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Based on interview, and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide a complete medical screening exam, stabilizing treatment, and an appropriate transfer for 1 of 20 patients (P-1), resulting in the potential for less than optimal outcomes for all patients seeking emergent care.


See specific tags:
2406 Failure to provide a medical screening exam
2407 Failure to provide stabilizing treatment
2409 Failure to provide an appropriate transfer

Based on interview and record review, the facility failed to provide a complete medical screening exam (MSE) for one (P-1) of 20 patients reviewed for an emergency medical condition, resulting in the potential for an adverse outcome. Findings include:

On 06/25/2024 at 1400, review of P-1's medical record revealed he was a 13-year-old male who presented to the emergency department via ambulance with his parents on 04/11/2024 at 2209. Nursing triage note dated 04/11/2024 at 2211 indicated his parents reported that P-1 was hearing voices, and he told his parents that he needed to kill himself that night and was scared. The triage note indicated P-1 reported having thoughts of suicide.
On 06/25/2024 at 1400, review of mental health social work note documented by Staff M, for P-1 dated 04/11/2024 with creation time of 2243 indicated Social Work (SW) consulted by attending provider. Social Work handoff was documented as "medically cleared for discharge: No, Assessed: no. Seeking placement ..."
Review of nursing documentation revealed no nursing re-assessment of P-1's mental health status, thoughts of self-harm, hallucinations or level of fear, or vital signs since arrival or prior to discharge.

Review of the one ED Provider note for P-1 dated 04/11/2024 at 2220 revealed P-1 had a prior psychiatric history with prior admission and was on multiple psychiatric medications. P-1 had reported hearing voices which had told him to kill himself. The note indicated P-1 was seen by social worker, who made arrangements for P-1 to follow-up the next day for psychiatric evaluation at a nearby children's hospital. Disposition listed as discharge with final impression as auditory hallucinations.

In an interview on 06/26/2024 at 1110, Staff N (Director of Case Management and Social Work) stated there is a template for a mental health assessment to be completed for a social work consult. After review of P-1's presentation and orders for consultation, Staff N stated it would be her expectation that the template for a complete mental health assessment should have been used for P-1.

Review of P-1's medical record revealed, there was no documentation of a psychiatric examination by a qualified licensed individual.

In an interview on 06/26/2024 at 1000, Staff O (ED physician director) stated even though P-1 was medically cleared, his psychiatric needs were not met.

On 06/26/2024 at 1215, review of the facility, "Emergency Medical Treatment and Labor Act (EMTALA), Comp-18" policy, revised date 11/2023 revealed under II. Policy Standards ...B. Patient with an EMC ...must be provided further medical examination and stabilizing treatment within UMHW Capacity and Capability and/or UMHW staff will arrange for an appropriate transfer ...

On 06/26/2024 at 1215, review of the facility, "Emergency Department (ED) Structure Standards" policy, review date 02/2023 revealed "RN complete and document an assessment related to chief complaint and current status of the patient prior to discharge."

Review of policy "Vital Signs and Monitoring, ED-D150" last revised on 02/2024, under procedure, step 2, revealed "Once in a treatment area, each individual will have vital signs rechecked and documented within the following initial frequency but is subject to change based on patient condition: ...ESI Level 2 - no less frequently than every 60 minutes until medically cleared then no less than every 4 hours ..."

Based on interview and record review, the facility failed to provide stabilizing treatment for one (P-1) of 20 patients reviewed for an emergency medical condition, resulting in the potential for an adverse outcome. Findings include:

On 06/25/2024 at 1400, review of P-1's medical record revealed he was a 13-year-old male who presented to the emergency department via ambulance with his parents on 04/11/2024 at 2209. Nursing triage note dated 04/11/2024 at 2211 indicated his parents reported that P-1 was hearing voices, and he told his parents that he needed to kill himself that night and was scared. The triage note indicated P-1 reported having thoughts of suicide. When asked in in the past month if he wished he were dead or could go to sleep and not wake up, P-1 answered yes. When asked in the past month if he actually had thoughts of killing himself, P-1 answered yes. When asked if he had intention of acting on these thoughts or had a plan, P-1 stated no. When asked if in his lifetime he had started to do anything, or prepared to do anything to end his life, P-1 stated yes, but not within the past 3 months. P-1 was categorized a low acute suicide risk upon documented assessment. Review of "SMART" medical clearance form completed at 2219 by emergency provider revealed: Suspect new onset psychiatric condition: No. Abnormal medical conditions: no. Risky Presentation: no. Psychiatric emergency screening completed at 2220 by emergency department (ED) Registered Nurse (RN) asked if P-1 presents with any acute psychosis, mania, paranoia, and/or delusions, the assessment indicated P-1 did. Behavioral assessment indicated P-1 was lethargic, with flat affect. ED provider placed an order at 2220 for Mental Health Safety Precautions and Social Work assessment and disposition. Lab results at 2350 revealed urine drug screen negative.

On 06/25/2024 at 1400, review of mental health social work note documented by Staff M, for P-1 dated 04/11/2024 with creation time of 2243 indicated Social Work (SW) consulted by attending provider due to P-1 seeing and hearing voices telling him to kill himself, sudden onset that evening, P-1 was fearful in presentation, eval/treat/psych. The note indicated for SW to please assess P-1 in the morning with mental health assessment and make clinical recommendations. Social Work handoff was documented as: medically cleared for discharge: No, Assessed: no. Seeking placement: SW. Behavioral updates: Calm and anxious. 1115 pm social work note indicated the social worker spoke with staff member at another hospital to arrange pre-arrival at the second hospital ED for psychiatry evaluation the next day, 04/12/2024. Social work note indicated family was willing and agreed on safety plan and monitoring child (P-1) for the evening... Follow-up in the morning with the secondary hospital emergency department. The social work note indicated summary of referrals to include a packet was sent to two psychiatric inpatient hospital facilities. However, the note did not indicate any communication back from either facility. The note did not include an assessment of P-1's mental health status, suicidal thoughts, status of hallucinations, or level of fear.

Review of nursing documentation revealed no nursing re-assessment of P-1's mental health status, thoughts of self harm, hallucinations or level of fear, since arrival or prior to discharge.

Review of the one ED Provider note for P-1 dated 04/11/2024 at 2220 revealed P-1 had a prior psychiatric history with prior admission and was on multiple psychiatric medications. P-1 had reported hearing voices which had told him to kill himself. The note indicated urine drug screen negative, P-1 was seen by social worker, who made arrangements for P-1 to follow-up the next day for psychiatric evaluation at a nearby children ' s hospital. Disposition listed as discharge with final impression as auditory hallucinations.

In an interview on 06/25/2024 at 1535, Staff M (Social Worker, SW) stated she met with P-1 and his parents while he was in the emergency department on 04/11/2024. She offered multiple options to P-1's parents including going to another hospital's inpatient psychiatric urgent care. Staff M stated she spoke to a staff member in the pre-arrival department of the emergency department at a nearby children's hospital and arranged with the pre-arrival registration staff for P-1 to go to their emergency department the next morning. When Staff M was queried about Emergency Medical Treatment and Labor Act (EMTALA) requirements and if P-1 was stable for discharge home until the next morning, Staff M stated she was not familiar with EMTALA.

In an interview on 06/26/2024 at 1110, Staff N (Director of Case Management and Social Work) stated there is a template for a mental health assessment to be completed for a social work consult. After review of P-1's presentation and orders for consultation, Staff N stated if would be her expectation that the template for a complete mental health assessment should have been used for P-1. When queried about P-1's discharge, Staff N stated no, it would not be her expectation nor the facility's process to discharge a patient with instructions which included follow up with another hospital's emergency department.

In an interview on 06/25/2024 at 1525, Staff L (ED Physician) stated he saw P-1 when he presented to the ED with auditory hallucinations and thoughts of suicide. He stated P-1 was to follow the plans of the social worker, which was to follow up at a children's hospital the next day. Staff L said the social worker made a safety plan with P-1's parents for the night and arranged for them to take P-1 to the children's hospital the next morning for a more thorough psychiatric evaluation.

In an interview on 06/26/2024 at 1000, Staff O (ED physician director) stated he had reviewed the medical record for P-1 and the discharge for P-1 was out of the normal process for what the facility would do. Staff O stated with pediatric patients it is not unusual to safety plan and set up plans for post discharge in order to get them home. However, a safety plan would not include going to another hospital's ED after discharge. Staff O stated even though P-1 was medically cleared, his psychiatric needs were not met. It is not protocol when discharging a patient to tell them to go to another emergency department.

On 06/26/2024 at 1400, review of P-1's medical record from facility B's emergency department visit on 04/12/2024 revealed P-1 arrived at the second children's hospital emergency department on 04/12/2024 at 0859 with a chief complaint of "was seen at another hospital yesterday and referred here because P-1 was hearing voices. Provider note indicated P-1 was a 13-year-old male with anxiety and history of suicidal ideation, presented to ED with parents with concern for behavioral health concerns. Father reported concern due to P-1 taking his nighttime medications along with Mucinex, Benadryl and Sudafed, then 20 minutes later experienced hallucinations and hearing voices. Father reported P-1 was terrified begging him to kill him and threatening to kill himself. P-1 stated he felt good "now", was calm, cooperative and social work assessed. P-1 was discharged from facility B at 1101.

No medical interventions were provided by the hospital to address the patient's EMC and there was no evidence the patient was stabilized before discharge.

On 06/26/2024 at 1215, review of the facility, "Emergency Medical Treatment and Labor Act (EMTALA), Comp-18" policy, revised date 11/2023 revealed "Stabilized: With respect to an emergency medical condition, means that no material deterioration of the condition is likely within reasonable medical probability, to result from or occur during a transfer or discharge. An individual will be deemed stabilized if the treating physician has determined, with reasonable clinical confidence, that the emergency medical condition has been resolved." "Stable for Discharge: The hospital has provided medical services necessary to assure that no material deterioration of the condition is likely to result from discharge, as a matter of reasonable medical probability. Further, the physician has determined that the patient's continued care, including further diagnostic workup and/or treatment can be reasonably performed as an outpatient or later as an inpatient, and the patient is provided a plan for appropriate follow-up care with discharge instructions. A psychiatric patient is considered "stable for discharge" if the patient is not considered to be an imminent threat to self or others."

On 06/26/2024 at 1215, review of the facility, "Emergency Department (ED) Structure Standards" policy, review date 02/2023 revealed "RN complete and document an assessment related to chief complaint and current status of the patient prior to discharge."

Based on interview and record review, the facility failed to restrict transfer to another facility's care before providing stabilizing treatment for one (P-1) of 20 patients reviewed for an emergency medical condition, resulting in the potential for an adverse outcome. Findings include:

On 06/25/2024 at 1400, review of P-1's medical record revealed he was a 13-year-old male who presented to the emergency department via ambulance with his parents on 04/11/2024 at 2209. Nursing triage note dated 04/11/2024 at 2211 indicated that P-1 was hearing voices, and he told his parents that he needed to kill himself that night and was scared. The triage note indicated P-1 reported having thoughts of suicide.

On 06/25/2024 at 1400, review of mental health social work note documented by Staff M, for P-1 dated 04/11/2024 with creation time of 2243 indicated Social Work (SW) consulted by attending provider due to P-1 seeing and hearing voices telling him to kill himself. Social Work handoff was documented as: medically cleared for discharge: No, Assessed: no. Seeking placement ... 1115 pm social work note indicated the social worker spoke with staff member at another hospital to arrange pre-arrival at the second hospital ED for psychiatry evaluation the next day, 04/12/2024. Social work note indicated family was willing and agreed on safety plan and monitoring child (P-1) for the evening. Follow-up in the morning with the secondary hospital emergency department. The social work note indicated summary of referrals to include a packet was sent to two psychiatric inpatient hospital facilities. However, the note did not indicate any communication back from either facility. The note did not include an assessment of P-1's mental health status, suicidal thoughts, status of hallucinations, or level of fear.

Review of the one ED Provider note for P-1 dated 04/11/2024 at 2220 revealed P-1 was seen by social worker, who made arrangements for P-1 to follow-up the next day for psychiatric evaluation at a nearby children's hospital. Disposition listed as discharge with final impression as auditory hallucinations.

In an interview on 06/25/2024 at 1535, Staff M (Social Worker, SW) stated she met with P-1 and his parents while he was in the emergency department on 04/11/2024. Staff M stated she spoke to a staff member in the pre-arrival department of the emergency department at a nearby children's hospital and arranged with the pre-arrival registration staff for P-1 to go to their emergency department the next morning. When Staff M was queried about Emergency Medical Treatment and Labor Act (EMTALA) requirements and if P-1 was stable for discharge home until the next morning, Staff M stated she was not familiar with what EMTALA was.

In an interview on 06/26/2024 at 1110, Staff N (Director of Case Management and Social Work) stated it would not be her expectation nor the facility's process to discharge a patient with instructions which included follow up with another hospital's emergency department.

In an interview on 06/26/2024 at 1000, Staff O (ED physician director) stated he had reviewed the medical record for P-1 and the discharge for P-1 was out of the normal process for what the facility would do. A, safety plan would not include going to another hospital's ED after discharge. Staff O stated even though P-1 was medically cleared, his psychiatric needs were not met. It is not protocol when discharging a patient to tell them to go to another emergency department.

There was no documentation demonstrating the physician communicated with anyone (outside of the pre-arrival clerk) at the receiving hospital or verification that the receiving hospital had the necessary resources to provide further treatment options that the current facility lacked. The patient was discharged without receiving any medication management, a safe transfer arrangement, or a physician certification of risks/benefits.

On 06/26/2024 at 1400, review of P-1's medical record from facility B's emergency department visit on 04/12/2024 revealed P-1 arrived at the second children's hospital emergency department on 04/12/2024 at 0859 with a chief complaint of "was seen at another hospital yesterday and referred here because P-1 was hearing voices.

On 06/26/2024 at 1215, review of the facility, "Emergency Medical Treatment and Labor Act (EMTALA), Comp-18" policy, revised date 11/2023 revealed "Stabilized: With respect to an emergency medical condition, means that no material deterioration of the condition is likely within reasonable medical probability, to result from or occur during a transfer or discharge. An individual will be deemed stabilized if the treating physician has determined, with reasonable clinical confidence, that the emergency medical condition has been resolved." "Stable for Discharge: The hospital has provided medical services necessary to assure that no material deterioration of the condition is likely to result from discharge, as a matter of reasonable medical probability. Further, the physician has determined that the patient's continued care, including further diagnostic workup and/or treatment can be reasonably performed as an outpatient or later as an inpatient, and the patient is provided a plan for appropriate follow-up care with discharge instructions. A psychiatric patient is considered "stable for discharge" if the patient is not considered to be an imminent threat to self or others."