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Based on review of facility policy and procedure, medical records (MR), video footage, and interviews with staff, it was determined the facility failed to:

1. Provide an appropriate medical screening examination within the capability of the hospital's Emergency Department (ED) for one of four MRs reviewed who presented to the ED with psychiatric (psych) complaints including Patient Identifier (PI) # 8.

2. Provide necessary stabilizing treatment for an emergency medical condition for one of one MRs reviewed with suicidal and homicidal ideations including PI # 21.

3. Complete an appropriate transfer for one of one transfer MRs reviewed including PI # 6.

These deficient findings had the potential to negatively affect all patients served by the facility ED.

Findings include:

Refer to A2406, A2407, and A2409 for findings.

Based on review of Medical Records (MR), facility policy and procedure, Life Tract Divert Log, staff interviews and video footage, it was determined the hospital failed to perform a Medical Screening Exam (MSE) 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 existed for a patient who presented to the Emergency Department (ED) with psychiatric (psych) complaints.

This affected Patient Identifier (PI) # 8, one of four MRs reviewed who presented to the ED with psych complaints and had the potential to negatively affect all patients seeking treatment for psychiatric illnesses.

Findings included:

Facility Policy: Emergency Treatment and Active Labor Act (EMTALA) Policy
Policy Number: ED Policy 17
Date Reviewed: 8/2022

I. Purpose:

To establish guidelines for MSE, stabilization, and/or appropriate transfer of individuals presenting for medical conditions...

II. Definitions:

...E. "Medical Screening Examination" (MSE) means the screening process (within the capability of the hospital and including ancillary services that are routinely available to the ED) required to determine with reasonable clinical confidence whether an Emergency Medical Condition (EMC) does or does not exist. Depending on the patient's presenting complaints and symptoms, the MSE represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures...

III. Policy:

A. Any individual who comes to Grandview ED, and on whose behalf a request is made for an examination or treatment for an EMC, shall receive a MSE by a Qualified Medical Person (QMP) to determine if the individual has an EMC.

B. In addition, the ED shall:


III. Procedure:

B. Presentment to Designated Emergency Department (DED):

1. If the individual presents to a DED seeking examination or treatment for ANY medical condition (not limited to EMCs), then an MSE must be provided by a QMP to determine if the individual has an EMC...

1. PI # 8 presented to the ED on 5/13/24. PI # 8 signed in on a clipboard at the registration desk and listed "psych" as the reason for the ED visit. PI # 8 was not listed on any other documentation and there was no MR for PI # 8 on 5/13/24.


A phone interview was conducted on 5/29/24 at 8:40 AM with PI # 8. PI # 8 stated it was late afternoon on 5/13/24 when he/she presented to the ED. PI # 8 stated the receptionist called the psych floor while he/she was standing at the desk and then proceeded to inform PI # 8 they were on diversion and there were no psych beds available. PI # 8 described what his/her hair, shoes, and bag looked like when presenting to the ED on 5/13/24.

Review of video surveillance was conducted on 5/29/24 at 12:20 PM with Employee Identifier (EI) # 1, Vice President of Quality and Risk Management and EI # 3, Director of Admitting (Patient Access). Review of the ED waiting room video footage on 5/13/24 at 5:00 PM revealed PI #8 arrived at the reception desk at 5:33 PM. The receptionist was identified as EI # 4, by EI # 1 and EI # 3. At 5:34:08, EI # 4 is seen making a phone call, which was confirmed by EI # 1 and EI # 3. At 5:34:44 EI # 4 hung up the phone and talked with PI # 8. At 5:36:06, PI # 8 left the ED lobby, then exited the ED at 5:36:20. PI # 8 is then seen getting in a vehicle and leaving the hospital grounds at 5:40:08 without having a MSE.

An interview was conducted on 5/29/24 at 4:56 PM with EI # 4. During the interview, EI # 4 stated that he/she "may have called bed control" to inquire if any beds were available on the psych unit. EI # 4 then stated that he/she would "never tell a patient to leave."

Review of the LifeTrac Divert Log dated 5/13/24 through 5/14/24 revealed the Adult Psych unit was on diversion from 5/13/24 at 3:12:42 PM for 32.8 hours. EI # 1 confirmed the facility was on diversion for the dates and times listed.


The facility failed to ensure that their own policy and procedures were followed as evidenced by failing to ensure that a medical screening examination was provided for Patient #8 on 5/13/2024 that was within the capability of the hospital's emergency department to include ancillary services routinely available in the emergency department to determine whether or not an emergency medical condition existed. Patient #8 presented to the hospital's ED seeking examination and treatment for his psychiatric complaints and was not evaluated by a QMP as stated in the facility's policies.

Based on review of medical records (MR), facility policies and procedures, psychiatric units bed census report, Transfer Center Call Summary, and interviews with staff, it was determined the hospital failed to:

a. Admit a patient for psychiatric stabilizing treatment as required when they had the capability and capacity to treat the patient.

b. Transfer the patient to another facility for treatment.

c. Provide a discharge plan for a patient with a psychiatric illness.

This affected Patient Identifier (PI) # 21, one of one patients reviewed who presented to the Emergency Department (ED) with Suicidal and Homicidal Ideations, and had the potential to affect all patients seeking treatment for psychiatric illnesses.

Findings include:

Facility Policy: Emergency Treatment and Active Labor Act (EMTALA) Policy
Policy Number: ED Policy 17
Date Reviewed: 8/2022

I. Purpose:

To establish guidelines for medical screening examination, stabilization, and /or appropriate transfer of individuals presenting for medical conditions...

II. Definitions:

...C. Emergency Medical Condition (EMC) means:
...3. An individual expressing suicidal or homicidal thought or gestures, if determined dangerous to self of others, would be considered to have an EMC.

...G. "To stabilize" or "stabilized" means:
...2. With respect to an individual with a psychiatric condition, the physician has determined that the patient is no longer considered to be a threat to himself/ herself or others (stable for discharge) or the patient has been protected and prevented from injuring himself/ herself or others (stable for transfer).

H. "Stable for Discharge" A patient is considered stable for discharge when, within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care... could reasonably be performed as an outpatient or later as in inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions. For the purpose of discharging a patient with psychiatric condition(s), the patient is considered to be stable for discharge when he/she is no longer considered to be a threat to himself/herself or to others.

Facility Policy: Suicide Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Setting
Policy Number: Interdisciplinary .016
Affected Departments: All Patient Care
Effective Date: 12/2022

I. Policy:

All adolescent and adult patients... who present for care and services will be screened for suicidal ideation and behavior...

II. Purpose:

...The answers help users identify whether a patient is at risk for suicide, assess the severity and immediacy of that risk, and gauge the level of interventions needed to keep patient safe.

...IV. Procedure:

...J. Discontinuing or reducing safety precautions... should only (be) done by a physician order.

...V. Discharge Planning:

...B. Post-discharge Mental Health Professional referral appointment for outpatient services should be scheduled within 1 - 3 days post-discharge...
C. Ensure the discharge plan is addressed verbally and in writing with the patient...and confirm understanding...

1. PI # 21 presented to the ED via ambulance on 3/9/24 with chief complaints of Suicidal Ideation (SI) and Homicidal Ideation (HI).

Review of the ED Physician documentation, dated 3/9/24 at 10:22 AM, revealed the following, "Patient is a 46 year old male/female history of bipolar that presents to the ER (Emergency Room) for manic episode as well as SI/HI. Patient reports that people are out to get him/her and plans to overdose on IV (Intravenous) drugs... "

Further review of the ED Physician documentation revealed "...Social History: Lives with: Homeless... Physical Examination: General: Alert, no acute distress. Psychiatric: Cooperative, Patient appears manic with pressured speech and flight of ideas. Medical Decision Making: ...Plan to admit to psychiatry for further care. Spoke with psych (Psychiatry) intake reports that patient is now (not) allowed to be admitted to Grandview due to aggressive behavior. Will transfer to outside facility."

Review of the nurse's documentation revealed a Columbia Suicide risk assessment, dated 3/9/24 at 10:23 AM, with the following questions and answers:

Columbia Suicide Cssrs (Columbia Suicide Severity Rating Scale) Total: 4

Wished you were dead or not wake up: "Yes."

Actual thoughts of killing yourself: "Yes."

Thinking about how you might do this: "Yes."

Worked out detail/ intention to carry out: "Yes."

Ever done/ started/ prepared to end life: "Yes."

...Nurse Identify Suicide Risk: High Risk Level

Risk for Suicide: Moderate Risk Level

High Suicide Risk Interventions: Physician Notification, Complete Safe Room Checklist, Initiate 1:1 cont. (continuous) Obs (Observations)/ dedicated ligature-resistant room...

Review of the continuous observation, every 15 minute checks, from 3/9/24 at 10:15 AM to 3/10/24 at 7:30 AM revealed the "Observation Behavior" was documented as "Talking" four times, and all other Behaviors were blank. "Observation Activity" included "Lying, Standing, Walking to Toilet, Sitting, and Sleeping." There was no documentation of aggressive or combative behavior during the ED continuous observations.

Further review of the MR revealed an order to Discharge Patient, dated 3/10/24 at 9:25 AM. Order details: to Home/Self Care.

The ED Disposition Summary, dated 3/10/24 at 9:41 AM, documented patient was discharged in care of: "Self" and disposition method: "Self Ambulated."

There was no documentation PI # 21 was reassessed for Suicidal Ideations every shift per policy or prior to discharge. There was no physician order to discontinue safety precautions. There was no documentation of Discharge Planning or follow up appointment with a Mental Healthcare Provider. There were no instructions signed by the patient prior to discharge per policy.

Review of the Transfer Center Call Summary revealed initial contact with Grandview BHU (Behavioral Health Unit) regarding PI # 21 on 3/9/24 at 12:45 PM, "Writer spoke to [Name] ...intake, they have no beds and pt (patient) needs to be placed due to SI, HI, and manic episodes. Will seek placement."

Further review of the Transfer Center Call Summary regarding PI # 21 revealed the Consulting Provider and Specialty, Employee Identifier (EI) # 5, Medical Doctor (MD), Decision: "Declined," dated 3/9/24 at 12:45 PM. Grandview BHU Acceptance Decision: "Decline," dated 3/9/24 at 12:45 PM. Explanation: "MD Decline." An additional note was dated 3/13/24 3:23 PM, "Per tracker, pt declined due to past behaviors on unit." Further review of the Transfer Center Call Summary revealed seven facilities declined the patient, and five facilities requests for transfer were canceled due to "Patient Discharge."

A review of the adult psych unit bed census for 3/9/24 revealed two semi-private rooms were empty (a total of four beds). One additional semi-private male bed was empty but blocked due to behaviors of the patient in the room.

Review of the staffing schedule for the adult psych unit on 3/9/24 revealed the unit was fully staffed.


An interview was conducted on 5/30/24 at 11:36 AM with EI # 1, Vice President Quality and Risk Management, who confirmed there was no aggressive behavior documented for PI # 21 while he/she was in the ED. EI # 1 further stated, "...the patient has a history of being combative with staff on a previous admission." EI # 1 further stated the Exclusionary Behavioral Criteria for admission to the BHU included "History of aggression that requires more nursing care than the department can safely provide."


On 3/9/2024 Patient #21 required inpatient psychiatric care due to his identified psychiatric emergency medical condition. The facility failed to provide stabilizing treatment as required for the patient. The facility had the capability because psychiatric services and beds available on 3/9/24 to provide stabilizing as required to stabilize the EMC.

Based on review of facility policies and procedures, medical records (MR), Transfer Center Call Summary, and interviews, it was determined the facility failed to complete an appropriate transfer for two of two transfer MRs reviewed and did affect Patient Identifier (PI) # 6, and PI # 21, and had the potential to affect all patients transferred from the hospital's Emergency Department.

Findings include:

Facility Policy: Emergency Treatment and Active Labor Act (EMTALA) Policy
Policy Number: ED Policy 17
Date Reviewed: 8/2022

I. Purpose:

To establish guidelines for...appropriate transfer of individuals presenting for medical conditions in accordance with the requirements of the Emergency Medical Treatment Active Labor Act (EMTALA).

II. Procedure:

...3. Appropriate Transfer:

...c. the receiving facility shall receive copies of all pertinent medical records available at the time of transfer, including
1) available medical history;
2) records related to the individual's EMC (emergency medical condition);
3) observations of signs or symptoms;
4) preliminary diagnoses;
5) results of diagnostic studies or telephone reports of the studies;
6) treatment provided;
7) results of any tests;
8) a copy of the patient's written consent to transfer or physician's certification of risks and benefits...

1. PI # 6 presented to the Emergency Department (ED) on 3/3/24 at 11:03 AM with a chief complaint of Depression and wanting to be admitted. PI # 6 stated he/she was "coming off crack."

A review of the ED Discharge Instructions dated 3/3/24 at 4:16 PM revealed Disposition Order: Transfer to hospital 3/3/24 CST (Central Standard Time), outside hospital for psych placement, transfer for hallucinations, depression, paranoia, no beds at our facility currently.

A review of the Community Health Systems Transfer Center Call Summary dated 3/3/24 at 6:13 PM revealed patient was accepted by Dr. [Name].

A review of the ED Disposition Summary dated 3/3/24 at 7:28 PM revealed,
ED Nurse Noted Disposition: Transfer
Admit Room Number: (Hospital Name) 5221
Report Called To: RN [Name]
Report Called At (time) 3/3/24 6:17 PM CST
Transported to Floor By: Transport
Transferred from ED By: EMS-ALS
ED Transferred To: (Hospital Name) 5221
ED Transfer Reason: Psychiatrics-Specialized Care

There was no documentation of risks and benefits explained to patient.
There was no documentation consent for transfer was signed by patient.
There was no documentation a copy of emergency records were transferred with patient.

An interview was conducted on 5/30/24 at 11:28 AM with EI # 1, Vice President of Quality and Risk Management, who confirmed the above findings.

2. PI # 21 presented to the ED via ambulance on 3/9/24 with chief complaints of Suicidal Ideation (SI) and Homicidal Ideation (HI).

Review of the ED Physician documentation, dated 3/9/24 at 10:22 AM, revealed the following, "Patient is a 46 year old male/female history of bipolar that presents to the ER (Emergency Room) for manic episode as well as SI/HI. Patient reports that people are out to get him/her and plans to overdose on IV (Intravenous) drugs... "

Further review of the ED Physician documentation revealed "...Social History: Lives with: Homeless... Physical Examination: General: Alert, no acute distress. Psychiatric: Cooperative, Patient appears manic with pressured speech and flight of ideas. Medical Decision Making: ...Plan to admit to psychiatry for further care. Spoke with psych (Psychiatry) intake reports that patient is now (not) allowed to be admitted to Grandview due to aggressive behavior. Will transfer to outside facility."

Further review of the MR revealed an order to Discharge Patient, dated 3/10/24 at 9:25 AM. Order details: to Home/Self Care.

The ED Disposition Summary, dated 3/10/24 at 9:41 AM, documented patient was discharged in care of: "Self" and disposition method: "Self Ambulated."

There was no documentation of Discharge Planning or follow up appointment with a Mental Healthcare Provider. There were no instructions signed by the patient prior to discharge per policy.

Review of the Transfer Center Call Summary revealed initial contact with Grandview BHU (Behavioral Health Unit) regarding PI # 21 on 3/9/24 at 12:45 PM, "Writer spoke to [Name] ...intake, they have no beds and pt (patient) needs to be placed due to SI, HI, and manic episodes. Will seek placement."

Further review of the Transfer Center Call Summary regarding PI # 21 revealed the Consulting Provider and Specialty, Employee Identifier (EI) # 5, Medical Doctor (MD), Decision: "Declined," dated 3/9/24 at 12:45 PM. Grandview BHU Acceptance Decision: "Decline," dated 3/9/24 at 12:45 PM. Explanation: "MD Decline." An additional note was dated 3/13/24 3:23 PM, "Per tracker, pt declined due to past behaviors on unit."

Further review of the Transfer Center Call Summary revealed seven facilities declined the patient, and five facilities requests for transfer were canceled due to "Patient Discharge."

An interview was conducted on 5/30/24 at 11:36 AM with EI # 1, Vice President Quality and Risk Management, who confirmed there was no documentation why PI # 21 was discharged to home and not transferred as planned.