HospitalInspections.org

Based on document review, record review, policy review and interview the Hospital failed to ensure the emergency medical treatment and labor act (EMTALA) requirements were met by failing to provide an appropriate medical screening exam (MSE) to determine if an emergency medical condition (EMC) exists for patients who present to the emergency department (ED) seeking medical care. Failure to provide an appropriate MSE places patients at risk for unidentified emergency medical conditions resulting harm and injury up to and including death.

Findings Include:

1. The hospital failed to perform an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) exists for 1 of 20 patients (Patient 1) who presented to the emergency department (ED) seeking medical care. (Refer to tag A2406)

Based on record review, policy review, document review and interview the Hospital failed to perform an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 1 of 20 patients (Patient 1) who presented to the emergency department (ED) seeking medical care. The hospital's failure to perform an appropriate MSE has the potential for patients to be discharged with an unidentified EMC which may lead to deterioration of the person's condition resulting harm and injury up to and including death.


Findings Include:


Review of a document titled, Criteria for Emergency Medicine-Core" Board Approved 08/18/16 showed, "CLINICAL DESCRIPTION A qualified Emergency Physician is defined as one who: is competent and capable to provide health care services to all patients who present themselves to the Emergency Department; evaluates the patient's health care needs and provides such services as are indicated in the Emergency Department setting; performs such definitive treatment as falls within the physician's competence and/or refers the patient to other appropriate physicians for definitive care when indicated; is qualified to care for life-threatening situations with the facilities and staff available in the Emergency Department until such time as another attending physician assumes responsibility for the patient's care or the patient is admitted and further care is then immediately transferred to the admitting physician ..."

Review of a document titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)" revised on 04/17/23 showed, "The purpose of this policy is to assure the appropriate provision of medical screening, stabilizing treatment and, when applicable, safe transfer of a patient to another acute care facility for the purpose of continued care of the patient ...

Standards for Medical Screening Examinations

1. Patients who come to a Dedicated Emergency Department requesting examination and treatment will be Triaged and receive a Medical Screening Examination by a QMP [Qualified Medical Professional].
2. The Medical Screening Examination extends until the point that the QMP determines that an Emergency Medical Condition does or does not exist. A patient should continue to be monitored based on the patient's needs, and monitoring should continue until the individual is Stabilized or admitted or appropriately transferred.
3. When an individual presents with psychiatric symptoms, the Medical Screening Exam should include an assessment of suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates danger to self or others. When the Hospital determines that an individual poses a danger to self or others, this is considered an Emergency Medical Condition [EMC].
4. If the Medical Screening Examination [MSE] does not reveal the existence of an Emergency Medical Condition, the patient may, if appropriate, be referred for further non-emergency treatment through the Hospital's facilities or a private physician and/or may be discharged with appropriate follow-up instructions documented according to department procedures ..."

"Medical screening examination" is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. Depending on the patient's presenting symptoms, the medical screening examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that involves ancillary studies and/or diagnostic tests and procedures. A medical screening examination is not an isolated event, but an ongoing process. The medical record shall include continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be documentation in the medical record of an evaluation prior to discharge or transfer."

"Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:

Placing the health of the individual (or, with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy;

Serious impairment to any bodily functions;
Serious dysfunction of any bodily organ or part ...
Some intoxicated individuals may meet the definition of "emergency medical condition" because the absence of medical treatment may place their health in serious jeopardy, result in serious impairment of bodily functions, or serious dysfunction of a bodily organ.

Likewise, an individual expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or to others, would be considered to have an emergency medical condition ..."

Review of a policy titled, "Suicide Prevention" Revised 10/28/2022 showed, "A. This policy is used to plan for care and management of a suicidal patient. Patients may be identified to be at risk of suicide either through patient-initiated statements/behaviors or through caregiver interactions. The intent of identifying a patient with suicide risk is to discern the imminent need for environmental safety measures to reduce potential attempts and to activate level of care necessary to mitigate the overall risk and offer resources available in the community at large ..."

Review of a document titled, "Suicide Prevention Work Instruction" Dated 11/01/22 showed, "Step 1. RN [Registered Nurse] to Screen for Suicide Risk using CSSRS [Columbia-Suicide Severity Rating Scale] Screen at point of patient entry in ED Triage/Admission History. Step 2. For Moderate (q15m) [every 15 minutes] or High Risk (constant observation): Place patients on appropriate observation levels while waiting for CSSRS Risk Assessment to be completed Step 3: For Moderate or High Risk: Notify house supervisor, contact security for patient search and complete Environmental Sweeper Tool. Step 4: For Moderate or High Risk: Physician/SW [Social Worker] /trained RN to complete C-SSRS Risk Assessment ...Step 5: Collaborate with the patient's clinical team using the C-SSRS Risk Assessment recommendation by placing the patient at the appropriate observation level (Low Risk: standard observation, Moderate Risk: q15m Observation & Telesitter permitted, High Risk: Constant 1:1 Observation Required) ... Definitions C-SSRS Screen: an evidence-based tool used to identify individuals who may be at risk for suicide. C-SSRS Risk Assessment: an evidence-based tool used to identify the person's suicide ideation, plan, intent for suicide or self-harm behaviors, protective factors and risk factors ..."


Review of a policy titled, "Patient Assessments and Reassessments" Revised 08/17/23 showed, "The frequency of patient assessment and reassessment will be completed as necessary based upon: A. The physician's order, B. Changes in the patient's condition.

1. The patient's diagnosis
2. Desire for care
3. Response to previous treatment
4. Discharge planning needs
5. Specialty/population standards of care (i.e., stroke, burn, trauma).
6. Observation Status ...

All records shall document reassessments and findings by clinical and other staff involved in the care of patients. Reassessments are entered as progress notes into the clinical record by each discipline providing care to the patient, at the time of the reassessment and at frequencies established within discipline specific standard(s) of practice ...Medical Staff Responsibilities:...B. Each patient will have initial assessment by a medical staff member who assesses the physical, psychological, and social status of the patient and identifies appropriate care and/or the need for future assessment ...Complete an initial evaluation specific to the diagnosis/chief complaint or to the reason the patient was referred. An initial assessment is documented by each discipline rendering service. This assessment is inclusive of physiologic, psychologic, sociocultural, spiritual, economic, and lifestyle factors appropriate to the service setting (inpatient, outpatient, and ambulatory care) and the age and presenting problems of the patient ..."


Patient 1


Review of Patient 1's ED medical record dated 10/03/23 at 7:04 PM, showed Patient 1 was brought to the ED by the police department for increasingly violent behavior throughout the day. A C-SSRS screen was completed and Patient 1 answered "Yes" to the following questions: "Wish to be Dead; Suicidal Thoughts; and Suicidal Behavior?" This placed Patient 1 at a Suicide Risk Level of "Moderate." Patient 1 was placed on suicide precautions at 7:21 PM on 10/03/23 and remained on suicide precautions until discharged on 10/04/23 at 12:46 AM. Patient 1 was transported by hospital transportation to the community mental health crisis center.


During an interview on 10/17/23 at 5:46 PM, Patient 1 stated, " They took me to [community mental health crisis center] I rang the bell no one came to door and they just left me in the middle of the night there ..."


Review of Patient 1's ED medical record dated 10/04/23 at 7:47 PM, 19 hours and 17 minutes after his previous discharge, showed Patient 1 returned to the Emergency Department (ED) via ambulance with complaint of, " Pt [patient] found unresponsive on sidewalk by EMS (Emergency Medical Services). Smells of ETOH [alcohol], repords [sic] to painful stimuli." by the Police Department and mother. Patient 1's past medical history included Autism (developmental disorder that impairs ability to communicate and/or interact appropriately); Bipolar Disorder (mood swings ranging from depressive lows and manic highs); Borderline Personality (unstable moods and behaviors); Traumatic Brain Injury (TBI) (injury affecting the brain function); Alcohol Use Disorder (dependence of alcohol); Alcohol Withdrawal Seizures (seizures related to not drinking alcohol).


Review of a document titled, "ED Note-Physician" dated 10/04/23 at 10:08 PM signed by Staff KK, Physician, showed, " ...His ethanol level is significantly elevated at 419 [mg] [Blood Alcohol Level (BAC) .419%]. CO2 [carbon dioxide] slightly low at 16 .... Patient will need significant time to sober. He was signed out to incoming ED physician ...for reevaluation after continued sobering and determination of final disposition ..." The legal limit at 0.08% BAC (0.08 grams of alcohol per deciliter of blood). Toxic concentration is dependent on individual tolerance and usage although levels greater than 300-400 mg/dL can be fatal due to respiratory depression.


Review of a document titled, "ED Note-Physician" dated 10/05/23 at 6:16 AM signed by Staff JJ, Physician, showed, " ...Patient slept in the emergency department overnight and Clinically sober. No indication for any further work-up. Patient was counseled on the importance of alcohol cessation as this area is harmful to physical and mental health. Patient slightly hyponatremic (low sodium levels in the blood) in the emergency department but not significantly so no indication for admission or further monitoring encourage patient to take p.o.[by mouth] water to improve hyponatremia. Well-appearing when sober no medical complaints and stable for discharge."


Review of Patient 1's ED medical record dated 10/04/24 at 7:47 PM, failed include a risk assessment for suicidality by Staff JJ, Physician, once Patient 1 was sober and failed to include a C-SSRS screen prior to discharge on 10/05/23 at 6:19 AM. The Hospital failed to follow their Suicide Prevention Work Instruction Procedure by completing a C-SSRS for Patient 1 who had recent history of a "Moderate" Suicide Risk Level.


Review of an ED medical record dated 10/05/23 at 2:07 PM, showed Patient 1 returned to the ED via ambulance, 7 hours and 48 minutes after he was discharged on 10/05/23 at 6:19 AM, with complaint of, "...patient was found down unresponsive with empty liquor bottles around him ..."


During an interview on 10/17/23 at 5:46 PM, Family (F1) stated that the charge nurse told her the ED doctor spoke to the Psychiatrist. The Psychiatrist said Patient 1 needed to go to the community mental health crisis center facility. F1 stated, "I asked which location and the charge nurse said downtown, I said to the charge nurse, " ...one side is detox, the other side is an office and isn't open this time at night..." We thought he was being admitted because he changed his clothes. Then the charge nurse said a higher up had to make the decision to admit him.


During an interview on 10/18/23 at 9:28 AM, Staff Y, RN stated, " ... Anyone that does the triage does the C-SSRS ... If guardian says patient needs to be admitted we take that into great consideration ...if they cannot get a hold of guardian, they do not normally discharge until they have made contact ..."

During an interview on 10/18/23 at 11:16 AM, Staff AA, MD stated that the RN completes the C-SSRS and if the patient screens moderate or high, the physician performs a psychiatric risk assessment and places an order for observation depending on the outcome of the assessment.


During an interview on 10/18/23 at 1:39 PM, Staff BB, MD stated, " ...sometimes I ask patients when it is pertinent if they are suicidal or homicidal ..."


During an interview on 10/18/23 at 3:15 PM, Staff DD, Manager of ED stated that C-SSRS is done every shift if they score moderate or high and if they score moderate or high then the APP (Advanced Practice Provider) or physician would complete a Risk Assessment.