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Based upon record review and interview, the facility failed to ensure a medical screening examination was conducted on 1 (patient #1) of 30 patients reviewed.

Review of the Behavioral Health policy #3.3.7, titled "Admission Process - Pre-Admission Screening of Psychiatric Patients" revealed the following: "B. Prior to admission to any of the Behavioral Health inpatient treatment programs, all patients will undergo an examination by a physician. The examination may be completed by an Emergency Department physician or a psychiatrist and shall include both a review of systems, physical examination, and a mental status examination."

Review of the Administrative policy #1.3.0006 titled "Medical Screening, Consultation, Treatment, and Transfer Policy, Section 1. Screening, Stabilization, and Transfer, A. Medical Screening Examination" revealed the following: "2. In the Emergency Department, the medical screening examination shall be performed by the Emergency Department physician, qualified medical personnel or specialists requested by the Emergency Department physician, or upon the request of the patient or the patient's representative, the individual's private physician. Qualified medical personnel include the personnel trained to perform a medical screening examination pursuant to Hospital policy and the Medical Staff Rules and Regulations. 4. The Emergency Department physician on duty shall be responsible for ensuring that a medical screening examination is performed on all individuals coming to the Emergency Department requesting an examination or treatment." Review of an attachment to this policy titled "Exhibit A-Qualified Medical Personnel" revealed "Qualified Medical Personnel who are authorized to initiate medical screening examinations, Emergency Department - 1. Physician Assistant, 2. Advanced Nurse Practitioner, Behavioral Health - 1. Advanced Nurse Practitioner".

Review of medical record of patient #1 revealed patient was a 43 year old female who arrived in the Behavioral Health emergency department on 02/07/13 at 5:52 am with the complaint of "Not making very good decisions and doesn't want to be here anymore." Nurses' notes revealed patient reported "feeling suicidal for a couple of months and came in because she feels like she's going crazy". Patient also reported she had "history of 2 suicide attempts as a teenager". Further review of the emergency department record revealed patient had triage assessment done at 6:13 am and equity was determined to be urgent - (3). Record revealed patient signed a voluntary request for psychiatric treatment and admission labs were drawn. The emergency department record revealed a section titled "(sic) MEDICAL SCREEN" that was done at 6:32 am by a Registered Nurse (RN). The Medical Screen consisted of a review of chief complaint and mental status. A Risk Assessment Tool was completed on 02/07/13 at 6:55 am. The score on the Risk Assessment Tool was scored with patient at Level 1. The description on the assessment tool for Level 1 was as follows: "Patient may be in need of inpatient care. This patient is most likely able to be admitted to an Adult Psychiatric Program with a minimal documented every hour monitoring for unpredictable behavior." The Risk Assessment Tool was completed on 02/07/13, however it was signed by Physician #14 on 02/11/13.

Further review of the emergency department record revealed nurses noted at 8:17 am - "Called (sic) Physician #14, received order to refer out, ... Patient signed a no harm, non-admit contract." Review of the "Non-Admission Referral List No Harm Contract" revealed 3 statements for the patient to acknowledge: 1. "I promise not to harm myself/others after leaving this facility. If I start to feel that I want to harm myself/others, I will seek help by one of the following actions:" (form contained a list of 4 emergency resources in the community). 2. "By initialing here you are acknowledging that you have been offered a medical evaluation at (sic)." 3. "By initialing here you are refusing a medical evaluation at (sic) emergency department. The patient had signed the form but did not acknowledge any of the 3 statements on the form. Further review revealed the patient was discharged from the emergency department at 8:19 am. by the psychiatrist on call (#14) who never saw the patient. The patient was not seen by any physician for a medical screening exam.

An interview was conducted with Staff #2, an RN in admissions, on 2/27/2013 at 9:30 am. Staff #2 provided a copy of a form titled "(sic) ED Medical Clearance Protocol". The form included standing physician admission orders that included the following:

Yes or No check box for History and Physical
#1. Hospitalize per Medical Staff Approved Protocol
#2. Emergency Room Physician _______________
#3. Labs: Check boxes to select CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), Blood Alcohol, Pregnancy Test, TSH (Thyroid Stimulating Hormone), UDS (Urine Drug Screen), Urinalysis
#4. Notify Emergency Room Physician of results

Staff #2 reported a patient is triaged and labs are drawn from orders on this form. Then the patient is assigned a bed in the hospital admission database and the Emergency Room Physician receives the patient assignment. Staff #2 reported the Emergency Room Physician then calls and does a medical clearance via telemedicine based upon the triage information and patient interview. When the Emergency Room Physician has completed the medical screening, the psychiatrist is called to see if they want to admit the patient. The staff in the Behavioral Health Emergency Department then calls the Emergency Room Physician and tells them the disposition of the patient so the Emergency Department Physician can complete the Emergency Department Record. Staff #2 also reported the Psychiatrist never does the medical screening exam.

An interview was conducted on 2/27/13 at 9:00 am. with staff #1, Director of Admissions at the Behavioral Health Unit. Staff #1 was allowed time to review the Emergency Department record for patient #1. Staff #1 confirmed that patient #1 did not receive a medical screening exam prior to being referred for outpatient services.