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Based on observation, record review, and interview, the facility (Hospital A) failed to comply with 489.24 and provide an appropriate medical screening exam for three of 32 patients (Patients #6, #26, #29)

1. Hospital A failed to provide an appropriate medical screening for Patient #6 to determine the presence of a medical emergency. On 10/01/23 Patient #6 was brought to Hospital A by Police who requested care on behalf of the patient. Patient #6 had been emergently detained, made nonsensical statements regarding God's creation, Satan, the matrix and three universes. Intake and Administrative Staff at Hospital A told the officers that they did not have a bed for Patient #6 and to take him to Hospital B more than 47 miles away. Police and Patient #6 arrived at Hospital B 73 minutes later. At that time, Patient #6 was in a psychotic state, extremely paranoid and agitated, and required inpatient stabilization due to his life threatening and destructive behavior to himself and others. Within less than an hour after admission, Patient #6 required emergency behavior and medication interventions when Patient #6 became an imminent danger to others in the treatment environment.
2. Hospital A failed to provide a medical screening examination for Patient #26 on 10/02/23 to determine whether or not an emergency medical condition existed.
3. Hospital A failed to provide evidence that a medical screening had been completed for Patient #29 to determine the existence of an emergency medical condition on 10/28/23.

Refer to A2406

Hospital A failed to complete appropriate transfer forms and /or complete a Memorandum of Transfer (MOT) for seven out of 32 patients who required emergency medical treatments.
Refer to A2409

Based on observation, record review, and interview, the hospital failed to maintain a central log on each individual who came to the emergency department for 1 of 20 (Patient #6) patients in that, on 10/01/2023, Patient #6 presented to the hospital for evaluation and was not listed on the hospital's central log.

Findings included:

On 10/01/23 at approximately 4:56 AM, Patient #6 arrived at Hospital A (University Behavioral Health) via Flower Mound Police Department. Officers #1, #2, and #3 were observed via body camera surveillance video escorting Patient #6 into Hospital A to be evaluated for a psychiatric medical condition. The body camera video surveillance revealed Officers #1, Officer #2, and Officer 3# were informed by Staff #9 (Intake Nurse) and Staff #6 (Chief Executive Officer) that a bed was not available for a male patient and requested that the officers seek care at another facility. Shortly after, Patient #6 is seen being escorted off of the Hospital premises by Flower Mound Police Officers.

A review of the facility EMTALA Intake Log on 11/14/2023 revealed on 10/01/2023, the document did not note Patient #6 as having come to the hospital for the evaluation of a psychiatric medical condition, as their name was not listed on the EMTALA Intake Log.

A review of the facility policy titled "Memorandum of Transfer (MOT)" status active, last revised on 5/2017 revealed, Pg. 2. "PROCEDURE: Responsibilities of Hospital Administration
...A central log must be kept in the intake/assessment area noting each individual who comes to the hospital seeking treatment. (This log must be kept for a minimum of 5 years).
Document in the log whether the individual:
Refused treatment
Was refused treatment
Was transferred, admitted and treated, or stabilized and transferred
Was discharged
Any other significant related information..."

In an interview with Staff #1 (Director of Intake) on 11/14/2023at 5:00 PM, he verified Patient #6's name was not listed on the EMTLA Intake Log on 10/01/23 even though it was confirmed Patient #6 had arrived seeking evaluation for a psychiatric medical condition.

Based on observation, medical record reviews, facility documentation reviews, and interviews, the facility (Hospital A) failed to provide a medical screening examination (MSE) for three (Patients #6, #26, and #29) of 20 patients whose records were reviewed. Patient #6 left the facility via police escort to seek treatment at Hospital B, where his admitting diagnosis to Hospital B included Bipolar Disorder, Manic, severe with psychotic features. Patient #6 was hospitalized for four days with an acute psychiatric life-threatening illness.
Within less than one hour after admission, Patient #6 required emergency behavioral and medication interventions after disrobing, making graphic threats to the safety of other patients, and initiating a physical altercation.
Patients #26 and #29 left Hospital A via 911/Emergency Medical Service transport with no documented evidence of ever receiving a medical screening examination.

Findings included:

Hospital A Review
A review of the bodycam video surveillance at Hospital A on 10/01/2023 provided by Officer #1, Officer #2, and Officer #3 from Flower Mound Police Department from 4:56:10 am to 5:12:30 am revealed the following:

4:56:10 AM- Patient #6 exits the back of the police vehicle, escorted by Officers.

4:56:30 AM - Officers #1, #2, and #3 and Patient #6 arrived at Hospital A. The front of Hospital A can be seen in the video.

4:56:57 AM - Officers and patient enter the first door corridor and press the on-call button on the right wall.

4:58:18 AM - Staff member #9, Intake Registered Nurse, in gray scrubs, is seen approaching the locked facility door to open it and allowing officers and patients into the lobby intake area.

4:58:37 AM - Officer #2 provides Staff #9 with paperwork and introduces the patient.

4:58:57 AM - Staff #9 reviews paperwork and informs Officer #3 that the facility has no beds and cannot take Patient #6. The House Supervisor states Hospital B is the facility that would accept the patient.

Patient #6 asks, "Can you please take me? I am so thirsty. I'll be good."

4:59:27 AM - Staff #9 exits the intake area and states she will return. Patient #6 is seen walking down the hall away from the officers.

5:01 AM - Staff # 11, House Supervisor, approaches and introduces herself as House Supervisor. She informs the officers that the facility does not have any beds except a female bed.

Officer #3 informs Staff # 11 of the requirement to provide a medical screening.

5:02:15 AM - Staff # 11 is seen calling someone on her phone and then exits the intake area.

5:02:51 AM - Staff #9 brings Patient #6 water. Officers attempt to provide water. The patient sniffs the cup and refuses to drink properly. Officers informs him that they would not provide water if he was uncooperative.

5:03:18 AM - Staff #9 informs officers that everyone is being sent to Facility B. Staff #9 exits the intake area and returns to the back.

5:05:30 -5:08:50 AM - Patient #6 begins to tell the officers, "Adam and Eve created a baby, and that baby is Satan ...son of God is [expletive]." Patient #6 continues to speak about God's creation, Satan, the matrix, and three universes. Patient #6 is seen rocking back and forth, talking about Satan.

5:08:50 AM - Patient #6 sits on the ground against the intake counter.

5:09:11 AM - Staff # 11 enters the intake area and indicates Staff #6 was on the phone.

5:09:29 AM (View from Officer #3's Body Camera) - Officer #3 asks Staff #11 to identify themselves and Staff # 9. Staff #11 indicates she does not know who Staff #9 is.

Staff #11 makes a call and hands the phone to Officer #2. Officer #3 asks Staff #11 if she was refusing to provide medical treatment. Staff # 6, Chief Executive Officer, is heard on the phone stating, "We have to do a medical screening. We can do that, but we cannot accept the patient because we do not have a bed. We can do a medical screening."

5:09:49 AM - Officer #3 asks Staff #6, "So yes, you are refusing him?" Staff #6 responds, "Yes." Officer #2 asks Staff #6 to state their name and notates it on Officer #2's notepad.

5:10:09 AM - Staff #11 shrugs her shoulders, states, "We can't do anything," and walks away. Officer #2 is seen assisting Patient #6 and asks him to stand. Patient #6 states he does not want to get up. Patient #6 is assisted by Officers #1 and #3.

5:12:30 AM - Staff #11 returns to the lobby and unlocks the door. Officers #1, #2, #3, and Patient #6 exit the building. Video ends.

A review of Hospital A policy titled "Appropriate Us of Involuntary Commitment," Status Active, ID 12148859, Last Revised on 08/2020 revealed,
"WHEN A PATIENT COMES TO THE HOSPITAL - EMTALA SCREEN TO IDENTIFY AN EMERGENCY CONDITION The federal Emergency Medical Treatment and Labor Act (EMTALA) requires a medical screening examination (MSE) for every person who presents to the Hospital and requests an assessment, whether the person presents on his/her own or is brought in by a peace/police officer. The purpose of the MSE is to determine whether the person has an emergency condition, which includes both medical and psychiatric/ substance abuse emergencies. Thus, an EMTALA MSE includes a preliminary psychiatric assessment."

Record review of Patient #6's medical record (Hospital B):

A review of the Patient Demographic Profile for Patient #6 at Hospital B reflected the patient was brought in by Police involuntarily for inpatient admission on 10/01/23 at 6:38 AM. He was discharged on 10/05/23 at 10:40 AM.

Patient #6's Hospital B Preadmission Evaluation and Medical Clearance Screening dated 10/01/23 at 6:36 AM revealed the patient had arrived at Facility B at 6:25 AM on an Emergency Detention Order (EDO). Staff noted the patient's delusional thinking and stated the patient believed he was "God." The patient displayed "rambling speech" and made "nonsensical statements ... incoherent ... believes he is 17 years old ...per EDO believes officers are from a different timeline ..." Patient #6 stated that he was a "Super hero," believed people were "on Universe one and he is preventing Universe two and three from taking over Universe one ...". Patient #6 was noted to be "extremely paranoid, has hallucinations and presents with agitation ..."

Hospital B Physician's Preadmission Examination and Admitting Orders dated 10/01/23 at 7:52 AM reflected Patient #6 was admitted to inpatient psychiatric care as an involuntary patient with preliminary psychiatric impressions that included Schizophrenia Paranoid Type. The patient's precautionary status included staff observation for assault/homicide, elopement, and self-harm.

Hospital B Standardized Intake Assessment dated 10/01/23 at 6:42 AM reflected Patient #6 was brought to the Hospital by Police and appeared to be in a psychotic state on arrival and asking whether staff were on his or "Satan's side." Staff noted that Patient #6 was " ...confused ..." and stated that he was there "to prevent timeline 2 and 3 to take over ..." Patient #6 needed inpatient acute psychiatric care and 24-hour monitoring for "life threatening, destructive or disabling [behavior] to self or others" and "acute behavioral control."

Seclusion/Restraint/Emergency Medication Order dated 10/01/23 at 7:15 AM reflected Patient #6 received intramuscular administration of Haldol 10mg, Lorazepam, 2mg, and Benadryl 50mg for "agitation." Nursing noted Patient #6 was of "imminent danger to self ...imminent danger to others ....pt [Patient#6] newly admit to unit, dysregulated the unit by making graphic threats to harm peers ...took off his pant in the hallway ...attacking peer ...unable to redirect ..."

Patient #6's Nursing Progress Notes, undated, reflected "at around 0715 patient [was] brought to unit by Intake staff ...patient began to pacing the hallway, yelling, making graphic threats to harm peers, took off his pants on the hallway, naked, dysregulated the unit by following peers and attempted to hit them, peer retaliated by hitting him on the hallway. All attempts to redirect failed. On call provider notified with order of emergency meds..."

Patient #6's Comprehensive Psychiatric Evaluation dated 10/01/23 at 2:00 PM reflected the reason for current hospitalization was Psychosis and Aggression. The patient believed he was "God" and "from a different timeline ..." The patient had asked the Police to take him to the Hospital. The patient had multiple cuts on his arms. Patient #6 had an "unkempt" appearance, was "agitated" and had "pressured speech." He was in an "angry" mood and with "labile" affect. The initial plan of care was to reduce the patient's "hallucinations agitation" and "minimize aggressive behavior." The patient was physician noted to be a danger to himself and others.

Patient #6's Hospital B Discharge Summary, signed by the attending physician on 10/28/23 at 12:51 PM, reflected Patient #6's initial and discharge diagnoses included Bipolar Disorder, Manic, severe with psychotic features. The reason for the patient's admission included " ...increased mood instability ... disturbance in thought process ...had physical altercation, believing he was God ...being from a different timeline ...continued to make odd references ...impairments of thought process ...to include increased risk of harm to others ...presented with cuts to arms and legs as well ...decompensated and admitted for inpatient crisis stabilization ..." The patient's prognosis at discharge was "fair."

A review of the medical record for Patient #26 revealed, the patient arrived to the facility on 10/2/2023. The patient was sent via 911/EMS (Emergency Medical Services) for difficulty breathing. The medical record did not include documentation to support a medical screening examination 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 exists.

A review of the medical record for Patient #29 revealed, the patient arrived to the facility on 10/28/2023. The patient was sent via 911/EMS (Emergency Medical Services) for chest paint. The medical record did not include documentation to support a medical screening examination 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 exists.

Interviews:
In an interview with Staff #6, Chief Executive Officer (CEO), on 11/14/2023, he revealed he was on call the weekend of 10/1/2023. Staff #6 stated his understanding is that everyone has to have a medical screening, even if they do not have a bed. He reviewed the video surveillance. He confirmed he did advise the Police that the patient was being refused. He did not know that they (facility staff) did not make a phone call to the other facility. He also revealed intake staff did not indicate that they needed stabilizing treatment; otherwise, they would have followed EMTALA.

In an interview with Staff #4, the Chief Nursing Officer stated on 11/14/2023, "I would have expected the House Supervisor to provide an MSE. In this situation, she escalated to the CEO, and the officers cut it and turned around and left. Everyone, at minimum, needs to get a medical assessment. If the facility is at capacity, they can take the patient in. They have the ability to consolidate. They will still admit the patient and transfer after that. They might have a quick phone call, reach out to MD, and be okay to consolidate people in. We are required to provide a medical screening exam."

Based on record review and interviews with staff, the Hospital failed to follow facility policy when they did not complete appropriate transfers for seven out of 32 records (Patients #3, #25, #26, #27, #28, #29, and #30) requiring emergency medical treatments and continuity of care. The facility failed to notify the receiving Hospital of patient transfer, failed to secure an accepting physician at the receiving Hospital, and did not complete a Memorandum of Transfer (MOT) form.

The findings included:

Record Review

Memorandum of Transfer records were reviewed for 32 patients between June 26, 2023, through October 11, 2023.

Patient #3
Date of Visit 10/23/2023- The patient was transferred to another facility for continuity of care. MOT did not include a physician's signature.

Patient #25
Date of Visit 11/2/2023- The patient was sent out on emergent transfer for blood pressure 157/105. MOT was missing the acceptance of the Hospital and transfer of hospital information. The Physician's signature was also missing.

Patient #26
Date of Visit 10/2/2023- The patient was sent via 911/EMS (Emergency Medical Services) for difficulty breathing. The MOT does not include any hospital information regarding transferring or accepting physicians. The Physician's signature was missing. The patient's signature was missing, and a checked box on the form indicated that he refused transfer. The medical record did not include any information regarding an assessment being completed.

Patient #27
Date of Visit 10/14/2023 - The patient was sent via doctors' orders for continuity of care. The patient's diagnosis was not provided. MOT did not include a physician's signature.

Patient #28
Date of Visit 10/17/2023 - The patient was sent via 911/EMS for chest pains as an emergent transfer. MOT did not include transfer/accepting facility information.

Patient #29
Date of Visit 10/28/2023- The patient was sent via 911/EMS for chest pain. Patient records do not include any information to support that intake was complete or that vitals were taken. MOT did not include any information regarding the receiving or transferring facility. The Physician's signature was also missing. Patient consent was also not provided.

Patient #30
Date of Visit 11/2/2023 - The patient was sent out via 911 due to low blood pressure and experiencing withdrawals.
MOT did not include accepting Hospital or transferring hospital information.

The Hospital's policy titled Memorandum of Transfer (MOT), last revised 05/2017, effective 10/2023, shows:

Page 3, section titled Transfer of Patients with Emergency Medical Conditions (EMC), includes, "If a patient at UBH has an emergency medical condition which has not been stabilized or when stabilization of the patient's condition is not possible ...the transfer shall be carried out as quickly as possible."

Page 6, section titled Memorandum of Transfer, includes the following: "Memorandum of Transfer must be completed for every patient transferred and must contain ...time and date which the transferring physician secured a receiving physician, signature, time and title of transferring hospital administration, a certification signed by the transferring physician who includes summary of risk and medical benefits."

Interviews

In an interview with the Intake Director, Staff # 1, on the afternoon of 11/14/2023, Staff #1 indicated the Intake Team oversees the completion of transfers at intake and completes the memorandum of transfer forms. Staff #1 indicated transfers are conducted for patients with medical emergencies, and an MOT is completed for each transfer. Staff #1 indicated this includes both emergent and non-emergent transfers. Staff #1 indicated that if a patient has a medical emergency, 911 is called, and the accepting Hospital is noted as 911. Staff #1 acknowledged the MOTs were incomplete and may not include the receiving hospital information due to a patient being transferred by ambulance and the Hospital not providing the name of a physician.

Interviews with Staff # 4 (Chief Nursing Officer), and Staff # 9 (Intake Nurse) revealed inconsistency of their understanding of the EMTALA requirements. Staff #9 stated "if we do not have a bed or accommodations then the officers have to be present during the MSE", while Staff #4 stated, "we will still admit the patient and transfer if you do not have a bed for them; we are required to provide a medical screening. We have a lot of contingency plans in place to address situations like this."