HospitalInspections.org

Based on interview and record review, the hospital failed to abide by the provider's agreement that required a hospital to comply with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The Hospital A was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements, citing 1 of 1 Individual (Individual #23) that showed up in Hospital A's property the early morning of 03/16/18 and in good faith was not provided a Medical Screening Examination.

Cross Refer to Tag 2406

Based on interview and record review, the facility in good faith failed to provide a Medical Screening Examination of 1 of 1 Individual (Individual #23) that showed up in Hospital A's property the early morning of 03/16/18.

Findings included:

During an interview on 06/18/18 at 10:13 AM, Personnel #16 stated Individual #23 was found in Hospital A's property on 03/16/18 at 3:50 AM. Individual #23 was approximately 150 feet from the ED patient entrance. Personnel #16 approached Individual #23. Personnel #16 observed the individual was "sweating and out of breath."

Personnel #16 stated he asked the individual if he could help him or if he wanted to be seen by a doctor. Personnel #16 stated Individual #23 refused. Personnel #16 stated Individual #23 told him he had been awake for 2 days' straight. Personnel #16 stated the individual asked him to call the police because he wanted to go to jail. Personnel #16 stated he called the police and waited for them to come. Personnel #16 stated while waiting for the police he received a call that his presence was needed in the ED. As he was walking away from the individual, he heard a glass break. He turned around and saw the individual with a rock on his hand and a shattered upper portion of a glass door. Personnel #16 called the police the second time. The police came 10 minutes later and arrested Individual #23.

During an interview on 06/18/18 at 6:58 PM via phone with Personnel #13, he stated he discharged Patient #22 and escorted him out of the emergency room. Personnel #13 stated he saw Individual #23 outside the ED throwing something. Personnel #13 stated he saw the glass break. Personnel #13 stated he heard the individual saying "now I bet they will arrest me." Personnel #13 stated he saw the security guards walking towards the individual. He heard a security guard saying "what's going on?" Personnel #13 stated he approached Individual #23 and asked him if he wanted to come in to the ER and see a doctor. The individual replied "no, I want to go to jail." The police arrived and Individual #23 went with the police "peacefully."

During an interview on 06/19/18 at 11:17 AM via phone Physician #6 confirmed she was the physician on-duty when the incident occurred the early morning of 03/16/18. She stated she heard a crashing sound and went out to see what was going on. Physician #6 saw shards of broken glass. Physician #6 stated she asked the nurse if there was something going on medically with Individual #23. The nurse replied no. So she went back inside the ER (emergency room). Physician #6 stated she did not talk to Individual #23. Physician #6 stated "I would have seen him if they (police) brought him in the ER." Physician #6 stated she did not talk to the police.

During an interview on 06/18/18 at 9:40 AM and 06/19/18 at 10:00 AM Personnel #1 stated on 03/20/18 she received a letter from Hospital B indicating that on 03/16/18 Individual #23 presented in their ED under police custody and requested the following information: "Patient's admission, date, time, mode of transportation; disposition upon arrival; care provided to the patient; date and reason for discharge; and, patient condition upon discharge/instructions given." On 03/26/18, Personnel #1 responded via email reflecting "After a search of the electronic health record under Individual #23 we can confirm...that the individual was not evaluated, nor was he refused care in the...ER. Individual #23 never entered the hospital at any time and the entire incident occurred outside on hospital grounds..." Personnel #1 was asked to provide evidence of the internal investigation and incident/event report regarding Individual #23. Personnel #1 replied there was none. Personnel #1 was asked for evidence that the hospital management discussed Individual #23's event on 03/16/18. She replied it would be in the Governing Body (GB) Meeting Minutes. Review of the GB meeting minutes dated 03/20/18, 04/17/18, and 05/15/18 did not include discussion about Individual #23's incident. Personnel #1 was informed of the above findings. She responded "we discussed this incident multiple times and I'm surprised there was no documentation."

Hospital B's medical record of Individual #23 reflected he presented in the ED (emergency department) on 03/16/18 at 4:50 AM. The chief complaint was "psychosocial assessment under emergency detention." The vital signs were taken at 5:01 AM with a blood pressure (BP) of "133/86," 1 hour and 11 minutes after the start of the incident in Hospital A. Per American Heart Association a systolic reading of 130 to 139 or diastolic reading of 80 to 89 was considered "Hypertension Stage 1." (Note: Information obtained on 06/26/18 at 3:30 PM at
http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/KnowYourNumbers/Understanding-Blood-Pressure-Readings_UCM_301764_Article.jsp#.WzKUlsKQzVg)

At 5:48 AM a nurse noted the "patient to be diaphoretic, attending...notified" which above Personnel #16 of Hospital A observed during his initial encounter with Individual #23.

At 10:09 AM a Licensed Clinical Social Worker noted "Social Work Psychosocial Extended Assessment...Arrived by: Emergency Detention...after he was displaying aggressive behavior and reporting suicidal ideation...Stated to Hospital A employees and officers he wanted to hurt himself. Stated to officers he's been up for 3 days and recently used drugs (ice) and wants medication...Presenting Problem: Suicidal Statement...Patient is a 36-year-old...bipolar disorder who arrives to Hospital B via DPD after he displayed aggressive behavior that throwing a rock at the window of Hospital A and told officers that he was going to harm himself...He states he has been living on the streets for the last 2 days...He admits he has been using methamphetamine, cocaine, and marijuana while on the streets..."

At 11:19 AM the attending physician noted the "Assessment and Plan...This is a 36-year-old male with history of Bipolar disorder who was brought to the ED by the police after being found throwing a rock at a window...not taken his psych meds for about 6 months. He has also been using cocaine, meth, and marijuana. He denies hallucination or delusions at this assessment...did not report suicidal or homicidal ideas. He wants help with stopping drug use and getting back on his psych meds...DSM Diagnosis 1. Polysubstance Dependence 2. Substance induced mood disorder 3. Bipolar disorder. Plan 1. Will give script for Seroquel 100 mg po qhs 2. Recommend outpatient follow-up-give resources for mental health and SUD [substance use disorder] treatment 3. Brief supportive therapy and psychoeducation provided 4. Will lift APOWW and clear patient for psychiatric discharge."

At 11:30 AM a "Social Work Discharge Summary" authored by the LCSW reflected "...does meet criteria for polysubstance dependence. In my opinion it would benefit the patient to seek D+A (drug and alcohol) treatment and then continue to follow outpatient mental health clinic to confirm diagnosis. This treatment plan was discussed with him as well and he is agreeable."

Individual #23 was eventually discharged that same day, 03/16/18.

Policy #8610.409 "EMTALA" reviewed 05/2018 reflected "Scope: This policy applies to Hospital A. Purpose...for Hospital's use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA). Definitions...B. Comes to the Emergency Department. For purposes of this policy, an individual is deemed to have come to the emergency department if the individual: 1. Presents at a dedicated emergency department...2. Presents on Hospital property, other than a dedicated emergency department, and request examination...In the absence of such request...a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs emergency examination or treatment..."