HospitalInspections.org

Based on interviews, record review, and policy review, the hospital failed to provide, within its capability and capacity, ongoing assessment and reassessment of a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#23) of 27 Emergency Department (ED) records reviewed from 08/03/24 to 03/05/25. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC.

Findings included:

Review of hospital policy titled, "EMTALA Guidelines for Transfer," dated 11/13/24, showed the Emergency Medical Treatment and Labor Act (EMTALA) required hospitals with Emergency Departments (ED) to provide a MSE to any individual who comes to the ED and requests such an examination, and prohibits hospitals with an ED from refusing to examine or treat individuals with an EMC. An EMC was defined as a medical condition with sufficient severity including severe pain, psychiatric (relating to mental illness) disturbances, symptoms of substance abuse, and pregnancy/active labor that the absence of immediate medical attention could place the individual's health at risk. A MSE was defined as the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not. All patients shall receive a MSE that included providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. The MSE requirements include the ED Log entry, including disposition of patient, patient's triage record, vital signs (VS, measurements of the body's most basic functions), history, physical examination of affected systems and potentially affected systems, exam of known chronic conditions, necessary testing to rule out an EMC, notification and use of on-call staff and physicians to complete guidelines, diagnose and/or stabilize the patient, VS upon discharge and complete documentation of the MSE.

Review of hospital policy titled, "Suicide Screening, Assessment & Prevention for Hospital Patients," dated 06/26/24, showed the use of the Columbia Suicide Severity Rating Scale (C-SSRS, a scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) was the standardized process for screening patients for suicide (to cause one's own death) risk. Every patient has the right to a safe environment that is appropriate to their clinical condition, including those patients identified to be at risk for suicide. All patients presenting to the hospital who are being evaluated or treated for behavioral health conditions as their primary reason for care will be screened for suicide risk using the C-SSRS. Patients identified as high risk for suicide will be re-assessed every 12 hours or more often as indicated by their clinical condition. A low risk was defined as a wish to die or suicidal ideation (SI, thoughts of causing one's own death) without a method, intent, plan or behavior, no reported history of SI or behavior. A medium risk was defined as SI with a method without a plan, intent or behavior in past month and no suicidal behavior within the last three months. A high risk was defined as SI with intent or intent with a plan in the past month, suicidal behaviors within the past month, answering yes to having thoughts and intention on acting on thoughts and started to work out the details of how to kill themselves.

Review of hospital policy titled, "Standards of care for the Emergency Department," dated 07/16/24, showed the patient should expect a triage assessment and a MSE by a licensed provider.

Please refer to 2406 for further details.

Based on interviews, record review, and policy review, the hospital failed to provide, within its capability and capacity, ongoing assessment and reassessment during a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#23) of 27 Emergency Department (ED) records reviewed from 08/03/24 to 03/05/25. This failed practice had the potential to cause harm to all patients who presented to the ED.

Findings included:

Review of hospital policy titled, "EMTALA Guidelines for Transfer," dated 11/13/24, showed the Emergency Medical Treatment and Labor Act (EMTALA) required hospitals with Emergency Departments (ED) to provide a medical screening examination to any individual who comes to the ED and requests such an examination, and prohibits hospitals with an ED from refusing to examine or treat individuals with an EMC. An EMC was defined as a medical condition with sufficient severity including severe pain, psychiatric (relating to mental illness) disturbances, symptoms of substance abuse, and pregnancy/active labor that the absence of immediate medical attention could place the individual's health at risk. A medical screening exam was defined as the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not. All patients shall receive a MSE that included providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. The MSE requirements include the ED Log entry, including disposition of patient, patient's triage record, vital signs (VS, measurements of the body's most basic functions), history, physical examination of affected systems and potentially affected systems, exam of known chronic conditions, necessary testing to rule out EMC, notification and use of on-call staff and physicians to complete guidelines, diagnose and/or stabilize the patient, VS upon discharge and complete documentation of the MSE.

Review of hospital policy titled, "Suicide Screening, Assessment & Prevention for Hospital Patients," dated 06/26/24, showed the use of the Columbia Suicide Severity Rating Scale (C-SSRS, a scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) was the standardized process for screening patients for suicide (to cause one's own death) risk. Every patient has the right to a safe environment that is appropriate to their clinical condition, to including those patients identified to be at risk for suicide. All patients presenting to the hospital who are being evaluated or treated for behavioral health conditions as their primary reason for care will be screened for suicide risk using the C-SSRS. Patients identified as high risk for suicide will be re-assessed every 12 hours or more often as indicated by their clinical condition. A low risk was defined as a wish to die or suicidal ideation (SI, thoughts of causing one's own death) without a method, intent, plan or behavior, no reported history of SI or behavior. A medium risk was defined as SI with a method without a plan, intent or behavior in past month and no suicidal behavior within the last three months. A high risk was defined as SI with intent or intent with a plan in the past month, suicidal behaviors within the past month, answering yes to having thoughts and intention on acting on thoughts and started to work out the details of how to kill themselves.

Review of hospital policy titled, "Standards of care for the Emergency Department," dated 07/16/24, showed the patient should expect a triage assessment and a MSE by a licensed provider.

Review of the Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) D's first trip report for Patient #23, dated 01/10/25 at 6:04 AM, showed she complained of SI and chest pain rated at a five on pain scale (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible). She was alert and oriented, calm and cooperative. She denied shortness of breath and VS were within normal limits. She had electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) leads still in place on her chest from a previous hospital visit. She stated she had a suicide plan but did not want to disclose it. An EKG was obtained which was unremarkable. She was transported to Hospital B (a nearby Acute Care Hospital) and care was transferred at 7:08 AM.

Review of Patient #23's Hospital B medical record, dated 01/10/25, showed the patient arrived via EMS complaining of chest pain and shortness of breath upon waking. She also reported to the EMS crew that she had suicidal thoughts with a plan but did not disclose the plan. She denied SI for the Hospital B staff, informing them that when EMS applied oxygen her SI, chest pain, and shortness of breath resolved. She was alert and oriented, her VS were stable, and CSSR-S was negative. Her bloodwork showed an elevated brain natriuretic peptide (BNP, blood test that measures levels of protein made by the heart and blood vessels that indicate heart failure) but was otherwise normal. She was given a dose of oral Lasix (medication used to treat water retention, swelling, and high blood pressure). She tested negative for respiratory viruses. Her EKG and chest x-ray (test that creates pictures of the structures inside the body-particularly bones) were unremarkable. Her assessment was normal, and her lung sounds were clear. She met with a social worker (SW) who contacted her husband to discuss her behavioral health assessment. SW documented that she believed the patient was malingering (to fake psychological or physical symptoms for secondary gains) and recommended discharge. Patient #23's husband was agreeable to the safety plan. She was discharged with diagnoses of sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts) and anxiety about health. She was instructed to follow up with her primary care provider.

Review of the EMS D's, second trip report for Patient #23, dated 01/10/25 at 12:48 PM, showed EMS transported her for concerns of suicidal thoughts. When asked if she had a plan she said yes, but she had difficulty explaining the plan. She denied pain or discomfort. Her VS were stable, an EKG was unremarkable. She was transported to Golden Valley Hospital and care was transferred at 1:42 PM.

Review of Patient #23's medical record, dated 01/10/25, showed:
- Patient #23 was a 57-year-old female who arrived at the ED at 1:54 PM for SI.
- She stated that she felt like cutting herself. EMS informed the ED staff that the patient had been seen at another hospital earlier that day for chest pain and SI, but had been discharged home.
- She had a past medical history of depression (extreme sadness that doesn't go away) anxiety, delirium tremors (DT, a life threatening for of alcohol withdrawal), alcohol abuse, osteopenia (low bone mineral density), polycythemia (abnormally high red blood cells), and nicotine dependence.
- Her VS were stable.
- Her C-SSRS showed she was a moderate suicide risk and psychiatric rounding (frequent or constant observation [as described in the hospital's policy]) was initiated.
- She was alert and oriented, calm and cooperative.
- Her bloodwork and EKG were unremarkable.
- She was given a behavioral health evaluation which showed she had a history of multiple inpatient psychiatric admissions, the most recent being the previous week. She had an established psychiatrist (physician who specializes in mental health disorders) and was supposed to be seeing a therapist. She also had a pattern of coming to the ED immediately after being discharged because she was afraid she would harm herself at home. At the time of her assessment the patient denied SI and felt safe. Discharge was recommended.
- The ED provider documented that she confronted the patient about her pattern of leaving an inpatient setting and immediately checking back into the ED. She suggested that her behavior didn't seem to be working. The patient responded that she just didn't like those facilities or the staff. They discussed the need for a long-term placement such as a nursing home. After the behavioral health screener recommended discharge, the patient stated that she did not feel safe any longer. The provider considered this manipulative behavior. The patient's husband was educated to secure all sharp objects in the home, and he was agreeable to keeping her safe.
- When the patient was signing her discharge instructions, she told the nurse she would "be back tomorrow."

Review of the EMS D's third trip report for Patient #23, dated 01/11/25 at 9:23 AM, showed the patient had been discharged by both Golden Valley Hospital and Hospital B the previous day. She informed EMS that she intended to either cut herself or take all of the pills in her house to kill herself. She stated that she did not feel safe because she had options to kill herself. She had no other complaints and her transport was uneventful. Care was transferred to Golden Valley ED staff at 10:20 AM.

Review of Patient #23's medical record dated 01/11/25 showed she arrived to the ED at 10:25 AM. She told the triage nurse that since her visit the previous day "everything feels magnified." She told EMS staff that she did not feel safe at home and had thoughts of cutting herself. Her VS were stable. A C-SSRS was not documented, but a depression screening showed severe depression. The ED provider documented that the patient was frequently evaluated at the hospital. She had received a complete mental health evaluation the day before and had resources available, such as a case worker and a therapist. He documented that she refused to use those resources and came in by EMS. The patient stated she was still not feeling well. He encouraged her to use the resources that had already been established and discharged her home at 10:47 AM. Her ED visit lasted a total of 22 minutes.

Review of EMS D's fourth trip report for Patient #23, dated 01/12/25 at 11:30 AM, showed she reported to EMS that she had taken too many of her prescribed medications. She disclosed that she had a history of chronic back pain that caused her to consider suicide. When asked how many pills she took, she was uncertain. The patient had a normal physical assessment, stable VS, and an unremarkable EKG. An IV was established and she was given fluids. Poison control was contacted and they advised EMS that the patient would require supportive care only. She might experience dryness, mood changes or lethargy. Care was transferred to Golden Valley ED staff at 12:19 PM.

Review of Patient #23's medical record dated 01/12/25-01/13/25 showed:
- At 12:26 PM, she arrived at the ED for an intentional overdose on an unknown quantity of dicyclomine (a medication used to treat abdominal cramping and irritable bowel syndrome).
- Her VS were stable. She was alert and oriented, in no acute distress.
- A behavioral health assessment was completed and an inpatient psychiatric admission was recommended.
- She was treated with calcium gluconate (used as protective agent in high blood potassium and counteract the effects for magnesium toxicity) and folic acid. Her home medications were provided while she awaited transfer.
- Her EKG and bloodwork were unremarkable except for a calcium level of 7.6 (normal is 8.4-10.2). She was considered medically cleared for psychiatric admission.
- On 01/13/25 at 10:47 AM, she was transferred for inpatient behavioral health care.

During an interview on 03/05/25 at 1:00 PM, Staff N, Registered Nurse (RN), stated Patient #23 presented to the ED on multiple occasions for various complaints, including abdominal pain, chest pain and SI. At times, her answers would change when she was asked questions on the C-SSRS. She was unable to recall any specific information for the specific dates.

During an interview on 03/05/25 PM at 11:00 AM, Staff T, Nurse Practitioner (NP), stated she assessed Patient #23 on 01/10/25. She had been seen at another hospital earlier that same day for chest pain and was discharged. She had called EMS and presented to the ED with complaints of SI. Patient #23 received a behavioral health assessment and was discharged with a safety plan in place. Her spouse was present and had agreed to the safety plan. It was the expectation that providers to obtain a behavioral health assessment on all patients that presented to the ED with SI complaints.

During an interview on 03/05/25 at 1:15 PM, Staff W, RN, stated she had been instructed by Staff Q, ED physician, to put Patient #23 in fast track on 01/11/25. Fast track was where they placed patients that could quickly be assessed, treated and discharged. Staff Q assessed Patient #23, stated that she had not made a suicide attempt, nothing had changed and discharged the patient.

During an interview on 03/05/25 at 2:00 PM, Staff Q, ED Physician, stated Patient #23 was seen frequently in the ED. On 01/11/25, she presented to the ED for SI. She had been evaluated the day before using tele-psychiatry services and had been discharged home with instructions to utilize her outpatient therapy. He stated "the charge nurse told me she was to go home and use her resources, we were not to get another behavioral health evaluation and they were not going to admit her again. So I let her go." Patient #23 was instructed to use her outpatient resources.

During an interview on 03/05/25 at 1:15 PM, Staff U, CN, stated that she had been Patient #23's nurse on 01/11/25 and was present when Staff Q, ED Physician, assessed her. He asked Patient #23 a few questions and walked out. He stated "nothing had changed and to discharge her". She did not tell Staff Q "Not do a behavioral health evaluation on Patient #23." She told him Patient #23 had been seen the day before and had received one. As a nurse "I do not give orders to the physician, they are in charge of patient's care."

During an interview on 03/05/25 at 2:50 PM, Staff I, NP, stated she had assessed Patient #23 multiple times. She stated "it was expected that providers obtain a behavioral health assessment if a patient has SI, no matter how many times they presented to the ED." She assessed Patient #23 on 01/12/25 after she took a bottle of pills. Patient #23 received a behavioral health assessment and was transferred for inpatient behavioral health care.

During an interview on 03/05/25 at 12:30 PM, Staff C, ED Director, stated Patient #23 was well known to ED staff and to the local EMS crews. She had psychiatric services available to her on an outpatient basis, including a dedicated person to assist her to her scheduled appointments. Patient #23 did not like to use these services because she does not like them. She had multiple admissions for inpatient care. She was seen in the ED 41 times in the last 12 months, for various complaints. She can be "very manipulative." The ED provided behavioral health assessments 24 hours per day. The expectation was for all suicidal patients to receive a behavioral health assessment.

During an interview on 03/05/25 at 3:00 PM, Staff R, ED Medical Director, stated Patient #23 was seen frequently in the ED. She was chronically suicidal and needed to be placed in an adult residential home. His expectation for ED staff were to utilize the C-SSRS. Patient #23 did not get assessed utilizing the C-SSRS on 01/11/25. Because of her chronic suicidal ideations "using the C-SSRS as a guide, was not accurate assessment" for her. If a provider was not utilizing the C-SSRS for whatever reason, he would expect the provider to document any deviations from hospital policy and to document the reason for making an exception. Staff Q, ED Physician, did not document his reason for not performing a C-SSRS assessment. Patient #23 did not receive a behavioral health consult on 01/11/25. Staff R was not aware that she had presented to the ED on that day with intensified thoughts of SI, which were worse than the ED visit on 01/10/25. He had not reviewed the record. He was not sure why Staff Q had indicated that he was instructed by Staff U, CN, to not obtain a behavioral health assessment for Patient #23. He expected the ED physician to make that decision based on his own assessment, not to rely on nursing recommendations.