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Based on record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#23) of 31 Emergency Department (ED) records reviewed from 11/01/23 through 08/15/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC).

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)," revised on 12/13/23, showed:
- A MSE should be performed for any individual who comes to the ED or hospital and requests emergency care regardless of diagnosis.
- If the patient displays mental disorders (organic, mental, or emotional impairment that effects a person's cognitive ability or a person's ability to participate in activities of normal living) then the patient should receive a medical screening by the physician.
- If the patient presents with the likelihood to harm self or others an affidavit (a written statement confirmed by oath, for use as evidence in court) should be completed to address involuntary status or emergency detention.
- If an EMC is determined to exist, any necessary stabilizing treatment or an appropriate transfer should be provided.
- Psychiatric patients are considered stable when they are protected and prevented from injuring or harming him/herself or others.
- If an individual chose to leave without an MSE or treatment, they were determined as leaving against medical advice (AMA) after they had been informed of the risks and benefits of remaining for further treatment. Reasonable attempts to obtain the individual's written refusal to examination or treatment should be completed and the medical record must contain a description of what was refused by or on behalf of the patient.
- If the patient refuses treatment and presents with likelihood of serious harm to themselves or others, staff were directed to complete an affidavit or other document to file with the courts to address involuntary status or emergency detention.
- There should be evidence of ongoing monitoring of the patient's EMC until the patient is stabilized and prior to discharge or transfer.

Review of the hospital's document titled, "Rules and Regulations," dated 01/05/23, showed, Qualified Medical Personnel (QMP) under EMTALA include physicians, RNs, Advanced Practice RNs (APRN), Physician Assistants (PA, a type of mid-level health care that can serve as a principal healthcare provider), and Behavioral Health (BH) Central Intake (CI) Assessors. QMPs were considered competent based on education, training, and experience to perform a MSE and to determine whether or not a patient has an EMC.

Review of the hospital's policy titled, "Required Elements of Daily Assessment/Reassessment (REDA)," revised 01/24/24, showed the RN was accountable for the nursing assessment of patients. Any reassessment, or review of patient information that had changed since the previous assessment, was based on the patient's diagnosis, change in condition, previous abnormal findings, and the response to interventions provided. Shift Assessments should include any changes in patient condition. There was no guidance in the policy to perform reassessment prior to discharge of ED patients.

Review of the hospital's policy titled, "Management of the Behavioral Health Patient in the ED," reviewed 11/15/22, showed patients that express homicidal ideation (HI, thoughts or attempts to cause another's death) may have their body or belongings searched and be placed in a safe environment. An affidavit should be completed.

Please refer to 2406 for further details.

Based on interviews, record review, and policy review, the hospital failed to provide, within its capability and capacity, ongoing assessment and reassessment of a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#23) of 31 Emergency Department (ED) records reviewed from 11/01/23 through 08/15/24. This failed practice had the potential to cause harm to all patients who presented to the ED.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC," revised 12/13/23, showed:
- The requirements of EMTALA ensured any individual presenting to the hospital or dedicated emergency department (ED) requesting emergency care received a MSE conducted by a Qualified Medical Personnel (QMP) to determine the presence of an EMC.
- An EMC was a medical condition manifested by acute symptoms of sufficient severity, including psychiatric (relating to mental illness) disturbances such that the absence of immediate medical attention could reasonably be expected to place the individual in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of any body part or organ.
- The MSE was an examination sufficient to reveal whether the patient suffers from an EMC and must include medically indicated screens, tests, mental status evaluations and a history and physical examination.
- Psychiatric patients were considered stable when they were protected and prevented from harming themselves or others. Administration of a physical (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) or chemical restraint (a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient) may stabilize a psychiatric patient for a period of time and remove the immediate EMC; however, the underlying medical condition may persist and the patient may experience an exacerbation of the EMC. Therefore, practitioners should use great care when determining if the medical condition was stable after a chemical or physical restraint was administered.
- An individual has the right to refuse a MSE. If the individual chose to leave without an MSE or treatment, they were determined as leaving against medical advice (AMA) after they had been informed of the risks and benefits of remaining for further treatment. The hospital's obligation under EMTALA was met after the refusing individual was informed of risks of refusing further care or treatment. Reasonable attempts to obtain the individual's written refusal to examination or treatment were to be completed and the medical record must contain a description of what was refused by or on behalf of the patient. The "Release of Responsibility (Refusal of Screening Exam, Refusal of Care, Leaving AMA)" form was completed and included in the medical record.
- Adult behavioral health patients who displayed mental disorders with effects to the person's cognitive or emotional function and impaired their ability to participate in activities of normal living should receive a medical screening by the physician. If the patient refuses treatment and presents with likelihood of serious harm to themselves or others, staff were directed to complete an affidavit (a written statement confirmed by oath, for use as evidence in court) or other document to file with the courts to address involuntary status or emergency detention. In the state of Missouri, the forms were called "Civil Involuntary Detention." Required documents are filed with the court and a copy retained in the patient's electronic medical record (EMR).
- The hospital's EMTALA obligation ended when the physician or QMP decided that there was no longer an EMC (even though the underlying medical condition persisted) and the patient was discharged with appropriate follow-up instructions; the EMC remained, and the patient was appropriately transferred; or the EMC remained, and the individual was admitted to the hospital.
- There should be evidence of ongoing monitoring of the status of the patient's EMC until the patient is stabilized and prior to discharge or transfer.

Review of the hospital's document titled, "Rules and Regulations," dated 01/05/23, showed, Qualified Medical Personnel (QMP) under EMTALA were deemed to include physicians and non-physician medical personnel. Non-physician QMPs included designated RNs, designated Advanced Practice RNs (Nurse Practitioner [NP, a nurse with advanced clinical education and training]) who were on the Allied Health Professional Staff, designated Physician Assistants (PA, a type of mid-level health care that can serve as a principal healthcare provider) who were on the Allied Health Professional Staff, and Behavioral Health Central Intake (CI) Assessors. Non-physician QMPs were considered competent by way of education, training, and experience to perform a MSE and determine, in consultation or collaboration with a physician, whether a patient did or did not have an EMC.

Review of the hospital's policy titled, "Required Elements of Daily Assessment/Reassessment (REDA)," revised 01/24/24, showed the RN was accountable for the nursing assessment of patients. Any reassessment, or review of patient information that had changed since the previous assessment, was based on the patient's diagnosis, change in condition, previous abnormal findings, and the response to interventions provided. Shift Assessments should include any changes in patient condition. There was no guidance in the policy to perform reassessment prior to discharge of ED patients.

Review of the hospital's policy titled, "Management of the Behavioral Health Patient in the ED," reviewed 11/15/22, showed patients that express homicidal ideation (HI, thoughts or attempts to cause another's death) may have their body or belongings searched and be placed in a safe environment. An affidavit should be completed.

Although requested, the hospital could not provide a policy on discharge criteria from the ED.

Review of Patient #23's medical record, dated 06/05/24, showed:
- He was a 16-year-old that presented to the ED at 11:57 PM by law enforcement for a psychiatric evaluation.
- Medical history included Autism and DMDD.
- His mother woke up and found him standing over her on the bed. He would not get off the bed, so the mother called the police.
- Patient #23 had been off all prescribed psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) for the past five to six months.
- The mother wanted him to be admitted for inpatient psychiatric treatment however, she did not want him started on any psychiatric medications.
- Staff R, ED physician, ordered a mental health assessment.
- On 06/06/24 at 1:24 AM, he was evaluated by Staff Z, Behavioral Health Therapist, and it was determined that Patient #23 did not meet criteria for inpatient psychiatric treatment. During the mental health assessment, he did not cooperate and answer the questions that were presented by Staff Z. Staff Z determined that he was not an imminent risk to harm self or others, not acutely psychotic (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature), or unable to care for himself. Patient #23 could continue treatment on an outpatient basis and was safe to discharge. He was able to contract for safety.
- The case was discussed with Staff QQ, APRN, who was the psychiatric provider on call. There was no report of suicidal (SI, thoughts of causing one's own death) or homicidal (HI, thoughts or attempts to cause another's death) ideation. She agreed that he did not meet criteria for inpatient psychiatric treatment. She talked to Staff R and he agreed as well that Patient #23 did not meet criteria for inpatient psychiatric treatment.
- On 06/06/24 at 1:40 AM, Patient #23 was discharged.

During an interview on 08/07/23 at 7:30 AM, Staff QQ, APRN, stated she was the on-call provider for psychiatry. Patient #23 had no SI/HI, no auditory (hearing things that are not heard by others, imaginary) or visual hallucinations (seeing things which are not there) and was not a threat to self or others. His mother specifically stated that she did not want any psychotropic medications administered but did request for him to be admitted. Patient #23, did not meet admission criteria.

During an interview on 08/07/24 at 3:30 PM, Staff Y, RN, stated Patient #23 had normal behaviors for a patient diagnosed with Autism. He showed no aggression, no screaming outbursts, and laid down and fell asleep. He had been evaluated by a behavioral health therapist and he denied SI/HI and did not meet criteria for inpatient psychiatric treatment. She stated that his mother stayed outside in the hallway and kept stating that he needed to be admitted for inpatient behavioral health care. Once he was discharged, Staff Y assisted Patient #23 out to the car without incident.

During an interview on 08/07/24 at 10:30 PM, Staff Z, Behavioral Health Therapist, stated she was assigned to do a mental health assessment for Patient #23. He was not suicidal or homicidal and was not a threat to himself or others. She did speak with the on-call psychiatric provider and it was determined that he did not meet criteria for inpatient behavioral health. She recommended discharge and for Patient #23 to continue with outpatient therapy. His mother did not want any psychiatric medications given or prescribed. He had been off all medications for the last five or six months.

Patient #23 refused to cooperate with the behavioral health assessment and answer the necessary questions to determine if he was stable for discharge, therefore an accurate psychiatric assessment was not completed. A MSE was not complete due to the inaccurate psychiatric assessment.