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Based on records reviewed and interviews the Hospital failed to ensure that, for 3 of 30 patients (Patients #2, #5 and #11) who presented to the Hospital seeking emergency care, an appropriate Medical Screening Examination was conducted by medical personnel (Behavioral Health Clinicians) determined qualified by Medical Staff Bylaws to determine whether or not an Emergency Psychiatric Medical Condition existed.

Findings included:

The Medical Staff Bylaws, dated 11/15/16, indicated the Hospital Governing Body approved, including "but not limited to", Physician Assistants, Clinical Nurse Specialists, and Nurse Anesthetists as Allied Health Professionals able to render healthcare, treatment and services under the supervision of a Physician, within their scope of practice and consistent with the granted privileges. The Medical Staff Bylaws did not indicate a clarification for "but not limited to". The Medical Staff Bylaws did not indicate that Licensed Independent Clinical Social Workers (LICSW), Licensed Clinical Social Workers (LCSW) and Licensed Mental Health Councilors (LMHC) were granted privileges. The Medical Staff Bylaws did not explicitly indicate the designation of qualified medical personnel approved by the Governing Body of the Hospital to conduct Medical Screening Examinations.

The Medical Staff Rules and Regulations, dated 11/15/16, indicated that if the attending practitioner did not have expertise with suicidal patients, homicidal patients or patients with severe psychiatric symptoms, the practitioner was required to consult with a qualified physician.

The policy titled EMTALA, dated 9/2016, indicated that patients who came to the Hospital Emergency Department and requested an examination for a medical condition would receive, within the capability of the Hospital, an appropriate medical screening examination provided by qualified medical personnel. The EMTALA policy indicated qualified medical personnel would perform medical screening examinations to determine within reasonable medical probability if patient was suffering from an emergency medical condition. The EMTALA policy did not indicate a definition of qualified medical personnel.

The Hospital policy titled Emergency Department Behavioral Health Consultations, dated 12/1990, indicated the Behavioral Health Clinicians performed psychiatric evaluations in the Emergency Department, kept Emergency Department Physicians informed of the psychiatric patient's evaluation progress and of recommendations for plans-of-care and level-of-care including recommended patient disposition (inpatient psychiatric hospitalization, outpatient psychiatric treatment or was safe for discharge) .

1.) The Emergency Department Clinical Chart, dated 3/3/17, indicated Patient #2 presented to the Emergency Department for a Behavioral Health Evaluation. The Emergency Department Clinical Chart indicated an Emergency Department Physician conducted a patient history, a review of systems and physical examination. The Emergency Department Clinical Chart did not indicate that the Emergency Department Physician conducted a psychiatric examination. The Emergency Department Physician Note indicated the Emergency Department Physician determined Patient #2 was medically stable (safe) for treatment and disposition as per the Behavioral Health Clinician's evaluation.

The Behavioral Health Consult Evaluation, dated 3/3/17, indicated a Licensed Independent Clinical Social Worker (LICSW) conducted the Behavioral Health Evaluation. The Behavioral Health Evaluation included information regarding Patient #2's presenting problem, previous treatment history, risk assessment (risk for self or other harm assessment), patient and family psychiatric or substance history, mental status examination, preliminary impression and diagnosis on evaluation and plan for voluntary hospitalization. The Behavioral Health Evaluation indicated the LICSW reviewed the evaluation and disposition with both the Psychiatrist and the Emergency Department Physician.

2.) The Emergency Department Clinical Chart, dated 2/1/17, indicated Patient #5 presented to the Emergency Department for a Behavioral Health Evaluation. The Emergency Department Clinical Chart indicated an Emergency Department Physician conducted a patient history, a review of systems and a physical examination. The Emergency Department Clinical Chart indicated the Emergency Department Physician conducted a brief psychiatric examination. The Emergency Department Clinical Chart indicated the Emergency Department Physician determined Patient #5 to be medically stable for treatment and disposition as per the Behavioral Health Clinician's Evaluation.

The Behavioral Health Consult Evaluation, dated 2/1/17, indicated a Licensed Independent Clinical Social Worker (LICSW) conducted the Behavioral Health Evaluation. The Behavioral Health Evaluation included information regarding Patient #5's presenting problem, previous treatment history, risk assessment, patient and family psychiatric or substance history, mental status examination, preliminary impression and diagnosis on evaluation and plan for an inpatient psychiatric hospitalization. The Behavioral Health Evaluation indicated the LICSW reviewed the evaluation and disposition with both the Psychiatrist and Emergency Department Physician.

3.) The Emergency Department Clinical Chart, dated 10/17/16, indicated Patient #11 presented to the Emergency Department for a Behavioral Health Evaluation. The Emergency Department Clinical Chart indicated an Emergency Department Physician conducted a patient history, a review of systems and a physical examination. The Emergency Department Clinical Chart indicated the Emergency Department physician conducted a brief psychiatric examination. The Emergency Department Clinical Chart indicated the Emergency Department Physician determined Patient #11 to be medically stable for treatment and disposition as per the Behavioral Health Clinician's Evaluation.

The Behavioral Health Consult Evaluation, dated 10/17/16, indicated a Licensed Clinical Social Worker (LCSW) conducted the Behavioral Health Evaluation. The Behavioral Health Evaluation included information regarding Patient #11's presenting problem, previous treatment history, risk assessment, patient and family psychiatric or substance history, mental status examination, preliminary impression and diagnosis on evaluation and plan for an inpatient psychiatric hospitalization. The Behavioral Health Evaluation indicated the LCSW reviewed the evaluation and disposition with both the Psychiatrist and Emergency Department Physician.

The Emergency Department Clinical Chart, dated 1/1/17, indicated Patient #11 presented to the Emergency Department for a Behavioral Health Evaluation. The Emergency Department Clinical Chart indicated an Emergency Department Physician conducted a patient history, a review of systems and a physical examination. The Emergency Department Clinical Chart indicated the Emergency Department Physician conducted a brief psychiatric examination. The Emergency Department Clinical Chart indicated the Emergency Department Physician determined Patient #11 to be medically stable for treatment and disposition as per the Behavioral Health Clinician's Evaluation.

The Behavioral Health Consult Evaluation, dated 1/1/17, indicated a Licensed Independent Clinical Social Worker (LICSW) conducted the Behavioral Health Evaluation. The Behavioral Health Evaluation included information regarding Patient #11's presenting problem, previous treatment history, risk assessment, patient and family psychiatric or substance history, mental status examination, preliminary impression and diagnosis on evaluation, and plan for an inpatient psychiatric hospitalization. The Behavioral Health Evaluation indicated the LICSW reviewed the evaluation and disposition with both the Psychiatrist and Emergency Department physician.

The Surveyor interviewed the Behavioral Health (Psychiatric) Operations Director at 2:30 P.M. on 3/6/17 and at 2:30 on 3/8/17, the Risk Manager at 9:30 A.M. on 3/8/17, the Emergency Department Medical Chair at 11 A.M. on 3/8/17 and the Behavioral Health Triage Team Leader at 1:30 P.M. on 3/8/17. The Behavioral Health Operations Director, the Risk Manager and the Behavioral Health Triage Team Leader said the Hospital's Behavioral Health Clinicians conducted the psychiatric examinations in the Emergency Department.

The Behavioral Health Operations Director said the psychiatric examination included information gathering and a mental status examination. The Behavioral Health Operations Director said the Behavioral Health Clinicians conducted the psychiatric examination because they were licensed by the State and qualified to diagnose and treat mental illness. The Behavioral Health Operations Director said the patient's disposition was determined by the Hospital Psychiatrist and the Emergency Department Physician. The Behavioral Health Operations Director said that the Behavioral Health Clinician and a Hospital Psychiatrist together determined if the patient needed inpatient psychiatric hospitalization or was safe for discharge.

The Risk Manager said the Hospital Psychiatrist made the decisions about patient disposition.

The Emergency Department Medical Chair Person said the process was comparable to an Emergency Department Physician requesting a Cardiology (heart) consultation and a cardiologist (cardiac physician) assigning a Physician Assistant to conduct a cardiac examination on a patient in the Emergency Department. The Emergency Department Medical Chair said that Allied Health Professionals were part of the Medical Staff and included Physician Assistants. The Emergency Department Medical Chair Person said the Hospital Psychiatrist and the Emergency Department Physician made the decisions about the patients need for psychiatric inpatient hospitalization or discharge.

The Behavioral Health Triage Team Leader said the Behavioral Health Clinicians consisted of Licensed Independent Clinical Social Workers, Licensed Clinical Social Workers and Licensed Mental Health Counselors. The Behavioral Health Triage Team Leader said that the Behavioral Health Clinicians conducted level-of-care assessments. The Behavioral Health Triage Team Leader said level-of-care assessments were assessments to determine the patient's need for inpatient psychiatric hospitalization, outpatient psychiatric treatment or safe for discharge.

The Behavioral Health Triage Team Leader said the Behavioral Health Clinicians recommended the patients disposition (inpatient psychiatric hospitalization, outpatient psychiatric treatment or safe for discharge) to the Emergency Department physician. The Behavioral Health Triage Team Leader said that the Psychiatrists did not evaluate the psychiatric patients that presented to the Emergency Department seeking care.

The Surveyor interviewed the Risk Manager at 1:00 P.M. on 3/6/17. The Risk Manager said the Hospital did not credential (approved by the Governing Body according to Medical Staff Bylaws) the Behavioral Health Triage Team Clinicians who conducted the Psychiatric Examinations for patients in the Emergency Department.

The Emergency Department Medical Chair said that the Behavioral Health Clinicians were not part of the Medical Staff.

The Behavioral Health Operations Director said the Hospital did not credential the Behavioral Health Clinicians who conducted Psychiatric Examinations in the Emergency Department.

The Surveyors interviewed the Behavioral Health Operations Director at 2:30 on 3/8/17. The Behavioral Health Operations Director said that the LICSWs, LCSWs and LMHCs all had the same job description (Behavioral Health Triage Clinician).

The document titled Triage Clinician, dated 4/6/09, indicated a job description for Triage Clinicians who conducted evaluations of patients that presented to the Emergency Department for psychiatric or substance abuse services to determine level-of-care and appropriate disposition. The Job Description indicated that the Triage Clinician reviewed all evaluations and dispositions with a Psychiatrist. The Job Description indicated that Triage Clinicians formulated follow-up care for patients discharged from the Emergency Department.

The Hospital policy titled Emergency Department Behavioral Health Consultations, dated 12/1990, indicated the Behavioral Health Triage Team Clinicians performed psychiatric evaluations in the Emergency Department. The Emergency Department Behavioral Health Consultations Policy indicated the Behavioral Health Triage Team Clinicians kept Emergency Department Physicians informed of the psychiatric patient's evaluation progress as well as recommendations for level-of-care and disposition.

The Behavioral Health Operations Director said Behavioral Health Triage Team Clinicians conducted psychiatric examinations on all psychiatric patients seeking emergency care, even the psychiatric patients from the Emergency Service Program (ESP). The Behavioral Health Operations Director said the ESP was a State program.

The Emergency Department Medical Chair Person said the ESP was a government imposed service, the ESP staff documented patient psychiatric examinations on the ESP forms and he did not know if the ESP staff was credentialed. The Emergency Department Medical Chair Person said he did not know if the Hospital had a contract with the ESP.

The Surveyors interviewed the Risk Manager and the Behavioral Health Operatons Director at 1:30 P.M. on 3/8/17. The Risk Manager and the Behavioral Health Operations Director said that the Hospital did not have a contract with the ESP Service (whose staff conducted Psychiatric Examinations on patients in the Hospital Emergency Department). The Risk Manager said that the ESP staff members were employed by the State. The Behavioral Health Operations Director said that the Hospital should have a contract with the ESP and that he did not know why the Hospital did not have a contract with the ESP.

The Email titled Emergency Department Service Contracts, dated 3/6/17, did not indicate the Hospital had a Contract, an Agreement or a Memorandum of Understanding with the ESP.

Based on records reviewed and interview, the Hospital failed to ensure a complete (accurate) Central Log for 2 of 30 patients (Patients #4 and #12) that came to the Emergency Department seeking assistance.

Findings included:

1.) The Central Log, dated 1/14/17, indicated the Hospital transferred Patient #4 to an Outside Hospital.

The Emergency Department Physician Note, dated 1/14/17 at 11:10 P.M., indicated an Emergency Department Physician evaluated Patient #4 safe for discharge with instructions for evaluation of an orbital (bone around the eye) fracture and transfer by car directly to the Outside Hospital.

The Authorization for Transfer Form, dated 1/25/17, indicated a private car transferred Patient #4 to the Outside Hospital.

2.) The Central Log, dated 1/21/17, indicated the Hospital transferred Patient #12 to an Outside Hospital.

The Emergency Department Physician Note, dated 1/21/17 at 10:27 A.M., indicated an Emergency Room Physician evaluated Patient #12 safe for discharge and recommended Patient #12 be evaluated at an Outside Hospital.

The Authorization for Transfer Form, dated 1/25/17, indicated the Hospital did not transfer Patient #12 to an Outside Hospital. The Authorization for Transfer Form indicated a private car transferred Patient #12 to the Outside Hospital.

The Surveyor interviewed the Emergency Department Medical Chair Person at 11 A.M. on 3/8/17. The Emergency Department Medical Chair Person said in review of Patients #4 and Patient #12's medical records, they were stable (safe) for discharge and could driven by private car to the Outside Hospital for follow-up care. The Emergency Department Medical Chair Person said he did not know why Emergency Department Physicians documented in Patient #4 and Patient #12's Medical Records using the Authorization for Transfer Form.