HospitalInspections.org

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to comply with 42 CFR 489.24 related to its failure to provide an appropriate medical screening examination (MSE), and, failure to provide stabilizing treatment to a patient with an unstable emergency medical condition (EMC), and failure to provide an appropriate transfer for one (1) of twenty (20) sampled patients, Patient #1, on 06/04/2022.

Refer to the findings in Tags, A-2406, A-2407 and A-2409.

Based on interview, record review, review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, review of the facility's Incident Information, review of the Emergency Department (ED) log, and review of the facility's policies, it was determined the facility failed to ensure all individuals that presented to the ED seeking assistance were entered into the ED log, for one (1) of twenty (20) sampled patients, Patient #1 who presented to the hospital with Suicidal ideations.

The findings include:

Review of Facility #1's policy titled, "EMTALA: Treatment and Transfer of Individuals in Need of Emergency Medical Services", Number 840-0004, effective date 03/2006, revealed the ED must follow the EMTALA Central Log Policy. Continued review revealed the Central Log was the log the facility was required to maintain on each individual who "comes to the Emergency Department" seeking assistance. Per the policy, the Central Log documented whether the presenting individual refused treatment; was refused treatment by the ED Staff; or whether he/she was transferred, admitted, treated, stabilized, and transferred or discharged. The policy stated the purpose of the Central Log was to track the care provided to each individual where EMTALA was triggered.

Review of the facility's policy titled, "EMTALA Central Log", Number 6220-0001, revised 04/2020, revealed the facility must maintain a Central Log that met all federal requirements for EMTALA. The purpose was to establish guidelines for tracking the care provided to each individual seeking care in a dedicated Emergency Department (DED) or seeking care in areas on hospital property other than a DED for an emergency medical condition (EMC) as required of any hospital with an Emergency Department by the Emergency Medical Treatment and Active Labor Act (EMTALA). Per the policy, the Central Log must contain at a minimum, patient visits to the emergency room in chronological order, including patient identification, means of arrival, and time of arrival. The policy also stated the log must document whether the patient refused treatment; was refused treatment by the ED staff; was transferred; was treated and admitted; was treated, stabilized, and transferred; or was treated, stabilized, and discharged.

Review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, dated June 08, 2022, reported by Facility #2 to the Centers for Medicare and Medicaid (CMS), via email, revealed Patient #1, a sixteen year old minor, walked into the ED of Facility #1(University of Louisville Hospital ), the late evening of 06/04/2022. The chief complaint was that Patient #1 was expressing suicidal ideation. It was reported Patient #1 was told by Facility #1's Registration Clerk (RC) #2 the facility did not provide psychiatric treatment to minors and he/she would have to go to Facility #2 for treatment.

Review of Facility #1's report, Incident Information, date created 06/10/2022, revealed in the late evening of 06/04/2022, a minor patient presented to the ED with suicidal ideations. The Registration Clerk was unsure of how to handle the situation and contacted the Registration Supervisor. The Supervisor was uncertain about the treatment of a minor for a psychiatric complaint, and called EPS for clarification. Per the report, EPS staff told the Supervisor that the facility did not see minors, and the patient should be referred to Facility #2, which did see minor patients. The report stated the Supervisor did not inform EPS that a minor patient with a psychiatric complaint was present. The Supervisor told the Registration Clerk to instruct the patient to go to Facility #2 to be evaluated and treated, which the clerk did. The report also stated all staff involved were re-trained on EMTALA and treating minors immediately after awareness of the incident. Per the report, system-wide education would proceed and would consist of all Registration staff, EPS staff, and ED staff within the facility.

Review of Facility #1's Central Log, dated 06/04/2022 and 06/05/2022, revealed Patient #1 was not documented as having presented to the ED.

Interview with Facility #1's Director of Compliance/Risk, on 06/11/2022 at 9:45 AM, revealed all aspects of EMTALA should have been followed, which included recording Patient #1's presentation to the ED, on 06/04/2022, on the Central Log.

Interview with the Supervisor of ED Patient Access (Registration) for Facility #1, on 06/13/2022 at 12:34 PM, revealed she was working the night of 06/04/2022 to fill a gap in scheduling. She stated RC #2 had asked her if the ED treated minors with psychiatric concerns, and she told RC #2 she did not know but would find out. She stated she called Emergency Psychiatric Services (EPS) to inquire if EPS treated minors. She stated the person that answered the phone was rude and disconnected the call after telling her that EPS did not treat minors. The Supervisor stated she told RC #2 they did not treat minors. She revealed RC #2 did not tell her Patient #1 was actually in Registration. Per the interview, she stated she did not know until the next day (06/05/2022) that minors were to be registered in the ED and examined by a medical provider. In addition, she continued, EMTALA re-education was conducted that day, via email, by the Director of the ED and included education on registering minors in the ED to be examined by a medical provider. She also stated she received additional re-training on EMTALA on 06/10/2022. She stated annual EMTALA education was presented annually.

Interview with Facility #1's Registration Clerk (RC) #2, on 06/14/2022 at 7:36 AM, revealed, on 06/04/2022, unable to remember the time, Patient #1 walked in alone. She stated Patient #1 was soft-spoken, with a calm demeanor, and asked if they treated minors. RC #2 stated she did not know the answer and asked the Patient Access Supervisor, who was working at the time. RC #2 stated the Supervisor told her that she did not know but would find out. RC #2 stated the Supervisor called EPS to ask; EPS staff did not identify self, said no and hung up. She stated Patient #1 left after she gave him/her the answer. She stated she was aware of EMTALA components, but at the time, was unsure about unaccompanied minors requesting psychiatric services.

Interview with Facility #1's Director of Patient Access (Registration), on 06/14/2022 at 11:37 AM, revealed she had been notified, on 06/05/2022, of the incident. She stated immediate education on EMTALA components were initiated, on 06/05/2022, which she received, and which included education on registering minors in the ED to be examined by a medical provider. She stated she received additional EMTALA education on 06/10/2022. She stated the failure was in turning Patient #1 away because no one should be turned away when requesting services.

Interview with Facility #1's Chief Medical Officer, on 06/16/2022 at 4:09 PM, revealed it was his expectation that everyone be aware of and follow EMTALA requirements for adults and minors.

Interview with Facility #1's Medical Director of Emergency Psychiatric Services (EPS), on 06/16/2022 at 4:12 PM, revealed it was her expectation that EMTALA guidelines be followed. She stated she received additional EMTALA education on 06/10/2022.

Interview with Patient #1's Aunt, on 06/17/2022 at 1:58 PM, who was listed as next of kin, revealed Patient #1 did not have a cell phone and lived with her. The Aunt stated she had no idea Patient #1 was suicidal, he/she went to school, worked, and took care of his/her infant son. The Aunt stated she was contacted when Patient #1 was going to be admitted to Facility #2's Pediatric Behavioral Health Unit. Additionally, she stated she received a couple of phone calls during Patient #1's admission but was unable to remember the content of the calls. She also stated she was currently out of town and would be out of town until the next week.

The State Survey Agency (SSA) Surveyor did not interview Patient #1 because he/she lived with his/her Aunt. Per the interview with the Aunt, Patient #1 did not have a cell phone. In addition, the Aunt stated she was out of town and would not be back until the following week. Also, Patient #1's Aunt's telephone number was listed as Patient #1's number.

Interview with Facility #1's ED Medical Director/Attending Physician #1, on 06/17/2022 at 2:17 PM, revealed it was his expectation that all EMTALA components be followed. He stated annual EMTALA education was presented to staff. He also stated he was re-educated after this event, along with the rest of the staff.

Based on interviews, medical record reviews, review of the facility's Incident Information report, review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, and review of the facility's policies, it was determined the facility failed to ensure all individuals that presented to the ED seeking assistance, received an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, that would accurately determine if there was an acute emergency medical condition (EMC) that required treatment, for one (1) of twenty (20) sampled patients, Patient #1.

The findings include:

Review of Facility #1's policy titled, "EMTALA: Treatment and Transfer of Individuals in Need of Emergency Medical Services", Number 840-0004, effective date, 03/2006, revealed the ED must provide any individual with a medical screening examination (MSE) to determine if a medical emergency did exist. The facility must also provide stabilizing treatment within the facility's capabilities and provide an appropriate transfer to another facility.

Review of Facility #1's policy titled, "Behavioral Health Care of Minors", Number 4160-0026, dated 02/25/2020, last reviewed 03/2022, revealed the purpose of the policy was to identify the roles of the Emergency Psychiatric Services (EPS) team in the care of minors that presented to the ED with a Behavioral Health Chief Complaint. Minors that presented with a Behavioral Health Chief Complaint would be housed in the ED to ensure their safety and security. Per the policy, the process was the ED Registered Nurse (RN) would call and notify the EPS RN, the EPS RN would then complete the triage process, and an EPS Physician would evaluate the minor. If further treatment was needed, the EPS Physician would then arrange an appropriate transfer.

Review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, dated June 08, 2022, reported by Facility #2 to the Centers for Medicare and Medicaid (CMS), via email, revealed Patient #1 had presented to Facility #1, on 06/04/2022, exact time unknown. Continued review of the report revealed Patient #1 had expressed he/she was sixteen years old (16) and had suicidal ideations, but left Facility #1. Further review revealed Patient #1 arrived at Facility #2 and was admitted to the ED, on 06/05/2022 at 12:15 AM. On 06/05/2022 at 4:11 AM, Patient #1 received a psychiatric assessment and was admitted to Facility #2's Pediatric Psychiatric Unit. Additional review of the report revealed, on 06/06/2022 at 10:47 AM, the possible EMTALA violation was referred to Facility #2's Compliance and Audit Department. An investigation was initiated at Facility #2 that included record review, interview with Patient #1, and staff interviews.

Continued review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, dated June 08, 2022, revealed, on 06/07/2022, no time listed, Facility #2 discussed the possible EMTALA violation with Facility #1's Director of Compliance, who informed Facility #2 the alleged occurrence was under review.

Continued review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, dated June 08, 2022, revealed Facility #1 reported to Facility #2, after Patient #1 presented to Registration Clerk (RC) #2 and requested to be seen in the ED, RC #2 had called the Behavioral Health Unit (BHU), or EPS, and asked if the Unit saw minors (a person under the age of eighteen (18)). The response was the BHU (Behavioral Health Unit) did not see minors. It was documented that RC #2 told Patient #1 the facility did not see minors, and he/she would have to go to Facility #2 to be seen. The BHU of Facility #1 was not informed that a minor was currently requesting to be seen by a medical provider.

Review of Facility #1's report, Incident Information, date created 06/10/2022, revealed in the late evening of 06/04/2022, a minor patient presented to the ED with suicidal ideations. The Registration Clerk was unsure of how to handle the situation and contacted the Registration Supervisor. The Supervisor was uncertain about the treatment of a minor for a psychiatric complaint, and called EPS for clarification. Per the report, EPS staff told the Supervisor that the facility did not see minors, and the patient should be referred to Facility #2, which did see minor patients. The report stated the Supervisor did not inform EPS that a minor patient with a psychiatric complaint was present. The Supervisor told the Registration Clerk to instruct the patient to go to Facility #2 to be evaluated and treated, which the clerk did. The report also stated all staff involved were re-trained on EMTALA and treating minors immediately after awareness of the incident. Per the report, system-wide education would proceed and would consist of all Registration staff, EPS staff, and ED staff within the facility.

However, per the facility's policy titled, "Behavioral Health Care of Minors" (see above), the process should have been that the ED Registered Nurse (RN) would have been notified; then he/she would call and notify the EPS RN; then the EPS RN would complete the triage process; and an EPS Physician would evaluate the minor. If further treatment was needed, the EPS Physician would then arrange an appropriate transfer.

There was no documented evidence, Patient #1 had a medical record generated at Facility #1 on 06/04/2022 or 06/05/2022. The facility failed to ensure that their policies and procedures were followed as evidenced by failing to provide an appropriate medical screening examination for patient #1 on 6/04/2022 or 006/05/22, a minor who presented to the facility complaining of suicidal ideations.

Review of Patient #1's medical record from Facility #2 revealed, on 06/05/2022 at 12:15 AM, he/she walked into the ED alone, without an accompanying adult. Continued review revealed Patient #1 was living with an aunt and his/her mother and ten (10) month old son were out of the country and could not be reached by phone. Additionally, the review revealed Facility #2 had received permission from Patient #1 to discuss his/her treatment with the Aunt. Further review revealed that Patient #1 was considered an emancipated minor because he/she had a child and was working to provide for the child's needs such as clothing, food, and housing. A physical examination (PE) and a medical screening examination (MSE) were completed by a medical provider.

Review of Facility #2's Medical Provider's Progress Note for Patient #1, dated 06/05/2022, no time listed, revealed the Review of Systems (ROS) was normal, except for Psychiatric/Behavior, which was positive for Depression and Suicidal Ideation. Review of the PE did not reveal abnormalities except Patient #1 was depressed, inattentive, and affect was flat; speech was noncommunicative, and behavior was uncooperative and withdrawn; and thought content included suicidal ideation. Per the note, the Urine Toxicology Screen was negative for drugs or alcohol. Patient #1 was admitted to the Pediatric Behavior Health Unit of Facility #2.

Interview with Facility #1's Chief Executive Officer, on 06/10/2022 at 3:57 PM, revealed he recognized it was a legitimate EMTALA violation when he was notified on 06/05/2022. He stated corrective action was taken immediately.

Interview with Facility #1's Director of Compliance/Risk, on 06/11/2022 at 9:45 AM, revealed when the Director of the ED was notified by staff, on 06/05/2022 at 6:47 AM, there was a possible EMTALA violation, the Director of the ED immediately instituted EMTALA re-education of ED staff. This education was sent out to Registration, ED, and EPS staff that had worked the 7:00 PM to 7:00 AM shift, 06/04/2022 into 06/05/2022. He stated that meetings with appropriate management staff, that included department heads, were held on 06/06/2022 and 06/10/2022 to formulate an Action Plan to provide EMTALA education for all employees, Enterprise wide, the weekend of 06/11/2022 to 06/12/2022. Additional interview revealed this would be an ongoing endeavor.

Interview with Registered Nurse (RN) #1, an ED Charge Nurse, on 06/11/2022 at 11:33 AM, revealed she strongly wanted it to be known that Patient #1 had not made his/her way into the ED. RN #1 stated, if Patient #1 had been in the ED, staff knew that any individual with psychiatric concerns would first need to been assessed by an ED Physician, regardless of age. Additional interview revealed staff had received EMTALA re-education after the incident and received annual EMTALA training.

Interview with the Supervisor of ED Patient Access (Registration), on 06/13/2022 at 12:34 PM, revealed she was working the night of 06/04/2022 to fill a gap in scheduling. She stated RC #2 had asked her if the ED treated minors with psychiatric concerns, and she told RC #2 she did not know but would find out. She stated she called EPS to inquire if EPS treated minors. She stated the person that answered the phone was rude and disconnected the call after telling her that EPS did not treat minors. The Supervisor stated she told RC #2 they did not treat minors. She revealed RC #2 did not tell her Patient #1 was actually in Registration. Per the interview, she stated she did not know until the next day (06/05/2022) that minors were to be registered in the ED and examined by a medical provider. Continued interview revealed EMTALA re-education was conducted that day, via email, by the Director of the ED and included education on minors. She also stated she received additional re-training on EMTALA on 06/10/2022. She stated annual EMTALA education was presented annually.

Interview with the ED Unit Coordinator, on 06/13/2022 at 2:11 PM, revealed she was aware that EMTALA meant that everyone was seen, no matter the complaint, when they walked through the door. Additional interview revealed she had received an email with EMTALA education, PowerPoint, and policies over the weekend on 06/12/2022. She stated information was also shared in weekly huddle points that were discussed before each shift started that week. She stated annual EMTALA training was also presented via Computer Based Training (CBT) the facility's electronic education site.

Interview with ED RN #2, on 06/13/2022 at 2:17 PM, revealed that annual EMTALA training was presented via CBT. She stated EMTALA ensured that all patients that came to the ED were provided a medical screening exam by a physician.

Interview with ED RN #3, on 06/13/2022 at 2:21 PM, revealed EMTALA meant that anyone that walked through the door was assessed, no matter the reason. ED RN #3 stated annual EMTALA training, along with a PowerPoint and policies were received via email on 06/12/2022. Also, ED RN #3 stated Charge Nurses had talked about EMTALA in each shift huddle since 06/10/2022.

Interview with Emergency Room Technician (ERT) #1, on 06/13/2022 at 2:26 PM, revealed EMTALA required that no person seeking treatment could be turned away. ERT #1 stated re-education occurred, on 06/11/2022, that included education on minors. In addition, the ERT stated annual EMTALA education was given via CBT.

Interview with the EPS Charge Nurse, on 06/13/2022 at 7:39 PM, revealed she was working at the time of the incident, but was unaware, until about 2:00 AM on 06/05/2022, that there had been an actual minor in Registration; she thought there had just been a question about EPS treating minors. She stated she was aware of EMTALA components and that EMTALA re-education had been presented, via email, on 06/05/2022, that included education on minors.

Interview with RC #2, on 06/14/2022 at 7:36 AM, revealed, on 06/04/2022, unable to remember the time, Patient #1 walked in alone. She stated Patient #1 was soft-spoken, with a calm demeanor, and asked if they treated minors. RC #2 stated she did not know the answer and asked the Patient Access Supervisor, who was working at the time. RC #2 stated the Supervisor told her that she did not know but would find out. RC #2 stated the Supervisor called EPS to ask; EPS staff did not identify self, said no and hung up. She stated Patient #1 left after she gave him/her the answer. She stated she was aware of EMTALA components but was unsure about unaccompanied minors requesting psychiatric services. RC #2 stated re-education was presented via email, on 06/05/2022, after the incident, and it included education on minors.

Interview with the ED Manager, on 06/14/2022 at 9:43 AM, revealed collaboration with Patient Access was a daily, ongoing effort. She stated Patient #1 should have been seen and assessed. She further stated she was aware of EMTALA components and had annual EMTALA education. The Manager stated Charge Nurses had talked about EMTALA in each shift huddle since 06/10/2022; email education had been distributed on EMTALA; and annual EMTALA training was also presented via CBT. Further, she stated emails with EMTALA education, PowerPoint and policies were distributed over the weekend on 06/11/2022 and 06/12/2022, and she had been re-trained on EMTALA on 06/10/2022.

Interview with the Director of ED Services, on 06/14/2022 at 10:17 AM, revealed she felt there had been miscommunication between the involved departments. She stated nursing should have been called to clarify whether the ED saw minors for psychiatric services, not EPS. She stated when she was notified, early on 06/05/2022, she independently initiated education for involved staff at that time.

Interview with the Director of Patient Access, on 06/14/2022 at 11:37 AM, revealed she had been notified, on 06/05/2022, of the incident. She stated immediate education on EMTALA components were initiated, on 06/05/2022, which she received. She also stated she had been re-trained on EMTALA on 06/10/2022. She stated the failure was in turning Patient #1 away because no one should be turned away when requesting services. In addition, she stated, if staff were not satisfied with a received answer, he/she should go up the chain because resources were available across all shifts and times for clarification.

Interview with the Director of Psychiatric Services, on 06/16/2022 at 11:02 AM, revealed she felt the failure was due to the lack of curiosity of both parties to identify the context of the question, "Does EPS treat minors?" She stated Registration should have said there was a minor present requesting EPS services, and EPS should have clarified if a minor was present when asked if the facility saw minors. She stated all staff should be trained in EMTALA and that nobody was turned away to include minors. She stated curiosity would have ensured Patient #1 received needed services. Additionally, she stated she was notified of the incident by email on 06/05/2022. A meeting, on 06/06/2022, she explained, included EMTALA re-education and formulating an Action Plan for going forward. In addition, she stated she received EMTALA re-training on 06/10/2022.

Interview with the Chief Medical Officer, on 06/16/2022 at 4:09 PM, revealed it was his expectation that everyone be aware of EMTALA requirements for adults and minors and follow them.

Interview with the Medical Director of EPS, on 06/16/2022 at 4:12 PM, revealed it was her expectation that EMTALA guidelines be followed.

Interview with EPS Program Assistant #1, on 06/16/2022 at 9:19 PM, revealed she had answered the phone when the Patient Access Supervisor had called, on 06/04/2022, but was unable to remember the time. She stated her job description was clerical in nature; it included answering phones, data entry, and anything that freed up nursing staff to provide patient care. She stated she was not told there was a minor patient in registration, and she was only asked if EPS treated minors. She stated if she had known there was a minor waiting, she would have said no, but the minor needed to be registered in the ED, and an EPS staff member would come to assess the patient. Also, she was able to verbalize EMTALA components. She stated she was a contract employee and received EMTALA education from her agency, but she did not remember the date of the education. She also stated she received EMTALA education from the facility, along with other staff, and on the same timeframe. She stated she received EMTALA re-training immediately, on 06/05/2022.

Interview with Patient #1's Aunt, on 06/17/2022 at 1:58 PM, who was listed as next of kin, revealed Patient #1 did not have a cell phone and lived with her. The Aunt stated she had no idea Patient #1 was suicidal, he/she went to school, worked, and took care of his/her infant son. The Aunt stated she was contacted when Patient #1 was going to be admitted to Facility #2's Pediatric Behavioral Health Unit. Additionally, she stated she received a couple of phone calls during Patient #1's admission but was unable to remember the content of the calls. She also stated she was currently out of town and would be out of town until the next week.

The State Survey Agency (SSA) Surveyor did not interview Patient #1 because he/she lived with his/her Aunt. Per the interview with the Aunt, Patient #1 did not have a cell phone. In addition, the Aunt stated she was out of town and would not be back until the following week. Also, Patient #1's Aunt's telephone number was listed as Patient #1's number.

Interview with ED Attending Physician #1, on 06/17/2022 at 2:17 PM, revealed he was responsible for overseeing the Resident Physicians and Intern Physicians in the ED, along with working in the ED. He stated consequences of an individual not receiving needed psychiatric services could be detrimental to the health and well-being of the individual, depending on the need. He stated, if someone had suicidal ideations and was not seen, it could be instrumental in the individual succeeding in harming him/herself. He stated annual EMTALA education was presented to staff. He also stated he was re-educated after this event, along with the rest of the staff.

Based on interview, record review, review of the facility's report Incident Information, review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, review of the website Bing Maps, and review of the facility's policies, it was determined the facility failed to ensure all individuals that presented to the Emergency Department (ED) with an emergent medical condition (EMC), received stabilizing medical treatment as required, for one (1) of twenty (20) sampled patients, Patient #1.

The findings include:

Review of Facility #1's policy titled, "EMTALA: Treatment and Transfer of Individuals in Need of Emergency Medical Services", Number 840-0004, effective date 03/2006, revealed per the policy the facility must also provide stabilizing treatment within the facility's capabilities.

Review of the facility's policy titled, "EMTALA Medical Screening Exam", Number 6220-0002, revised 05/2020, revealed the purpose was to establish guidelines for providing appropriate medical screening examinations (MSE) and, if the individual was determined to have an emergency medical condition (EMC), any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA. Further review revealed an individual must receive an MSE, within the capabilities of the hospital's ED, to determine whether or not an EMC existed and whether or not the treatment requested was explicitly for an emergency condition.

Review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, dated June 08, 2022, reported by Facility #2 to the Centers for Medicare and Medicaid (CMS), via email, revealed Patient #1 had presented to Facility #1, on 06/04/2022, exact time unknown. Continued review of the report revealed Patient #1 had expressed he/she was sixteen years old (16) and had suicidal ideations, but left Facility #1. Further review revealed Patient #1 arrived at Facility #2 and was admitted to the ED, on 06/05/2022 at 12:15 AM. On 06/05/2022 at 4:11 AM, Patient #1 received a psychiatric assessment and was admitted to Facility #2's Pediatric Psychiatric Unit. Additional review of the report revealed, on 06/06/2022 at 10:47 AM, the possible EMTALA violation was referred to Facility #2's Compliance and Audit Department. An investigation was initiated at Facility #2 that included record review, interview with Patient #1, and staff interviews.

Continued review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, dated June 08, 2022, revealed, on 06/07/2022, no time listed, Facility #2 discussed the possible EMTALA violation with Facility #1's Director of Compliance, who informed Facility #2 the alleged occurrence was under review.

Continued review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, dated June 08, 2022, revealed Facility #1 reported to Facility #2, after Patient #1 presented to Registration Clerk (RC) #2 and requested to be seen in the ED, RC #2 had called the Behavioral Health Unit (BHU), or EPS, and asked if the Unit saw minors (a person under the age of eighteen (18)). The response was the BHU did not see minors. It was documented that RC #2 told Patient #1 the facility did not see minors, and he/she would have to go to Facility #2 to be seen. The BHU of Facility #1 was not informed that a minor was currently requesting to be seen by a medical provider.

Review of Facility #1's report, Incident Information, date created 06/10/2022, revealed in the late evening of 06/04/2022, a minor patient presented to the ED with suicidal ideations. The Registration Clerk was unsure of how to handle the situation and contacted the Registration Supervisor. The Supervisor was uncertain about the treatment of a minor for a psychiatric complaint, and called EPS for clarification. Per the report, EPS staff told the Supervisor that the facility did not see minors, and the patient should be referred to Facility #2, which did see minor patients. The report stated the Supervisor did not inform EPS that a minor patient with a psychiatric complaint was present. The Supervisor told the Registration Clerk to instruct the patient to go to Facility #2 to be evaluated and treated, which the clerk did. The report also stated all staff involved were re-trained on EMTALA and treating minors immediately after awareness of the incident. Per the report, system-wide education would proceed and would consist of all Registration staff, EPS staff, and ED staff within the facility.

Review of the website Bing Maps, https://www.bing.com/maps/directions, revealed Facility #2 was three-tenths (0.3) of a mile and and approximately a six (6) minute walk from Facility #1. On 06/13/2022, the State Survey Agency (SSA) Surveyor, accompanied by Facility #1's Director of Compliance, left Facility #1, at approximately 10:47 AM, and arrived at Facility #2 at approximately 10:54 AM, an approximate seven (7) minute walk.

There was no documented evidence, Patient #1 had a medical record generated at Facility #1 on 06/04/2022 or 06/05/2022.

Review of Patient #1's Medical Record from Facility #2 revealed, on 06/05/2022 at 12:15 AM, he/she walked into the ED alone, without an accompanying adult. Continued review revealed Patient #1 was living with an Aunt. The record stated Patient #1's mother and ten (10) month old son were in Africa and could not be reached by phone. Per the record, a physical exam (PE) and a medical screening examination (MSE) were completed by a medical provider.

Review of Facility #2's Medical Provider's Progress note, dated 06/05/2022, revealed the Review of Systems (ROS) was normal, except for Psychiatric/Behavior, which was positive for Depression and Suicidal Ideation. Review of the PE did not reveal abnormalities except Patient #1 was depressed; inattentive, and affect was flat; speech was noncommunicative; behavior was uncooperative and withdrawn; and thought content included suicidal ideation. The Urine Toxicology Screen was negative for drugs or alcohol. Patient #1 was admitted to the Pediatric Behavior Health Unit of Facility #2.

Interview with Facility #1's Director of Compliance/Risk, on 06/11/2022 at 9:45 AM, revealed Patient #1 should have been examined and assessed in the ED and any needed treatment provided which would have included a transfer, if appropriate. He stated when the Director of the ED was notified by staff, on 06/05/2022 at 6:47 AM, there was a possible EMTALA violation, the Director of the ED immediately instituted EMTALA re-education of ED staff. This education was sent out to Registration, ED, and EPS staff that had worked the 7:00 PM to 7:00 AM shift, 06/04/2022 into 06/05/2022. He stated that meetings with appropriate management staff, that included department heads, were held on 06/06/2022 and 06/10/2022 to formulate an Action Plan to provide EMTALA education for all employees, Enterprise wide, the weekend of 06/11/2022 to 06/12/2022.

Interview with Registered Nurse (RN) #1, an ED Charge Nurse for Facility #1, on 06/11/2022 at 11:33 AM, revealed she strongly wanted it to be known that Patient #1 had not made his/her way into the ED. RN #1 stated, if Patient #1 had been admitted to the ED, staff knew that any individual with psychiatric concerns would first need to be assessed and treated by an ED Physician, regardless of age. Additional interview revealed staff had received EMTALA re-education after the incident and received annual EMTALA training.

Interview with the Supervisor of ED Patient Access (Registration) for Facility #1, on 06/13/2022 at 12:34 PM, revealed she was working the night of 06/04/2022 to fill a gap in scheduling. She stated RC #2 had asked her if the ED treated minors with psychiatric concerns, and she told RC #2 she did not know but would find out. She stated she called EPS to inquire if EPS treated minors. She stated the person that answered the phone was rude and disconnected the call after telling her that EPS did not treat minors. The Supervisor stated she told RC #2 they did not treat minors. She revealed RC #2 did not tell her Patient #1 was actually in Registration. Per the interview, she stated she did not know until the next day (06/05/2022) that minors were to be registered in the ED and examined by a medical provider. Continued interview revealed EMTALA re-education was conducted that day, via email, by the Director of the ED and included education on minors. She also stated received additional EMTALA re-training on 06/10/2022. She stated EMTALA education was presented annually.

Interview with Facility #1's ED Unit Coordinator, on 06/13/2022 at 2:11 PM, revealed she was aware that EMTALA meant that everyone was seen and treated, no matter the complaint when they walked through the door. Additional interview revealed she had received an email with EMTALA education, PowerPoint, and policies over the weekend on 06/12/2022. She stated information was also shared in weekly huddle points that were discussed before each shift started that week. She stated annual EMTALA training was also presented via CBT, the facility's electronic education site.

Interview with Facility #1's ED RN #2, on 06/13/2022 at 2:17 PM, revealed that annual EMTALA training was presented via CBT, the facility's electronic education system. She stated EMTALA regulations ensured all patients that came to the ED were provided an exam and treatment by a Physician.

Interview with Facility #1's ED RN #3, on 06/13/2022 at 2:21 PM, revealed that EMTALA meant that anyone that walked through the door was treated and assessed, no matter the reason. ED RN #3 stated annual EMTALA training, along with a PowerPoint and policies were received via email on 06/12/2022. Also, ED RN #3 stated Charge Nurses have talked about EMTALA in each shift huddle since 06/10/2022.

Interview with Facility #1's Emergency Room Technician (ERT) #1, on 06/13/2022 at 2:26 PM, revealed EMTALA components required that no one could be turned away. ERT #1 stated re-education occurred, on 06/11/2022, that included education on minors. In addition, the ERT stated annual EMTALA education was given via CBT.

Interview with Facility #1's Registration Clerk (RC) #2, on 06/14/2022 at 7:36 AM, revealed, she was working on 06/04/2022, when Patient #1 walked in alone (exact time unknown). She stated Patient #1 asked if the facility treated minors (individuals less than eighteen (18) years of age). RC #2 stated she did not know the answer and asked the Patient Access Supervisor (working that night to fill a scheduling gap). RC #2 stated the Supervisor told RC #2 that she did not know but would find out. RC #2 stated the Supervisor called EPS to ask. RC #2 stated, during the call, EPS staff did not identify self, said no, and hung up. She stated Patient #1 left after she gave him/her the answer. RC #2 stated she was aware of EMTALA components but was unsure about unaccompanied minors requesting psychiatric services. RC #2 stated re-education was presented via email, on 06/05/2022, after the incident, and it included education on minors.

Interview with Facility #1's ED Manager, on 06/14/2022 at 9:43 AM, revealed she was aware of EMTALA components that required any individual that came to the ED needed to be assessed and treated. She further stated she was aware of EMTALA components and had annual EMTALA education. The Manager stated Charge Nurses had talked about EMTALA in each shift huddle since 06/10/2022; email education had been distributed on EMTALA; and annual EMTALA training was also presented via CBT. Further, she stated emails with EMTALA education, PowerPoint and policies were distributed over the weekend on 06/11/2022 and 06/12/2022, and she had been re-trained on EMTALA on 06/10/2022.

Interview with Facility #1's Director of ED Services, on 06/14/2022 at 10:17 AM, revealed annual EMTALA education was provided that included all individuals presenting to the ED needed to be assessed and treated. She stated she felt there had been miscommunication between the involved departments. She stated nursing should have been called to clarify whether the ED saw minors for psychiatric services, not EPS. She stated when she was notified, early on 06/05/2022, she independently initiated education for involved staff at that time.

Interview with Facility #1's Medical Director of EPS, on 06/16/2022 at 4:12 PM, revealed it was her expectation that EMTALA guidelines be followed.

Interview with Facility #1's EPS Program Assistant #1, on 06/16/2022 at 9:19 PM, revealed she had answered the phone when the Patient Access Supervisor had called, on 06/04/2022, but was unable to remember the time. Additional interview revealed she was not told there was a minor patient in Registration; she was only asked if EPS treated minors. She stated, if she had known there was a minor waiting, she would have still said no. However, she stated she would also have added that the minor needed to be registered in the ED, and an EPS staff member would come to assess and treat the minor. In addition, she was able to verbalize EMTALA components.
She stated she was a contract employee and received EMTALA education from her agency, but she did not remember the date of the education. She also stated she received EMTALA education from the facility, along with other staff, and on the same timeframe. She stated she received EMTALA re-training immediately, on 06/05/2022.

Interview with Patient #1's Aunt, on 06/17/2022 at 1:58 PM, who was listed as next of kin, revealed Patient #1 did not have a cell phone and lived with her. The Aunt stated she had no idea Patient #1 was suicidal, he/she went to school, worked, and took care of his/her infant son. The Aunt stated she was contacted when Patient #1 was going to be admitted to Facility #2's Pediatric Behavioral Health Unit. Additionally, she stated she received a couple of phone calls during Patient #1's admission but was unable to remember the content of the calls. She also stated she was currently out of town and would be out of town until the next week.

The State Survey Agency (SSA) Surveyor did not interview Patient #1 because he/she lived with his/her Aunt. Per the interview with the Aunt, Patient #1 did not have a cell phone. In addition, the Aunt stated she was out of town and would not be back until the following week. Also, Patient #1's Aunt's telephone number was listed as Patient #1's number.

Interview with Facility #1's ED Medical Director/Attending Physician #1, on 06/17/2022 at 2:17 PM, revealed his expectation was that EMTALA guidelines should have been followed when Patient #1 arrived. Additionally, he stated the guidelines would have included the facility examining Patient #1 and treating him/her, as needed. He stated annual EMTALA education was presented to staff. He also stated he was re-educated after this event, along with the rest of the staff.

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to provide Patient #1 stabilizing treatment as required when she presented to the Emergency department with a chief complaint of suicidal ideations.

Based on interview, record review, review of the facility's report Incident Information, review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, review of the Bing Maps website, and review of the facility's policies, it was determined the facility failed to ensure all individuals that presented to the Emergency Department (ED) with an emergent condition were stabilized, and if the facility could not provide needed treatment, the patient was given an appropriate transfer to another facility who could provide needed treatment, for one (1) of twenty (20) sampled patients, Patient #1.

The findings include:

Review of Facility #1's policy titled, "EMTALA: Treatment and Transfer of Individuals in Need of Emergency Medical Services", Number 840-0004, effective date 03/2006, revealed the ED must provide any individual with a medical screening examination (MSE) to determine if a medical emergency did exist. The facility must also provide stabilizing treatment within the facility's capabilities and provide an appropriate transfer to another facility if indicated.

Review of the facility's policy titled "EMTALA Medical Screening Exam", Number 6220-0002, revised 05/2020, revealed the purpose was to establish guidelines for providing appropriate medical screening examinations (MSE) and, if the individual was determined to have an emergency medical condition (EMC), any necessary stabilizing treatment or an appropriate transfer for the individual as required by the Emergency Medical Treatment and Active Labor Act (EMTALA).

Review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, dated June 08, 2022, reported by Facility #2 to the Centers for Medicare and Medicaid (CMS), via email, revealed Patient #1 had presented to Facility #1, on 06/04/2022, exact time unknown. Continued review of the report revealed Patient #1 had expressed he/she was sixteen years old (16) and had suicidal ideations, but left Facility #1. Further review revealed Patient #1 arrived at Facility #2 and was admitted to the ED, on 06/05/2022 at 12:15 AM. On 06/05/2022 at 4:11 AM, Patient #1 received a psychiatric assessment and was admitted to Facility #2's Pediatric Psychiatric Unit. Additional review of the report revealed, on 06/06/2022 at 10:47 AM, the possible EMTALA violation was referred to Facility #2's Compliance and Audit Department. An investigation was initiated at Facility #2 that included record review, interview with Patient #1, and staff interviews.

Continued review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, dated June 08, 2022, revealed, on 06/07/2022, no time listed, Facility #2 discussed the possible EMTALA violation with Facility #1's Director of Compliance, who informed Facility #2 the alleged occurrence was under review.

Continued review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, dated June 08, 2022, revealed Facility #1 reported to Facility #2, after Patient #1 presented to Registration Clerk (RC) #2 and requested to be seen in the ED, RC #2 had called the Behavioral Health Unit (BHU), or EPS, and asked if the Unit saw minors (a person under the age of eighteen (18)). The response was the BHU did not see minors. It was documented that RC #2 told Patient #1 the facility did not see minors, and he/she would have to go to Facility #2 to be seen. The BHU of Facility #1 was not informed that a minor was currently requesting to be seen by a medical provider.

Review of Facility #1's report, Incident Information, date created 06/10/2022, revealed in the late evening of 06/04/2022, a minor patient presented to the ED with suicidal ideations. The Registration Clerk was unsure of how to handle the situation and contacted the Registration Supervisor. The Supervisor was uncertain about the treatment of a minor for a psychiatric complaint, and called EPS for clarification. Per the report, EPS staff told the Supervisor that the facility did not see minors, and the patient should be referred to Facility #2, which did see minor patients. The report stated the Supervisor did not inform EPS that a minor patient with a psychiatric complaint was present. The Supervisor told the Registration Clerk to instruct the patient to go to Facility #2 to be evaluated and treated, which the clerk did. The report also stated all staff involved were re-trained on EMTALA and treating minors immediately after awareness of the incident. Per the report, system-wide education would proceed and would consist of all Registration staff, EPS staff, and ED staff within the facility.

Review of the website Bing Maps, https://www.bing.com/maps/directions, revealed Facility #2 was three-tenths (0.3) of a mile and and approximately a six (6) minute walk from Facility #1. On 06/13/2022, the State Survey Agency (SSA) Surveyor, accompanied by Facility #1's Director of Compliance, left Facility #1, at approximately 10:47 AM, and arrived at Facility #2 at approximately 10:54 AM, an approximate seven (7) minute walk.

There was no documented evidence, Patient #1 had a medical record generated at Facility #1 on 06/04/2022 or 06/05/2022.

Review of Patient #1's medical record from Facility #2 revealed, on 06/05/2022 at 12:15 AM, he/she walked into the ED alone, without an accompanying adult. Continued review revealed Patient #1 was working and living with an aunt, his/her mother, and a ten (10) month old son. Patient #1's mother and his/her son were in Africa, visiting his/her grandmother and could not be reached by phone. A physical examination (PE) and a medical screening examination (MSE) were completed by a medical provider.

Review of Facility #2's Medical Provider Progress Note, dated 06/05/2022, revealed the Review of Systems (ROS) was normal, except for Psychiatric/Behavior, which was positive for Depression and Suicidal Ideation. Review of the PE did not reveal abnormalities except Patient #1 was depressed, inattentive, and affect was flat; speech was noncommunicative and behavior was uncooperative and withdrawn; and thought content included suicidal ideation. Per the note, the Urine Toxicology Screen was negative for drugs or alcohol. Patient #1 was admitted to the Pediatric Behavior Health Unit of Facility #2.

Interview with Facility #1's Director of Compliance/Risk, on 06/11/2022 at 9:45 AM, revealed Patient #1 should have been examined and assessed in the ED and any needed treatment provided which would have included a transfer, if appropriate. He stated when the Director of the ED was notified by staff, on 06/05/2022 at 6:47 AM, there was a possible EMTALA violation, the Director of the ED immediately instituted EMTALA re-education of ED staff. This education was sent out to Registration, ED, and EPS staff that had worked the 7:00 PM to 7:00 AM shift, 06/04/2022 into 06/05/2022. He stated that meetings with appropriate management staff, that included department heads, were held on 06/06/2022 and 06/10/2022 to formulate an Action Plan to provide EMTALA education for all employees, Enterprise wide, the weekend of 06/11/2022 to 06/12/2022.

Interview with Registered Nurse (RN) #1, an ED Charge Nurse for Facility #1, on 06/11/2022 at 11:33 AM, revealed she was aware that if Patient #1 had been assessed and a transfer was deemed necessary, the facility would have been required to provide that transfer. Additional interview revealed staff had received EMTALA re-education after the incident and received annual EMTALA training.

Interview with Facility #1's ED Unit Coordinator, on 06/13/2022 at 2:11 PM, revealed she was aware that EMTALA meant that everyone was seen, treated, and provided an appropriate transfer as needed, no matter the complaint when they walked through the door. Additional interview revealed she had received an email with EMTALA education, PowerPoint, and policies over the weekend on 06/12/2022. She stated information was also shared in weekly huddle points that were discussed before each shift started that week. She stated annual EMTALA training was also presented via CBT, the facility's electronic education site.

Interview with Facility #1's ED RN #2, on 06/13/2022 at 2:17 PM, revealed that annual EMTALA training was presented via CBT, the facility's electronic education system. She continued by stating that EMTALA ensured that all patients that came to the ED were provided an examination and treatment by a physician, and if a transfer was needed, it was ordered.

Interview with Facility #1's ED RN #3, on 06/13/2022 at 2:21 PM, revealed that EMTALA meant that anyone that walked through the door was treated and assessed, no matter the reason. ED RN #3 stated the facility had to provide a transfer with appropriate transport if ordered. ED RN #3 stated annual EMTALA training, along with a PowerPoint and policies were received via email on 06/12/2022. Also, ED RN #3 stated Charge Nurses had talked about EMTALA in each shift huddle since 06/10/2022.

Interview with Facility #1's ED Manager, on 06/14/2022 at 9:43 AM, revealed she was aware of EMTALA components that included an appropriate transfer if needed. She further stated she annual EMTALA education. The Manager stated Charge Nurses had talked about EMTALA in each shift huddle since 06/10/2022; email education had been distributed on EMTALA; and annual EMTALA training was also presented via CBT. Further, she stated emails with EMTALA education, PowerPoint and policies were distributed over the weekend on 06/11/2022 and 06/12/2022, and she had been re-trained on EMTALA on 06/10/2022.

Interview with Facility #1's Director of ED Services, on 06/14/2022 at 10:17 AM, revealed annual EMTALA education was provided that included all individuals presenting to the ED needed to be assessed, treated, and transferred if needed. She stated it would not be appropriate for an individual to take themselves to the receiving facility. She stated when she was notified of the incident with Patient #1, early on 06/05/2022, she independently initiated EMTALA education for involved staff at that time.

Interview with Facility #1's Medical Director of EPS, on 06/16/2022 at 4:12 PM, revealed it was her expectation that EMTALA guidelines be followed.

Interview with Patient #1's Aunt, on 06/17/2022 at 1:58 PM, who was listed as next of kin, revealed Patient #1 did not have a cell phone and lived with her. The Aunt stated she had no idea Patient #1 was suicidal, he/she went to school, worked, and took care of his/her infant son. The Aunt stated she was contacted when Patient #1 was going to be admitted to Facility #2's Pediatric Behavioral Health Unit. Additionally, she stated she received a couple of phone calls during Patient #1's admission but was unable to remember the content of the calls. She also stated she was currently out of town and would be out of town until the next week.

The State Survey Agency (SSA) Surveyor did not interview Patient #1 because he/she lived with his/her Aunt. Per the interview with the Aunt, Patient #1 did not have a cell phone. In addition, the Aunt stated she was out of town and would not be back until the following week. Also, Patient #1's Aunt's telephone number was listed as Patient #1's number.

Interview with Facility #1's ED Medical Director/Attending Physician #1, on 06/17/2022 at 2:17 PM, revealed his expectation was that EMTALA guidelines should have been followed when Patient #1 arrived. He further stated that if Patient #1 had been examined, treated, and a transfer was ordered, the facility should have provided the transport. He stated annual EMTALA education was presented to staff. He also stated he was re-educated after this event, along with the rest of the staff.