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Based on a review of the facility's Medical Staff Bylaws and Rules and Regulations, a review of policy and procedures, a review of an emergency medical service report, a review of medical records, and interviews with facility staff, it was determined that the facility failed to provide an appropriate medical screening examination within its capability and capacity sufficient to determine the presence of an emergency medical condition for one patient (P) (P#7) out of 24 sampled patients. In addition, it was determined that the facility failed to provide stabilizing treatment to one patient (P#6) out of 24 sampled patients.

The findings included:

Cross-reference to 2407 as it relates to the facility's failure to provide stabilizing treatment until an appropriate transfer could be completed.

Cross-reference to 2406 as it relates to the facility's failure to provide an appropriate medical screening exam.

Based on a review of the facility's Medical Staff Bylaws and Rules and Regulations, a review of policy and procedures, a review of an Emergency Medical Service (EMS) report, a review of medical records, and interviews with facility staff, it was determined that the facility failed to provide an appropriate medical screening examination sufficient to determine the presence of an Emergency Medical Condition (MSE) for one (1) patients out of 24 sampled (Patient #7).

The findings included:

A review of the Medical Staff Bylaws and Rules and Regulations, approved by the Board of Trustees on 1/1/2020, Section 2-2, "Emergency Patients," revealed that the hospital was required to provide an appropriate MSE for all patients who presented to the emergency department (ED) within the capability of the hospital's ED, to determine if a medical condition existed. The MSE would be provided by an appropriately credentialed physician, nurse practitioner, physician's assistant, or psychologist.

A review of the facility's policy titled "Triage," policy #ES-61, revised 10/19, revealed that triage was the first step after a patient entered the ED requesting care. Patients requiring immediate treatment would be transferred immediately to the triage area. Acuity (severity) would be assigned to each patient based on the nurse's judgment of a patient's need for medical attention. Every patient would be offered an MSE to determine if an emergency medical condition was present. If the exam were refused, the patient would sign a Left Before Seen (LBS) form.

A review of the facility's policy titled "Care of Behavioral Health Patient in Emergency Department" policy #ES-73, revised 6/21/21, revealed that patients would be triaged for acuity level by a registered nurse (RN). An acuity level of two would indicate a high-risk condition. The patient would be immediately placed in a treatment room without waiting in the lobby. The safest strategy to avoid left without being seen (LWBS) or elopement would begin. The patient would be placed in a prepared treatment room with a sitter or security to monitor the patient. Safe Room Guidelines would be utilized. The patient would be evaluated by a physician, given a physical exam, and medically cleared for behavioral health services. The Psychiatric Evaluation Team (PET) would be contacted following facility guidelines. The physician would determine the necessity for an involuntary hold (1013/2013) as soon as possible. High-Risk Behaviors would include a high risk for suicide or other concerning behaviors, including risk to self, a risk to staff, risk to other patients, acute psychosis, and elopement risk. The policy further revealed that the RN could determine the need for continuous observation and, pending involuntary hold, request patient observation by staff. The physician and security would be notified in the event of elopement. Documentation in the medical record and incident reporting would be completed.

A review of the facility's policy titled "Emergency Medical Treat and Labor Act - EMTALA" policy #LD-108, revised 12/21, revealed the hospital would provide an MSE within the capability of the ED to determine if an Emergency Medical Condition (EMC) existed. The policy further revealed that an individual had come to the emergency department when the individual presented to the ED and requested examination or treatment or the individual was on hospital property, and there was reason to believe the individual needed treatment. Triage was not a medical screening exam.

A review of an EMS report dated 5/22/22 at 5:37 a.m. revealed that EMS arrived on scene to assess P#7 with complaints of a possible asthma attack that followed an altercation. P#7 reported being upset. Various minor abrasions were observed to P#7's arms, legs, and back. P#7 was transported to the ED. While in the ambulance, P#7 stated, I want to die. P#7 said, I just don't want to live anymore; I don't have anything to live for. P#7 arrived at the ED at 6:14 a.m., and a verbal report of all EMS findings and interventions was given to the RN that assumed P#7's care.

A medical record review revealed that P#7 presented to the ED via EMS. The chief complaint was depression and psychiatric evaluation. P#7 was triaged at 6:52 a.m. and was assigned an acuity level of two. A review of the Behavioral Risk Screening at 6:54 a.m. revealed that an answer to whether P#7 had wished to be dead in the past month was 'yes.' The result of the Behavioral Risk Screening was low acute. P#7 was transferred to the ED Overflow Unit at 6:56 a.m. The physician's first contact with P#7 was at 7:41 a.m. Medical Doctor (MD) FF ordered a Behavioral Health Consult at 7:42 a.m. A review of the ED notes by Registered Nurse (RN) GG at 8:15 a.m., 8:30 a.m., and 8:45 a.m. revealed that P#7 was not in the assigned room. P#7 was discharged at 8:45 a.m., and a disposition was documented as Left Without Being Seen (LWBS). A review of ED nurse notes failed to reveal documentation that P#7 was monitored by a sitter or that a 1013 had been initiated.

An interview was conducted with MD BB on 7/26/22 at 1:33 p.m. in the conference room. MD BB stated that the first step for a psychiatric patient arriving at the ED was to assess the patient in triage to determine if the patient was medically stable. If a patient had suicidal or homicidal ideations, a sitter would stay with the patient in the exam room. MD BB said if there were any questions about whether the patient was suicidal or homicidal, MD BB would put a 1013 on the patient, and the patient would be evaluated. MD BB further said that if a 1013 patient wanted to leave the ED, enough security would be involved to subdue the patient so there was no injury or doubts that the patient could be subdued. MD BB further said that if a patient came to the ED for suicidal ideations, then denied being suicidal, the physician would still evaluate the patient. MD BB stated he would want to get a shared decision with a social worker. MD BB explained that if a patient were suicidal, the patient would wait at the facility with a sitter until evaluated and transferred. MD BB further confirmed that a 1013 had not been initiated for P#7.

An interview was conducted with the ED Charge Nurse, RN EE, on 7/26/22 at 2:13 p.m. in the conference room. RN EE stated that if a patient were suicidal or homicidal, the patient would be placed in one of the behavioral health rooms where security was present. A physician would assess the patient to see if a 1013 was needed. Staff was always available to watch a patient, and there would be documentation that there was a sitter. If a patient denied being suicidal, the nurse would try to have the physician talk to the patient to see if the patient was a harm to themselves or others. If a psychiatric patient had not been assessed by a physician and wanted to leave the ED, the staff would try to get the patient to stay. RN EE stated that the nurses could not physically hold a patient who wanted to leave. If a patient came to the ED with suicidal ideations and had not been screened prior to leaving, dispatch would be notified that a suicidal patient had left and try to get the patient to come back to the ED. RN EE further said that high-risk suicide patients were always given an acuity of two and were required to have a sitter. If a patient came to the ED for a psychiatric assessment, then denied being suicidal, the provider would try to see the patient. RN EE further acknowledged that P#7 should have had a sitter.

An interview was conducted with the ED Manager, (RN) AA, on 7/26/22 at 2:45 p.m. in the conference room. RN AA stated the first step for every patient was registration and triage. If a patient came through the front door of the ED, the patient would be screened by a nurse. If a patient arrived by ambulance, the patient would be met by the charge nurse, who would assign room placement. If a physician were available, the physician would try to see the patient before the patient was unloaded. RN AA said suicidal/homicidal patients would have to go to a safe room. While waiting for placement, high-risk patients would require one-to-one (1:1) observation. If a patient wanted to leave before being assessed and there was not an assigned hold order, there would be an attempt to get the patient to stay to allow the physician to evaluate the patient. Security would be called if there was a hold order and the patient wanted to leave the ED. If a patient were combative, the police would be called. If security was not on hand and a patient wanted to hurt a nurse, the nurses had been instructed to let the police handle the patient. RN AA acknowledged that the process of having a sitter should have been followed for P#7.

Based on a review of the facility's policy and procedures, a review of medical records, and interviews with facility staff, it was determined that the facility failed to provide Stabilizing treatment for one (1) out of 24 sampled (Patient #6). P#6 was determined to have an emergency medical condition (EMC) by a facility medical doctor, but was not given stabilizing treatment and appropriately transferred to a receiving facility.

The findings included:

A review of the facility's policy titled "Emergency Medical Treat and Labor Act - EMTALA" policy #LD-108, revised 12/21, revealed the hospital would provide an individual who was determined to have an EMC such further examination and treatment as was required to stabilize the emergency medical condition (EMC) or arrange transfer of the individual to another medical facility. An EMC was a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing an individual's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. If an MSE were determined to exist, the hospital would provide the treatment necessary to stabilize the EMC, admit the individual to the hospital to stabilize the EMC or arrange for an appropriate transfer if the individual's EMC was beyond the capabilities of the hospital.

A review of an emergency department (ED) medical record revealed that P#6 arrived at the ED by emergency medical services (EMS) on 7/21/22 at 10:33 a.m. for suicidal ideations. A review of the Behavioral Risk Screening by Registered Nurse (RN) CC at 11:08 a.m. revealed that an answer to whether P#6 had wished to be dead in the past month was 'yes.' The result of the Behavioral Risk Screening was High Acute Behavioral Risk. A 1013 form for P#6 was signed by medical doctor (MD) BB at 11:17 a.m. A review of physician orders written by MD BB revealed that a face-to-face sitter was ordered at 11:20 a.m. A review of ED flowsheets at 11:42 a.m. revealed that P#6 required an escort to the restroom. A Nurse note written by RN DD at approximately 11:50 a.m. revealed that after P#6 provided a urine sample, the patient walked out of the front ED lobby door. Facility security and local law enforcement were notified. A review of the Medical Screening Exam (MSE) notes by MD BB at 11:51 a.m. revealed that P#6 had a plan to shoot himself in the head and had two guns at home. P#6 had persistent depression for over two weeks, felt alone, and could not live by guiding himself. Primary symptoms included a dysphoric mood (inability to enjoy life) and feelings of worthlessness. P#6 admitted to suicidal ideations and a plan to attempt suicide. A 1013 was initiated, but P#6 eloped before being fully secured.

The facility failed to recover P#6 after elopement and provide stabilizing treatment until a transfer to an appropriate facility could be completed.

An interview was conducted with MD BB on 7/26/22 at 1:33 p.m. in the conference room. MD BB stated that the first step for a psychiatric patient arriving at the ED was to assess the patient in triage to determine if the patient was medically stable. If a patient had suicidal or homicidal ideations, a sitter would stay with the patient in the exam room. MD BB said if there were any questions about whether the patient was suicidal or homicidal, MD BB would put a 1013 on the patient, and the patient would be evaluated. MD BB further said that if a 1013 patient wanted to leave the ED, enough security would be involved to subdue the patient so there was no injury or doubts that the patient could be subdued. MD BB determined that P#6 had suicidal intent, so a 1013 was initiated. MD BB said the nurse did not realize the gravity of the situation, and it was a situation where there was not a sitter. P#6 was in a hall bed, was not restrained, and left the ED. Local law enforcement was informed to pick up P#6.

An interview was conducted with the ED Charge Nurse, RN EE, on 7/26/22 at 2:13 p.m. in the conference room. RN EE stated that if a patient were suicidal or homicidal, the patient would be placed in one of the behavioral health rooms where security was present. A physician would assess the patient to see if a 1013 was needed. There would always be someone watching a patient, and there would be documentation that there was a sitter. RN EE stated that the nurses could not physically hold a patient who wanted to leave. RN EE said P#6 had not been placed in a room and was on a hall stretcher. There were no rooms available in the behavioral area. RN EE said a sitter was in the hallway beside P#6 and was asked to watch P#6 until another sitter could sit with him. RN EE stated that at the time, another sitter was not available to sit with P#6. RN EE further said that high-risk suicide patients were always given an acuity of two and were required to have a sitter.

An interview was conducted with the ED Manager, (RN) AA, on 7/26/22 at 2:45 p.m. in the conference room. RN AA stated suicidal/homicidal patients in the ED would have to go to a safe room. While waiting for placement, high-risk patients would require one-to-one (1:1) observation. If a patient wanted to leave before being assessed and there was not an assigned hold order, there would be an attempt to get the patient to stay to allow the physician to evaluate the patient. Security would be called if there was a hold order and the patient wanted to leave the ED. If a patient were combative, the police would be called. If security was not on hand and a patient wanted to hurt a nurse, the nurses had been instructed to let the police handle the patient.

A telephone interview was conducted with Sitter (S) KK on 7/28/22 at 1:08 p.m. S KK stated that when P#6 was in the hallway, S KK was watching three patients. S KK said she looked down to complete documentation for her patients, and when S KK looked back up, P#6 was not there. S KK said she thought P#6 had gone with the nurse, but nobody in the ED had seen P#6. S KK said the ED staff were panicking and trying to locate P#6. S KK further stated that the most she would watch at one time were three patients. If a patient needed something, S KK would notify the nurse and would not leave her post. S KK said she was still in the hallway when P#6 got up to do a urine sample and then walked out of the ED.

A telephone interview was conducted with RN CC on 7/29/22 at 9:28 a.m. RN CC stated that P#6 came to the ED by EMS and was brought straight to the hallway on a stretcher. During triage, P#6 told RN CC that there was stress at home, and he was having suicidal thoughts without a plan. All the ED rooms were full, and P#6 stayed in the hallway. RN CC said she was familiar with the policy concerning behavioral health patients in the ED, and the higher the risk, the higher the acuity. High risk should have a sitter. RN CC explained that the day P#6 came to the ED, there was only one sitter who was watching two other patients.

A telephone interview was conducted with RN DD on 7/29/22 at 9:39 a.m. RN DD stated that P#6 came to the ED for a psychiatric evaluation and was not suicidal. P#6 was in the hallway since there were no exam rooms available in the ED. The medical screening exam took place in the hallway. RN DD was transferring a patient out of the ED to make room for P#6. When RN DD returned to move P#6, P#6 was not there. The charge nurse, RN EE, was involved, and Security pulled up camera footage. P#6 was observed on video leaving the ED between 11:50 a.m. and 12:00 p.m. P#6 walked out the front door of the ED unaccompanied. The police department was contacted and would be on the lookout for P#6. The police never called or came back to the facility. RN DD further said a sitter was watching P#6, but the other patients were difficult, and the sitter was in a room with another patient. RN DD further said that security would be involved if a 1013 patient tried to leave.