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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag 2406: (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital's obligation under this section ends, as specified in paragraph (d)(2) of this section. Based on document reviews and interviews, the facility failed to ensure a thorough medical screening exam was completed to rule out an emergency medical condition in one of one medical records reviewed of a patient who was treated at a separately certified facility approximately 12 hours after being released from the facility's emergency department (ED) for similar symptoms.

Based on document reviews and interviews, the facility failed to ensure a thorough medical screening exam was completed to rule out an emergency medical condition in one of one medical records reviewed of a patient who was treated at a separately certified facility approximately 12 hours after being released from the facility's emergency department (ED) for similar symptoms. (Patient #3)

Findings include:

Facility policy:

The Assessment and Diagnosis policy read, the Psychiatric Emergency Department (PED) assessment will consist of a Medical Screening Exam (MSE) completed by a Qualified Medical Professional. The MSE will include the patient's chief complaints, assessment of danger to self, danger to others, grave disability, and assessment of emergency medical needs including any withdrawal management required by the patient.

Reference:

According to the American Psychiatric Association Practice Guidelines for Psychiatric Evaluation of Adults (2015), retrieved from https://psychiatryonline.org
/doi/pdf/10.1176/appi.books.9780890426760, the American Psychiatric Association (APA) recommends the initial psychiatric evaluation of a patient include review of the five aspects of the patient's psychiatric treatment history. The first is the past and current psychiatric diagnoses. The second is the past psychiatric treatments, which include the type, duration, and where applicable, doses of medication. The third is adherence to past and current pharmacological and nonpharmacological psychiatric treatments. The fourth is the response to psychiatric treatments. The fifth is the history of psychiatric hospitalization and emergency department visits for psychiatric issues.

1. The facility failed to ensure a patient received a thorough medical screening exam to diagnose an emergent medical condition.

a. Medical record review revealed Patient #3 was brought to the facility on 5/14/23 at 12:18 a.m. by his mother for a possible schizo-affective episode (an episode of psychosis and mood symptoms) after he was found walking in the desert naked. Patient #3 was documented to say he walked through the desert for what he believed in a test to "show him who he was." Record review also revealed Patient #3 had strained his abdominal muscles when he swam across the river earlier that night, and he had texted his father the previous morning acting unusual. Record review further revealed Patient #3 had stopped his medications for mental health issues and was documented to say he had never felt better in his life. There was no evidence showing the mental health issues Patient #3 received treatment for, which medications Patient #3 stopped taking, and how long he had been off of the medications.

Medical record review also revealed Patient #3 was a low suicide risk on the Columbia-Suicide Severity Rating Scale (C-SSRS). Patient #3's Brief Mental Status Exam revealed Patient #3 was alert and oriented, calm, cooperative, and denied anxiety, depression, suicidal ideations, homicidal ideations, and auditory verbal hallucinations. Record review also revealed Patient #3's urine drug screen was positive for marijuana.

Additionally, medical record review revealed, on 5/14/23 at 12:53 a.m., registered nurse (RN) #1 presented Patient #3's information to the on-call provider, Advanced Psychiatric Nurse Practitioner (NP) #2. NP #2 requested collateral information to be obtained.

The PED Nursing Intake Assessment from 5/14/23 revealed RN #1 called Patient #3's fiancée, who was documented to say Patient #3 was highly religious and had told her he went to the desert for some alone time. Patient #3's fiancée was also documented to say she had not noticed anything unusual with Patient #3, but he was sad about a conversation he had with his father. Assessment also revealed RN #1 called Patient #3's mother, who reported Patient #3 had texted her husband at approximately 2:00 a.m. the previous morning and had acted unusually. There was no evidence in the medical record that Patient #3's father had been contacted for collateral information and no evidence of questions to the mother about symptoms that had occurred with Patient #3's previous schizo-affective episode.

The PED Nursing Intake Assessment further revealed, on 5/14/23 at 1:17 a.m., a phone conversation occurred between RN #1 and NP #2. Documentation by RN #1 revealed NP #2 had determined Patient #3 was safe to safety plan and discharge at that time.

Review of the PED Provider Discharge Summary, rationale at the time of discharge, revealed Patient #3 denied suicidal or homicidal ideations, intent, plan, or behavior. During his time in the PED, Patient #3 had good behavior control, was future oriented, problem solved, and was treatment seeking which suggested no imminent threat to self or others and was thus appropriate for discharge to a lower level of care.

Medical record review revealed, on 5/14/23 at 2:00 a.m., Patient #3 was discharged home with a safety plan and was instructed to follow up with an outpatient provider and his primary care physician. Documented rationale showing how the patient was determined safe for discharge after being found walking naked in the desert at night and attempting to cross a river was not present in the patient's medical record.

Furthermore, Patient #3's medical record revealed a memo to his medical record documented by RN #1 on 5/14/23 (no time indicated), which read the facility was contacted by a separately certified facility for placement for Patient #3. RN #1 documented Patient #3 was appropriate for inpatient placement, but was refused by the facility due to bed capacity.

b. A medical record review for Patient #3 from a separately certified facility was conducted and revealed law enforcement brought Patient #3 to their ED approximately twelve hours after leaving the facility, on 5/14/23 at 2:10 p.m., after being found walking in the desert naked and without food or water. According to the Behavioral Health Assessment, Patient #3 was released home from a prior facility at 2:00 a.m. that morning into the care of his fiancée. Documentation from the Assessment revealed that according to the fiancée, Patient #3 told her he would not leave home while she was at work; however, when she checked on the patient during a break, the patient was gone. Patient #3's fiancée further reported she was looking for Patient #3 for five hours until the patient's mother was notified that Patient #3 was picked up by law enforcement.

The Assessment continued by documenting Patient #3 was dehydrated and sunburnt upon arrival to the ED. According to the Assessment, Patient #3 was unable to explain why he was not wearing any clothes and seemed to have no awareness of the dangerousness of his situation.

Under the Diagnostic Impression section of the Assessment, the provider documented the patient presented with symptoms of mania consistent with schizoaffective disorder bipolar type (a mental illness that affects thoughts, mood, and/or behavior).

Patient #3's disposition from the separately certified facility documented the patient was placed on an M1 hold (an involuntary hold placed on a patient deemed to be in imminent danger of harming himself or herself or who is deemed gravely disabled) for grave disability. Patient #3 was documented as being unaware of the dangerousness of his behavior and at risk for serious bodily injury. Patient #3 stated he felt that his brain functioned better on medication. After receiving two liters of intravenous fluid, the patient was transferred to a third location for inpatient treatment.

c. An interview was conducted with NP #2 on 5/24/23 at 2:28 p.m. NP #2 stated she was the provider who determined Patient #3 was appropriate for discharge with a safety plan. NP #2 stated she received a call from RN #1 on 5/14/23 at 1:17 a.m., where RN #1 provided NP #2 with information gathered during Patient #3's intake evaluation. NP #2 stated she decided Patient #3 was safe for discharged with a safety plan based on information gathered and provided by RN #1.

NP #2 stated she was not provided the information Patient #3 was found naked in the desert at night after an attempted river crossing. NP #2 stated she would have determined Patient #3 met criteria for inpatient psychiatric hospitalization and would not have been safe to discharge if she had been provided information about Patient #3 being naked in the desert and having made an attempt to cross a river at night. NP #2 stated she did not inquire into past psychiatric treatments or adherence to past and current pharmacological and nonpharmacological treatments for Patient #3.

This was in contrast to The APA Practice Guidelines for Psychiatric Evaluation of Adults which read, the initial psychiatric evaluation of a patient included the patient's adherence to past and current pharmacological and nonpharmacological psychiatric treatments and the response to psychiatric treatments. In addition, the initial psychiatric evaluation should have included the history of psychiatric hospitalization and emergency department visits for psychiatric issues.

d. An interview was conducted with medical director (Director) #1 on 5/24/23 at 3:31 p.m. Director #1 stated the American Psychiatric Association was the gold standard for practice guidelines used at the facility. Director #1 stated providing a rationale for discharge was standard practice at the facility. Director #1 based on his review of Patient #3's medical record, he was unable to determine how the patient was determined to be safe for discharge.