HospitalInspections.org

Based on a review of documentation and interviews with staff, the hospital failed to comply with §489.24, as they failed to provide an appropriate medical screening exam and stabilizing treatment for one of thirty six patients reviewed. Refer to A2406

Based on review of facility policy, EMTALA logs, patient record review, and confirmed in interviews, the facility failed to ensure a patient presenting to the hospital's emergency department with complaints of suicidal and homicidal ideation received an appropriate medical screening examination prior to discharge in 1 (Patient # A) of 36 patient medical records reviewed.

Findings include:

Review of the facility policy Emergency Medical Treatment and Active Labor Act (EMTALA) (policy Stat ID 16438131, effective 12/2024), it stated "if an EMC exists and it is within the specific [facility] capacity and capability to treat the patient, the [facility] will provide stabilizing medical (including psychiatric) treatment, including inpatient hospitalization, if appropriate. The person's stabilized condition should be documented in the medical records. A person is deemed stabilized for a psychiatric or substance use condition if the person is not in danger of harming themselves or others, they are protected from harming themselves or others, or their condition no longer presents a significant medical risk of material deterioration. If the specific [facility] does not have the capacity or capability to treat the patient's EMC, or the patient requests transfers, the hospital will stabilize the patient's medical condition within its capacity and capability and appropriately transfer the patient to another facility for further appropriate care.

Review of the facility policy Safety Assessment (policy Stat 17392565, effective 01/2025) it stated "To provide screening of all potential patients upon entering the facility for: reason for visit, recent thoughts of self-harm or harming others, safety, vital signs baseline, special equipment use, underlining medical conditions that may need acute medical attention, and blood sugar monitoring if insulin dependent.
Procedures
o Upon arrival, the client will be asked to complete the Safety Assessment Form.
o After completion of the Safety Assessment Form, the Vital Signs will be completed and include a Breathalyzer and Blood Glucose level if the patient is an insulin dependent diabetic...
If the client answers "Yes" to any of the screening questions, the Receptionist will immediately notify the Assessment Specialist who will review the form and determine order of screening if multiple clients are present at the same time.
If the client selects "I feel concerned, unsafe" to the level of safety question, the Receptionist will immediately notify the Assessment Specialist who will review the form and determine order of screening if multiple clients are present at the same time.
Once screening is complete, if the client is determined to meet criteria for services, the Safety Assessment Form becomes a permanent part of the Medical Record.
If the client is determined not to meet criteria for treatment, The Safety Assessment Form is scanned into a shared drive to record the screening session."

Review of the facility policy Screening Assessment and/or Level of Care/Psychosocial Assessment (PolicyStat 16376835, effective 12/2024) it stated "The Screening Assessment will be used for all assessments and should be filled out in its entirety. No section of the assessment should be left blank without explanation... Every patient must have a Screening assessment. If the patient doesn't meet criteria for Inpatient, PHP, or IOP then the Screening assessment is staffed with a provider, signed and outpatient resources provided...The Screening and Level of Care Assessments will be conducted by the qualified medical personnel (QMP) in the Assessment Department...The assessment is completed on every patient who comes to the facility seeking services."

Review of the EMTALA logs revealed Patient #A arrived to the facility lobby on 12/11/2024 at 07:25 PM and vitals were taken at 07:30 PM with a disposition of 'referred out' with comments "referred out...cannot complete ADLs." No time was indicated for assessment start or end time.

A review of Patient # A's medical records revealed:

Patient # A (20-year-old male with bipolar I, autism, IDD, ADHD) arrived at the facility on 12/11/2024 at 07:25 PM with complaints of suicidal and homicidal ideation. Patient arrived via private vehicle and was accompanied by his mother (legal guardian). The patient's mother documented the following safety assessment form on 12/11/2024 at 07:40 PM:

"Are you having current thoughts to harm yourself? Yes
Are you having current thoughts to harm others? Yes.
Have you attempted to harm yourself within the last 24 hours? Yes
Please indicate below which best applies to your level of safety at this time: I feel concerned, unsafe"

No vital signs were assessed per the facility policy.

Further review of the above medical record showed Patient #A was assessed only by Staff #7, a qualified medical professional with a master's license in social work. There was no documentation that Staff #7 consulted a psychiatrist who was on call and/or the telemedicine services of other providers available to the facility 24/7.

Review of Patient #A's Personalized Treatment Recommendation revealed Staff #7 made recommendations for patient to be referred to [Facility B] and [Facility C] for "proper services for patient's needs. If crisis occurs, please call 988, 911, or take to nearest ER." Recommendation was signed and dated on 12/11/2024 at 11:24 PM, 3 hours 59 minutes after patient entered the facility.

In an interview with Staff #5 on 02/28/2025 at 03:55 pm via Zoom she stated that the QMP (qualified medical professional) would consult with provider when doing assessments even if patient met exclusionary criteria such as autism or anyone who is unable to complete ADLs. The intake staff would then provide a list of resources who are able to accept the patient and the facility assessors would come to lobby and screen for safety.

Review of all records available revealed no documentation the patient was assessed for a possible EMC nor were the family offered a transfer to another facility who had services available for the patient. There was no documentation the patient or family's refusal to transfer to another facility for further evaluation and treatment. No documentation that the patient EMC was stabilized prior to discharge home. Surveyor requested documentation of the assessment and transfer for Patient #A on 02/27/2025 and again on 2/28/2025. None was provided by the end of the survey on 02/28/2025.


key:
ADL - activities of daily living
EMC - emergency medical condition