse's station.

1. A patient came to the facility's ED seeking emergency medical care and was not documented on the facility's central log.

a) On 10/26/17, Patient #18 came to the facility's ED seeking emergency medical care and was not documented on the facility's central log. According to a Telephone Triage form completed by Registered Nurse (RN) #1 on 10/26/17, Patient #18 arrived at the ED entry door at 10:50 p.m. and stated she wanted to speak with a nurse or the doctor. Patient #18 was provided a wheelchair to sit in and stated "I started cramping and this came out". Patient #18 was holding a cardboard box with a lid which contained "something red (fetus like)". Patient #18 had been seen in the ED the previous morning for abdominal cramping and bleeding. Review of the ER book revealed no entry was made to show Patient #11's presentation to the ED on 10/26/17 as required by the EMTALA policy referenced above. There was no record of contact with the on-call physician on the Telephone Triage form for 10/26/17.

b) On 11/30/2017 at 1:58 p.m. an interview was conducted with Chief Executive Officer (CEO) #3 who also functions as Chief Nursing Officer. CEO #3 explained the purpose of the ER book was to track individuals who presented to the ED and registered to receive care as required by EMTALA regulations.

The Telephone Triage book was used to document patient's who called for nursing advice and was also used for patients who presented to the inpatient nursing unit for nursing advice. Copies of the Telephone Triage sheets are then sent to the outpatient clinic and placed in the patient's record there. There are times a patient would enter the inpatient unit and request information for care of a minor medical concern. When patients just walk up to the inpatient nurse "I hope they would complete a telephone triage sheet" but there was no requirement for the nurse to do so. According to CEO #3, if a patient is not registered into the ED their information is not placed in the ER book. In the case of Patient #18, she was not logged in the ER book because she was not a registered ED patient.

CEO #3 stated sexual assault victims are not identified by name to protect their privacy as stipulated by our sexual assault policy. S/he was unsure why the psychiatric patients were listed by number only and suggested the nursing staff may have believed a number should be used for anything sensitive in nature.

When asked how the facility assured every patient who presented to to the facility seeking assistance received a screening for an emergency medical condition, CEO #3 stated, anyone who presents to the ED was admitted and screened. The encounter with Patient #18 was a "fluke" occurrence. The Patient Care Services Director ensures every entry in the ER book has a matching charge sheet and the house supervisor on duty is responsible to ensure everyone is placed in the ER book.

c) An interview with the Medical Director of the ED (Physician #6) was completed on 11/30/17 at 8:27 a.m. Physician #6 stated s/he reviewed the ER book for personal interest not for accuracy. S/he was unsure what the process was to review the accuracy of the ER book. When presented with the events surrounding Patient #18, Physician #6 stated s/he should have been made aware of the situation but was not.

Cross reference: Tag -C2406: The facility failed to provide a medical screening examination to a patient who presented to the Emergency Department seeking emergency medical care.

Based on interviews and record review, the facility failed to provide an appropriate Medical Screen Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation by Qualified Medical Personnel (QMP) in 7 of 8 emergency department patients reviewed who presented with psychiatric and behavioral health emergencies and were not admitted to the hospital (Patients#2, #3, #4, #5, #6, #7, #8, #9,#10, and #11 ). Specifically, the facility relied on an external mental health provider entity, who had no relationship with the hospital, to conduct psychiatric and behavioral health medical screening examinations for patients with psychiatric emergencies. Additionally, the facility failed to ensure every patient who presented to the Emergency Department (ED) received a MSE by Qualified Medical Personnel (QMP) in 1 of 21 Telephone Triage forms reviewed (Patient #18).

This failure created the potential for delays in diagnosis and treatment of emergency medical conditions and potential negative patient outcomes.

FINDINGS

POLICY

According to the policy, EMTALA (Emergency Medical Treatment and Labor Act) Guidelines, apply to all areas of the hospital and ensure the patient's right to appropriate and timely care. A medical screening exam (MSE) must be done on all patients that present to the hospital. The scope of an MSE is to provide all necessary testing and on-call services within the capability of the hospital to reach a diagnosis that excludes the presence of legally defined Emergency Medical Condition (EMC).

An EMC includes any condition that is a danger to the health and safety of the patient or unborn fetus; or may result in a risk of impairment or dysfunction to the smallest bodily organ or part if not treated in the foreseeable future, and includes a specific range of itemized conditions: undiagnosed, acute pain sufficient to impair normal functioning; pregnancy with contractions present; symptoms of substance abuse; psychiatric disturbance.

Medical screening examinations are to be performed by personnel capable of ordering tests and diagnosing. An on-call system will be maintained to provide care for all patients that present in the emergency department (ED). On-call medical staff must respond to the hospital and render evaluation and care in the hospital.

Every patient who presents to the hospital will be documented in the Log (ER Book). A patient has "presented" when they enter onto the premises, campus (and 250 yard zone around the hospital), and remote sites.

The Management of Psychiatric Patients policy states psychiatric patients admitted through the ER will be held for observation waiting for decision of disposition. Arrangement will be made for the immediate transfer of patients who are violent and may be a danger to self or others. Centennial Mental Health, Social Services, Mountain Crest, or Psycare Family Recovery Center may be called to assist in appropriate referral and transfer or admit as indicated.

According to the policy, Logging of ER Patients in ER Book, an ER book will be used as a ready reference for ER visits and will be kept at the nurse's station. After treatment has been rendered, the ER patient is to be logged in the ER book. All ER admissions are to be logged. The date, time, name, address, age, sex, physician and service, nature of injury, services rendered, and disposition of the case are to be filled in.

The policy, Telephone Triage, defines the process for licensed nursing personnel. The policy provides guidance for nurses when a patient calls the hospital to obtain information regarding care. The "Telephone Triage Protocols for Nursing" is a reference book will be used by all nurses that provide information and/or care over the phone to patient or their family member.

The patient will always be offered to come to the Emergency Room or to talk with the Medical Staff member that is on call. If at any time the RN (Registered Nurse) does not feel comfortable in providing the information and feels that directing the call to a member of the Medical Staff is needed, s/he shall do so.

All phone calls, requesting phone advice, will be documented on the Telephone Triage form and placed in the Telephone Triage book kept at the nurse's station.



REFERENCE

According to the Bylaws of the Board of Directors (Board), the Board shall have full power and authority to adopt policies and procedures for the operation of the hospital. The Board shall have the following powers and duties: To review and approve the bylaws, rules and regulations, policies, procedures, plans and manuals of the hospital medical staff; To determine which categories of healthcare practitioners are entitled to join the hospital's medical staff and/or exercise clinical privileges.

The Medical Staff Bylaws define the term "medical staff" as that group of healthcare professionals who have been granted appointment by the Board of Trustees. The medical staff is responsible for the quality of medical care in the hospital and is subject to the ultimate authority of the hospital's governing body. The cooperative efforts of the medical staff, the chief executive officer, and the governing body are necessary to fulfill the hospital's obligations to its patients.

According to the Medical Staff Rules and Regulations, all patients presenting to the Emergency Department shall be screened by the ED on call provider.

1. The facility failed to ensure all patients who presented at the facility seeking emergency medical treatment received a medical screening examination by a QMP to determine if a emergency medical condition existed.

a) According to a Telephone Triage form completed by Registered Nurse (RN) #1 on 10/26/17, Patient #18 arrived at the ED entry door at 10:50 p.m. and stated s/he wanted to speak with a nurse or the doctor. Patient #18 was provided a wheelchair to sit in and stated "I started cramping and this came out". Patient #18 was holding a cardboard box with a lid which contained "something red (fetus like)". Patient #18 had been seen in the ED the previous morning for abdominal cramping and bleeding.

Review of the ED record dated 10/25/17 revealed Physician #2 had examined and stabilized Patient #18 for spontaneous abortion. Physician #2's discharge instructions to Patient #18 included to return to the ED if s/he developed severe pain, fevers, chills, or heavy bleeding.

RN #1 documented on the Telephone Triage form on 10/26/17, that Patient #18 declined an ED visit and would go to the walk-in clinic the next morning. RN #1 recommended Patient #18 take her pain pill and arrive at the walk-in clinic by 8:30 a.m on 10/27/17.

Review of the ER book revealed no entry was made to show Patient #18's presentation to the ED as required by the EMTALA policy referenced above. There was no record of contact with the on-call physician on the Telephone Triage form.

b) On 11/30/17 at 11:02 a.m. an interview was conducted with RN #1 in which s/he explained the encounter with Patient #18. According to RN #1, Patient #18 walked to the ED entrance and rang the phone and a female voice stated s/he wanted to speak with a nurse or a doctor. Through the monitor RN #1 could see Patient #18 was accompanied by a male and female. The house supervisor on duty and RN #1 went to the ED entrance with a wheelchair and had Patient #18 sit. Patient #18 spoke only Spanish. Since RN #1 was a certified interpreter s/he conversed with the patient in Spanish. RN #1 stated the patient was conversing as though s/he only wanted advice about the miscarriage and never directly stated s/he wanted to be seen by a physician. The patient seemed upset that an appointment s/he had at another facility that day had been cancelled.

RN #1 stated s/he did ask Patient #18 if a physician was needed but could not remember if a clear cut "yes" or "no" answer was given by Patient #18. The patient stated s/he had been seen by Physician #2 previously. RN #1 informed Patient #18 that Physician #2 would be in the clinic the next morning and s/he could see the physician then. According to RN #1, the patient was satisfied with waiting to the physician the next morning and the departed the building.

RN #1 explained, since s/he had not registered Patient #18 as a patient in the ED the only place to document the encounter was the Telephone Triage book. S/he had never recorded in the ER book patient's who did not want to be seen.

c) The house supervisor (RN #5) on duty when Patient #18 presented to the ED was interviewed on 11/30/17 at 9:52 a.m. RN #5 confirmed the arrival of Patient #18 on the evening of 10/26/17 and that s/he was accompanied by a male and female. When the group rang the bell and the phone answered the female requested to speak with a nurse or doctor. RN #5 accompanied RN #1 to ED entry door with a wheelchair to speak with Patient #18. Since the patient spoke only Spanish s/he relied on RN #1 to interpret. The patient had explained his/her miscarriage and wanted to know if the item in box was the fetus. The patient had gone to another facility to have a dilation and curettage (D & C) that day but the appointment had been cancelled because there was no one there to perform it. According to RN #5 the patient was asked if s/he was bleeding and stated the bleeding had been ongoing for a few days but did not state if it was heavier. Patient #18 then showed the nurses a paper for pain pills s/he had been given by Physician #2 the previous day. The woman who accompanied Patient #18 asked us to take the temperature of the patient which was normal. The group then went "on their way". No one seemed disgruntled. No one had asked to see a doctor.

RN #5 stated, since the encounter was a discussion similar to a telephone call s/he directed RN #1 to document the encounter in the Triage Telephone book. The ER book was only for patients who had been registered to receive care in the ED.

d) An interview was conducted with a house supervisor (RN #4) on 11/29/17 at 4:22 p.m. According to RN #4, inpatient nurses also staff the ED because of the low census on the inpatient side. At the beginning of each shift, one nurse is assigned to manage ED patients when they arrive and will also manage/provide care on the inpatient unit when there are no ED patients. When a patient presents to the ED outside door there is a sign which instructs them to pick up a phone which rings to the inpatient nurse's station and a camera allows viewing of the individual at the door. When a patient is transported by ambulance the Emergency Medical Technician would call ahead to notify the ED staff of their estimated time of arrival. Once the patient entered the ED the nurse was supposed to assess their needs, take their vital signs and call the physician on-call. An ED documentation sheet is started. Should a patient decide they want to leave we try to convince them to stay for the physician so that an Against Medical Advice (AMA) form can be completed and signed. If they choose not to wait for the physician, their information is documented in the ER book to show the patient left without being seen (LWOBS) and did not sign an AMA. No nurse can perform a MSE.

e) On 11/30/2017 at 1:58 p.m. an interview was conducted with Chief Executive Officer (CEO) #3) who also functions as Chief Nursing Officer. CEO #3 explained the purpose of the ER book was to track individuals who presented to the ED and registered to receive care as required by EMTALA regulations.

The Telephone Triage book was used to document patient's who called for nursing advice and was also used for patients who presented to the inpatient nursing unit for nursing advice. Copies of the Telephone Triage sheets are then sent to the outpatient clinic and placed in the patient's record there.There are times a patient would enter the inpatient unit and request information for care of a minor medical concern. When patients just walk up to the inpatient nurse "I hope they would complete a telephone triage sheet" but there was no requirement for the nurse to do so. S/he stated, the advice nurses provide over the phone or to walk-in patients was within their scope of practice. A nurse can advise a patient to be seen by the on-call physician or if something can wait to be assessed in the clinic. Every patient was offered the option to be seen in the ED by the on-call physician.

According to CEO #3, physician's are the only individuals qualified to perform a MSE. In the encounter with Patient #18 the nurses were unsure the patient was actually seeking medical care. They should have registered the patient and contacted the on-call physician to conduct an examination.

f) Physician #2 was interviewed on 11/29/17 at 3:49 p.m. According to Physician #2 the on-call physician is not always in the facility and must be called by the nurse when a patient presents to the ED. It was the role of the physician to perform the MSE, not the nurse.

g) An interview was conducted with the Medical Director of ED (Physician #6) on 11/30/17 at 8:27 a.m. Physician #6 explained the process when a patient presents to the ED. The nurse will register the patient, take their vital signs then call the on-call physician to perform the MSE. Physician's are qualified to perform the MSE, no nurse is qualified. After review of an internal investigation document surrounding Patient #18, Physician #6 stated the case had not been brought to his/her attention though it should have. This patient should have been seen unless s/he said s/he did not want to be seen. Nurse's can't make the decision whether a patient should be examined. Our rule is to see everyone who comes through that door. According to Physician #6, if the on-call is not present in the ED at the time the patient presents the nurse was supposed to call the physician. If the information is not documented in the ER book there would be now way to know a patient had presented and not been evaluated for an emergency medical condition (EMC). If a patient leaves before it is determined an EMC does not exist there could be a bad outcome for the patient.

2. The facility used an external mental health provider entity to conduct MSEs for emergency department patients with psychiatric emergencies.

a) An interview was conducted with the Chief Executive Officer (CEO #3) on 11/28/17 at 3:45 p.m. CEO #3 stated once patients have been medically cleared by the on-call ED physician, the external mental health provider is called in to perform behavioral health evaluations. If they feel the patient needs to admitted to an inpatient psychiatric facility the external mental health provider will then arrange for placement and transportation as well as give a verbal report to the receiving facility. If the patient is deemed safe for discharge, the external mental health provider will discuss the plan with the facility physician. CEO #3 stated the facility does not receive a profile of the employees from the external mental health provider but accept they are QMPs.

During a second interview with CEO #3 on 11/29/17 at 10:57 a.m., s/he stated anyone who provides care within the facility must be qualified. There was no contract or written agreement with the external mental health provider. It was assumed the staff were QMPs based on their employment with the external mental health service.

b) On 11/30/17 at 8:27 a.m. an interview was conducted with the Medical Director of ED (Physician #6). S/he stated when patients with psychiatric emergencies or behavioral issues presented to the emergency department, s/he would medically stabilize the patient and call the outside mental health provider entity to request a mental health assessment. The facility staff would provide for the safety of the patient while waiting for the mental health provider to arrive and assess the patient. Documentation was expected to be provided by the external provider and scanned into the medical record. Physician #6 stated s/he did not know the credentials of the personnel providing the mental health assessments but assumed they were vetted by the mental health service.

c) On 11/29/17 at 3:49 p.m. an emergency department physician (Physician #2) was interviewed. Physician #2 stated, s/he performed the MSE which included the psychiatric evaluation and decided what the patient needs. The external mental health provider was contacted as a consultant like any other medical consultation and then a plan was devised based on their recommendations. Physician #2 stated s/he is not sure how the facility obtains the documentation from the external mental health provider for the medical record since the patient has to sign a release before that information could be provided. A standardized process should be in place to ensure their documentation is placed in the patient's record. Since "I'm not a therapist" there should be documentation to show why behavioral health was involved. When asked if s/he knew there was not a contract or agreement with the external mental health provider, Physician #2 stated s/he was not aware and did not know the qualifications. S/he added, the external mental health provider was relied upon to provide the mental health services.

d) During an interview with the Chief of Staff (Physician #7) on 11/28/17 at 4:03 p.m. s/he confirmed an external mental health provider was relied upon to perform the behavioral health evaluations for patients with psychiatric emergencies once they are medically cleared. The external mental health service develops the plan and schedules follow up appointments. If the patient requires transfer to an inpatient psychiatric facility or acute medications, then the external provider talks to us. Once the external mental health provider takes over, our responsibility ends, we are entrusting them with the care of the patient.

3. Record review showed multiple examples where the external mental health entity conducted the behavioral health portion of the medical screening examination to determine if an emergent medical condition existed and decided treatment plans for patients who were currently receiving emergency services at the hospital. As example,

a) Patient #4 presented to the emergency department on 7/29/17 at 8:37 a.m. for agitation and violent behavior with a history of Schizoeffective disorder. The skilled nursing facility (SNF) where s/he resided was concerned for the safety of other residents and staff. Physician #7 documented in the Assessment/Plan section that Patient #4 was cleared medically and not thought to be a danger to self or others. The external mental health provider called to evaluate the patient.

Registered Nurse (RN) #8 documented the external mental health provider was called and arrived at 10:30 p.m. to perform the mental health evaluation. The evaluation was completed at 10:45 p.m. and the external provider deemed Patient #4 safe to return to the SNF and stated the evaluation documentation would be faxed to the facility later. RN #8 called the SNF to provide report and arrange for Patient #4's return to the SNF. The SNF was documented to have declined acceptance of Patient #4 until they received paperwork to show the patient was safe to return. RN #8 wrote s/he contacted the external mental health provider's answering service to obtain the evaluation. At 12:45 a.m. on 7/30/17 the external provider faxed a report to the ED. At 1:15 a.m. the SNF still had not received documentation from the external mental health provider. RN #8 documented s/he faxed the facility copy of the evaluation the SNF. The SNF could not arrange transport of the patient until 7:10 a.m. on 7/30/17.

Of note, the external mental health provider faxed a Summary of Evaluation at 12:43 a.m. on 7/30/17 which was not signed or dated.

There was no documentation Patient #4 received a medical screening exam, by a QMP, for his/her agitation and violent behavior prior to being discharged from the facility.

b) Patient #2 was brought to the emergency department for the second time Friday, 4/28/17 with a complaint of suicidal thoughts. According to documentation by Physician #9, the patient had made razor blade cuts to multiple areas of the left forearm. Wound care was provided to the patient by RN #1. Patient #2 was documented to feel like s/he was going to harm his/herself more. In the plan documented by Physician #9 the external mental health provider "will evaluate and manage disposition of this patient". S/he "is cleared from a medical standpoint".

RN #1 documented Patient #2 was placed on suicide precautions.The external mental health provider was contacted at 9:53 p.m. and stated s/he would call back later the same night. The external mental health provider called the facility at 12:25 a.m. on 4/29/17 to inform RN #1 s/he would perform the mental health evaluation by phone. The external mental health provider completed a conversation with Patient #2 from 12:32 a.m. to 1:11 a.m. At 1:42 a.m. the external mental health provider spoke with RN #1 by phone and documented the statement from the provider as: S/he "is low risk at this time. [S/he] has some ideation, but no plan or prep. [S/he] has a safe place to go home with [his/her] sister". The patient was to check back with the external mental health provider the following Monday. The patient was discharged home on 4/29/17 at 2:12 a.m.

There was no documentation from the mental health provider entity of the patient's evaluation, findings or clinical decision making. Additionally, there was no documentation the individual who conducted the behavioral health evaluation was qualified and a designated QMP.

c) Patient #9 presented to the emergency department by ambulance on 9/08/17, at 5:35 p.m. after cutting his/her left wrist with scissors. According to the History of Present Illness, Patient #9 was tearful and stated "if I can't get help, one of these days I am going to kill myself, I just have to find a way". The patient was provided pain medication for a previous leg injury in the ambulance and provided additional pain medication once in the ED.

Review of nursing progress notes revealed the external mental health provider was called 6:50 p.m. to perform a mental health evaluation. The record indicates the external mental health provider arrived at 8:39 p.m and completed the mental health evaluation at 9:45 p.m. RN #5 documented the external mental health provider was making arrangements to transfer the patient to an outside mental health facility. The patient was subsequently transported to the outside mental health facility by the outside facility's transport service.

Although Physician #10 documented s/he agreed the patient was not safe to return home, there was no documentation within the medical record to show the mental health provider's evaluation. And no documentation to the mental health provider was qualified to perform the MSE.

d) Record review revealed Patient #10 presented to the ED on 11/01/17 for suicide attempt. According to the physician's ED Reports, the patient presented for suicide attempt and had a history of suicide attempts in the past. The ED provider's plan documented stated the external mental health provider entity had been contacted for evaluation of the patient. Disposition of the patient was dependent upon the external mental health provider's evaluation but "Likely discharge later today to inpatient psychiatric unit for observation".

According to the ED reports the external mental health provider entity came to the ED and evaluated Patient #10 for his/her suicide risk. Review of a document, titled My Safety and Action Plan, dated 11/01/17, showed Patient #10 met with an individual from the external mental health provider entity and signed the safety plan. However, there was no documentation from the the mental health provider entity on the patient's evaluation, findings or clinical decision making. Additionally, there was no documentation Patient #10 received a psychiatric or mental health evaluation from the facility or a QMP to ensure s/he did not have an emergent medical condition. The patient was discharged home on 11/01/17 at 8:35 p.m.

4. The facility maintained no personnel records on any of the external mental health providers who conducted behavioral health evaluations and decided treatment plans for patients who present to the CAH with psychiatric and behavioral health emergencies. There was no documentation the behavioral health evaluators were Qualified Medical Personnel.

The facility's standard practice of using the unaffiliated mental health provider entity to conduct medical screening examinations to determine if an emergent medical condition existed left all patients who presented to the emergency department with behavioral and psychiatric emergencies at risk for treatment delays and potential negative patient outcomes.