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Based on review of medical records, specialty physician on-call schedules, Medical Staff Bylaws and Rules and Regulations, Emergency Medical Treatment And Labor Act (EMTALA) policies and procedures related to medical screening examination and stabilization, the facility failed to provide a Medical Screening Examination (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) within the facility's capacity and capability for one patient (#4) of 30 patients' Emergency Department (ED) records reviewed for patients who presented to the ED seeking care from 03/01/16 through 09/06/16. The average monthly census for the ED was 2319.

Findings included:

Record review of the undated facility policy titled, "Emergency Medical Screening, Treatment, Transfer and On-Call Policy," showed that any individual who presents to the ED shall be provided an MSE to determine whether that individual is experiencing an EMC. Generally, an "EMC" is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organs or function, or serious jeopardy to the health of the individual or fetus. All patients shall be examined by qualified medical personnel, which shall be defined as a licensed physician. An individual experiencing an EMC must be stabilized prior to transfer or discharge . . .

Patient #4 resided in a residential care facility and on 08/26/16 the patient had barricaded himself in the bathroom and law enforcement had to force the bathroom door open so the Emergency Medical Service (EMS) paramedics could get to the patient. The patient was naked and his behavior was described as "abnormal and bizarre". He had been sexually aggressive toward female staff at the Long Term Care (LTC) Facility and verbally and physically aggressive towards police officers at the LTC facility. The paramedics administered 5 mg (milligrams) of Haldol (a medication used to treat mental conditions) medication enroute to the ED. Upon arrival to the ED at 8:17 PM, the patient had "altered mental status", was difficult to awaken and would not open his eyes or answer questions. The patient was triaged at 8:25 PM as "Emergent" and mumbled insensibly, tried to get out of bed, grabbed his penis and asked staff if they wanted to see it.

Patient #4's current diagnoses included Undifferentiated Schizophrenia (severely impaired thinking, emotions, and behaviors), Moderate Mental Retardation (an intellectual functioning level measured by standard tests for intelligence that is well below average and significant limitations in daily living skills) and a history of aggressive behavior. While in the ED he was given a total of two Haldol injections for a total of 20 mg and two Ativan (medication is used to treat anxiety) injections for a total of 2 mg. The patient's medical record contained five Involuntary Commitment Affidavits that supported transfer to a psychiatric facility. The ED Physician wrote the order for discharge on 08/27/16 at 1:54 AM and the patient was discharged at 3:47 AM back to the LTC facility without a mental health MSE.

Mercy Hospital Lebanon had the capacity and capability to provide an appropriate MSE and/or transfer for Patient #4.

Based on interview and record review, the facility failed to provide a Medical Screening Examination sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#4) of 30 records reviewed of patients who presented to the Emergency Department (ED) seeking care from 09/06/16 to 09/08/16. The average monthly census for the ED was 2319.

Findings included:

Record review of the Medical Emergency Medical Service (EMS) Patient Care Record dated 08/26/16, showed that on 08/26/16 at 8:10 PM EMS was dispatched to the Long Term Care (LTC) Facility where Patient #4 lived. Patient #4 was exhibiting "abnormal behavior". The patient had been non-compliant with his medications and had been acting bizarre and locking himself in the bathroom. Patient #4 had been aggressive toward the LTC staff. Law Enforcement arrived at the LTC facility and escorted EMS to the patient. The patient immediately locked himself in the bathroom. Law enforcement forced open the bathroom door and found the patient seated naked on the toilet. Law enforcement put a hospital gown on the patient and escorted him to the EMS cot (a light portable bed). The patient was secured to the cot for transport to the ED and due to his bizarre behavior was injected with 5 mg (milligrams) of Haldol (a medication used to treat mental conditions) "with good results".

Record review of Patient #4's closed medical record dated 08/26/16, showed that he presented to the ED by EMS at 8:17 PM, with altered mental status; difficult to awaken; will not open his eyes or answer questions. He was triaged as "Emergent" and had a high blood pressure of 148/94 (normal is 120/80). At 9:00 PM the patient awakened and was mumbling insensibly, tried to get out of bed, grabbed his penis and asked staff if they wanted to see it. The Physician ordered a computerized tomography (CT) (combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues inside your body) at 9:08 PM. At 9:23 PM it was documented that the patient was unable to have the CT scan due to psychotic and schizophrenic symptoms, agitation, and altered mental status. At 9:41 PM the documentation showed that Patient #4 was sexually agitated; grabbed and rubbed his penis; and could not be redirected by staff. At 10:00 PM the patient was agitated; fidgety; impulsive; exhibited auditory and visual hallucinations; had disorganized thoughts; flight of ideas and sexually acted out at hospital staff. The physician ordered the patient's discharge on 08/27/16 at 1:54 AM. At 2:05 AM the patient became uncooperative, refused to return to the LTC facility and at 2:30 AM 10 mg Haldol and at 2:45 AM 1 mg Ativan (a medication used to treat anxiety) was administered IM (within the muscle). The patient was discharged at 3:47 AM with no evidence that the ED physician (Staff O) re-assessed the patient after the medication injections prior to discharge.

Record review of the ED On Call Schedule and through an interview with Staff E, Executive Director of Nursing, on 09/06/16 at 2:00 PM, confirmed that there was no psychiatrist on staff or on call for psychiatric evaluations. Staff I stated that the ED physicians would perform a mental health exam. There was no evidence that a mental health exam was performed on Patient #4.

During an interview on 09/07/16 at 11:17 AM, Staff M, Registered Nurse, Case Manager, stated that she or one of the other Case Managers or Social Workers were always available to contact any of 33 Inpatient Mental Health Facilities for psychiatric patient assessments or inpatient arrangements.

The hospital failed to provide Patient #4 with an adequate MSE that included a mental health/psychiatric exam to rule out an EMC. The patient's care was compromised and he returned to the ED days later and was transferred to an inpatient mental health facility for psychiatric care.