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Based on record reviews and interviews, the hospital failed to meet the requirement of §489.24 as evidenced by failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. There was no documented evidence that a medical screening examination was provided to Patient #2 when the patient had returned to the hospital's ED for a third time and presented with a new complaint of expressed thoughts of self-harm. The patient was subsequently found hanging, with a belt around his neck, from the handicapped hand rail in ED lobby bathroom. This deficient practice was evident for 1 (#2) of 20 sampled patients reviewed. (see findings in A-2406).

Based on record review and staff interviews, the hospital failed to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. There was no documented evidence that a medical screening examination was provided to Patient #2 when the patient had returned to the hospital's ED for a third time and presented with a new complaint of expressed thoughts of self-harm. The patient was subsequently found hanging, with a belt around his neck, from the handicapped hand rail in the ED lobby restroom. This deficient practice was evident for 1 (#2) of 20 sampled patients reviewed.

Findings:

Review of the hospital's Medical Staff Rules and Regulations revealed in part: Emergency Services: 1. All members of the Medical Staff shall accept responsibility for emergency service care in accordance with the hospital's emergency service policies and procedures. 3. All members of the Medical Staff shall follow hospital policies and procedures related to EMTALA regulations. 20. A Medical Screening Examination (MSE) will be performed on any person presenting to the hospital (as defined in the hospital's EMTALA Policy and Procedure).

Review of the hospital policy titled," EMTALA (Signage, Central Log, Medical Screening Stabilization, and Transfers), effective date: 8/1/12, reviewed 7/2015, revealed in part: Purpose: To ensure all patients coming to the hospital requesting emergency services receive an appropriate MSE as required by the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C., Section 1395 and all Federal regulations and interpretive guidelines promulgated thereunder. Policy: Any patient who comes to the hospital requesting emergency services is entitled to and will receive a MSE performed by individuals qualified to perform such examination to determine whether an emergency medical condition exists.
A.Definitions: Emergency Medical Condition means: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: 1.Placing the health of the individual in serious jeopardy, 2. Serious impairment in bodily functions, 3. Serious dysfunction of any bodily organ or part.
Medical Screening Examination: is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an emergency condition exists. The MSE is an ongoing process and the medical records must reflect continued monitoring based on patient's needs and continue until the patient is either stabilized or appropriately transferred.

Review of the hospital policy titled, "Triage Policy", effective date: 8/1/12, revised 11/2015, revealed in part: Policy: 1. Patients who present for care on hospital property at this hospital will be offered a MSE to determine if they have an emergency medical condition. 2. Any patient presenting with psychiatric or emotional disturbance and has not already arranged to be seen by mental health authorities or if the patient appears to be in severe distress will be immediately assessed. Any patient who presents with suicidal thoughts will be immediately placed in a bed and PEC protocol until Physician has assessed the patient.

Review of Patient #2's EMR revealed the following entries:
1st Visit -11/21/17 at 11:30 p.m. Patient arrived via ambulance, chief complaint: left thumb pain, several hours, unknown injury, swelling noted. Patient intoxicated publicly and concerned citizen called EMS, patient intoxicated, smelled of ETOH (alcohol), lethargic, slurred speech, angry and uncooperative. Triage status: 3
Nursing Assessment: All systems assessed, patient administered a Thiamine injection, X-ray of hand completed. Glascow Coma Scale + 15, refusing further care of thumb, explained thumb was fractured, patient refusing further care; non-displaced fracture of left thumb. Alcoholic intoxication without complication. Diagnosis of contusion of left thumb without damage to nail Initial encounter closed non-displaced fx of distal phalanx of left thumb, initial encounter also pertinent to this visit. Disposition: discharged.

2nd Visit- 11/22/17 at 3:36 a.m. Chief Complaint: Thumb pain; Triage level: 4
Nursing assessment completed. Care provided: Finger splint and Tylenol 650 mg by mouth administered.
S2MD assessment: Pt. was just seen here for alcohol intoxication and thumb fracture which he did not allow us to treat and while in waiting room due to pain in his thumb pt. checked back in to get treatment. Left thumb positive tenderness to palpation, positive edema, ecchymnosis, full range of motion, neurovascular intact, Impression: closed non- displaced fracture of distal phalanx of left thumb with routine healing - subsequent encounter.

3rd visit- 11/22/17 at 05:25 a.m.: Chief Complaint: at 5:21 a.m. Pt. found unresponsive in lobby restroom, after being discharged, with a belt around neck, pulse noted, pt. not breathing at this time. S2MD at pt.'s side.
11/22/17 provider note: after 2nd discharge this evening pt. was in lobby requesting Medicaid to get him a ride home, when this was not feasible pt. then requested cab vouchers to home, when this was not immediately provided pt. became irate and demanded to be admitted. I (S2MD) went to lobby to speak with patient to address his concerns and pt. stated, "He wanted to be admitted because he felt suicidal at this point due to lack of transportation to his house." Explained to pt. that admission because he did not have a ride home was an unreasonable request at this time however he was welcome to check in and be evaluated again. Pt. promptly stood up and said he had to go to the bathroom. Approximately 20 minutes later pt. was not responding to knocks at bathroom door. Security opened door and found pt. with belt tied around his neck and around the handicapped railing, unresponsive.
Unable to do a systems assessments; Physical assessment per S2MD: ashen unresponsive, pt. on floor as belt had been cut by security guard, blood noted in right nare, neck no crepitus noted, C-collar placed by staff, bradycardia with faint pulse, agonal respirations, course breath sounds, Glascow Coma Scale: 3 (score of 3-8 generally indicates patient is in a coma), Skin: pallor.

Further review of Patient #2's medical record revealed no documented evidence that a Medical Screening Examination had been performed on the patient after stating he was suicidal on his third visit to the ED.

Disposition: Transferred to a higher level of care- departure: 9:12 a.m.

Review of Patient #2's medical record from Hospital "B" (hospital patient was transferred to for a higher level of care) revealed the following, in part: Death Summary: Admit date: 11/22/17, Disposition: Death 11/30/17 at 12:49 a.m.: Indication for Admission: Hypoxic Encephalopathy and cardiac arrest status post hanging injury. Hospital Course: 53year old male transferred to Hospital "B" 11/22/17 from Hospital "A" after being found hanging in facility restroom. Cessation of cardiac activity and time of death declared 12:49 a.m. on 11/30/17.


In an interview on 12/18/17 at 2:50 p.m. with S3EDRNMgr, he indicated patients presenting to the ED with thoughts of self-harm were brought to the back for triage and assessment and placed in a secured room as soon as the ED nursing staff was notified (by security and/or the ED clerk). S3EDRNMgr reported patients expressing thoughts of self-harm who had not been assessed yet or had been assessed as at risk for self-harm would not have been allowed to go to bathroom unattended by staff. S3EDRNMgr reported Patient #2 had been treated in the ED multiple times. He further reported Patient #2 had been PEC'd in the past and had been admitted to psychiatric hospitals for inpatient psychiatric care. S3EDRNMgr confirmed the Patient #2 had not had a MSE on the third time he presented to the ED with a new complaint of thoughts of self-harm.

In an interview on 12/19/17 at 7:46 a.m. with S4Security, he indicated he remembered Patient #2. He said he was frequently a patient in the ED. S4Security indicated Patient #2 had been seen and treated twice in the ED that night (11/21/17 - 11/22/17), prior to presenting back a third time with a new complaint of being suicidal. S4Security indicated the patient had not had a ride home and had been requesting cab vouchers and for Medicaid to transport him home. After repeatedly telling the patient he had to call family or friends to give him a ride home, the patient stated well then I am suicidal. He said at that time he walked into the ED and made them aware that the pt. had said he was suicidal. S4Security reported S2MD came into the lobby and told Patient #2 he could check himself back in to be seen again, but he was just going to discharge him again. He said S2MD had left after speaking to Patient #2 and had gone back into the ED. S4Security confirmed the patient was not taken back at that time. S4Security reported Patient #2 had stood up and said he had to use the restroom again and he went into the ED lobby restroom. S4Security further reported 41 minutes had passed by and the ED Clerk had asked him to go and check on Patient #2 in the bathroom. S4Security indicated he had knocked on the ED lobby restroom door several times and found the door was locked. S4Security further indicated Patient #2 was lying on his right side, with his head 8-10 inches off of the floor, with his belt tied around his neck, secured to the handicapped rail. S4Security said he supported Patient #2's head and cut the belt to release him. S4Security indicated S2MD and ED nursing staff were called and the patient was taken back to trauma room 1.

In an interview on 12/19/17 at 11:40 a.m. with S2MD (ED Medical Director) he indicated Patient #2 had been treated at the hospital's ED multiple times. S2MDconfirmed Patient #2 had been PEC'd in the past and had been treated as an inpatient at a psychiatric hospital in the past due to depression and thoughts of self-harm. S2MD reported he remembered he had seen the Patient #2 twice on the night he had attempted suicide in the ED lobby restroom. S2MD reported Patient #2 was intoxicated that night and was brought in for a chief complaint of injury to his thumb. S2MD reported he had x-rayed the patient's thumb and had diagnosed him with a thumb fracture. S2MD further reported Patient #2 had refused to let them treat his thumb, became angry, and left after being discharged. S2MD said Patient #2 had gone to the lobby and asked for a ride home. S2MD reported Patient #2 signed back in to be seen for thumb pain. He said he splinted Patient #2's thumb and treated his pain. S2MD indicated he had overheard Patient #2 in the ED lobby and he had gone out to see what the issue was. S2MD reported Patient #2 had wanted to be admitted because he had not had a ride home and was feeling suicidal due to having no ride. S2MD further reported he had told the patient he was free to check back in and to be seen when he reported he was suicidal but the patient had said he need to go to the restroom. S2MD indicated he had gone back into the ED and confirmed he had not seen the patient again until he was called to treat the patient because they had found him unresponsive in the ED lobby restroom with a his belt tied around his neck and the handicapped hand rail.