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Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they did not maintain an accurate central log for patients whom presented to the Emergency Department (ED) for care when they failed to accurately document the dispositions of seven patients (#4, #10, #11, #18, #21, #29 and #30) and failed to provide an appropriate medical screening examination (MSE) within its capability and capacity, to determine if an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid serious harm or serious impairment) existed for one patient (#28) out of 32 ED sampled cases from 02/01/22 through 07/31/22. Patient #28 presented to the ED on 07/05/22 at 12:34 AM and was discharged at 3:08 AM prior to a mental health evaluation was completed to determine if an EMC existed.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," reviewed 02/16/2021 showed that the hospital was to provide an appropriate MSE and stabilizing treatment to any individual who presented and requested examination or treatment for a medical/psychiatric condition. The MSE was a screening process to determine the presence or absence of an EMC. An Emergency Medical Care Log must be maintained and include, directly or by reference, individual logs from all departments of the hospital including the ED where an individual might present for emergency medical services or receive an MSE. The log must contain the name of the individual who is seeking emergency medical treatment and whether the individual was refused treatment; refused treatment himself/herself; was transferred; was admitted and treated; was stabilized and transferred; or was stabilized and discharged.

Reviews of ED log and ED medical records for Patient's #4, #10, #11, #18, #21, #29 and #30 showed inaccurate dispositions documented on the ED log in comparison to documentation found within the patient's medical records.

Review of the hospital's policy titled, "Scope of Service-Inpatient Psychiatry: Child-Adolescent, Adult and Senior Adult Service," reviewed 12/03/20, showed that referral for mental health examinations were completed by the Psychiatric Intervention Team (PIT) Registered Nurse (RN) utilizing the pre-admission intake form and the findings were shared with a psychiatrist. The psychiatrist determined if inpatient admission was appropriate.

Review of the hospital's undated policy titled "Medically Necessary Hold," showed that when a patient exhibited moderate or high risk of harm to themselves, the physician may place a medically necessary hold order to prevent the patient from leaving a non-psychiatric setting. The medically necessary hold order was kept in place to keep the patient safe until a physician determined that the patient was no longer at risk for self-harm. The policy showed that a physician placed an order for a medically necessary hold and documented the reason for the hold. The policy included an Appendix titled "Medically Necessary Hold-Harm Risk Decision Tree," which showed that a patient with an order for medically necessary hold who received three consecutive assessments which indicated no risk for self-harm and the provider determined that there was no risk or low risk could have the medically necessary hold removed and could discontinue constant observation.

Review of the policy titled "Affidavit for Mental Health Hold," reviewed 06/15/21 showed that a patient with a moderate or risk of harm may require a medically necessary hold order in the ED.

Patient #28 presented to the ED on 07/05/22 requesting psychiatric evaluation for SI. The patient's care was managed by Staff J, ED Physician, from 1:12 AM until 2:49 AM and then transitioned to Staff K, ED Physician. Staff K ordered Patient #28's discharge at 2:57 AM despite an affidavit on file, an order for Medically Necessary Hold and continued constant observation with recently reported escalated behavior. In a span of eight minutes, the patient was determined to be stable for discharge, contracted for safety and "released" without receiving an MHE to adequately determine if an EMC existed.

Please see A-2405 and A-2406 for additional information.

Based on interview and record review, the hospital failed to maintain an accurate central log for patients presenting to the emergency department (ED) for care. The log failed to accurately document the disposition of seven patients (#4, #10, #11, #18, #21, #29 and #30) of 32 ED records reviewed from the ED log from February 2022 through July 2022. The hos pital's average monthly ED census over the past six months was 3,378.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," reviewed 02/16/2021 showed that an Emergency Medical Care Log must be maintained and include, directly or by reference, individual logs from all departments of the hospital including the ED where an individual might present for emergency medical services or receive an medical screening exam (MSE). The log must contain the name of the individual who is seeking emergency medical treatment and whether the individual was refused treatment; refused treatment himself/herself; was transferred; was admitted and treated; was stabilized and transferred; or was stabilized and discharged.

Review of the ED log dated 02/20/22, showed that Patient #4 presented to the ED on 02/02/22 at 6:58 PM, for alcohol detoxification (the process of removing drugs or alcohol from the body) with a disposition as discharged.

Review of Patient #4's medical record showed he presented to the ED at 6:58 PM for alcohol detoxification and was triaged (process of determining the priority of a patient's treatment based on the severity of their condition) at 7:11 PM. He reported last alcohol consumption of approximately one hour prior to his arrival to the ED. Patient #4 left without being seen (LWBS) after he was triaged.

Review of the ED log dated 04/07/22 showed that Patient #10 presented to the ED on 04/07/22 at 4:17 AM with a disposition of discharged.

Review of Patient #10's medical record showed she presented to the ED on 04/07/22 at 4:17 AM by ambulance with severe vaginal bleeding and was approximately 10 weeks pregnant. Patient #10 received an MSE and it was determined that she was miscarrying with retained products of conception within the uterus and was taken to the operating room.

Review of the ED log dated 04/07/22 showed that Patient #11 presented to the ED on 04/07/22 at 10:22 AM with disposition of discharged home.

Review of Patient #11's medical record showed that she presented to the ED on 04/07/22 at 10:22 AM with a psychiatric problem. Patient #11 was later admitted to the Adult Psychiatric Unit (APU).

Review of the ED log dated 05/12/22 showed that Patient #18 presented to the ED on 05/12/22 at 10:22 AM with suicidal ideations (SI, thoughts of causing one's own death) with a disposition of left against medical advice (AMA).

Review of Patient #18's medical record showed that she presented to the ED on 05/12/22 at 10:22 AM with SI and was later admitted to the APU.

Review of the ED log dated 06/13/22 showed that Patient #21 presented to the ED on 06/13/22 at 6:39 PM with a disposition of expired (death).

Review of Patient #21's medical record showed that he presented to the ED on 06/13/22 at 6:39 PM by ambulance after cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness) and was later admitted to the intensive care unit (ICU).

Review of the ED log dated 07/06/22 showed that Patient #29 presented to the ED on 07/06/22 at 10:37 AM with a disposition of left AMA.

Review of Patient #29's medical record showed that he presented to the ED on 07/06/22 at 10:37 AM with alcohol intoxication and LWBS after triage.

Review of the ED log dated 07/07/22 showed that Patient #30 presented to the ED on 07/07/22 at 9:31 AM for SI with a disposition of admission.

Review of Patient #30's medical record showed that he presented to the ED on 07/07/22 at 9:31 AM for SI and was later transferred to another hospital for inpatient treatment.

During an interview on 08/03/22 at 9:35 AM, Staff C, ED Manager verified that Patient's #4, #10, #11, #18, #21, #29 and #30 dispositions from their ED visit were incorrectly logged.

Based on interview, record review and policy review, the hospital failed to provide a complete medical screening examination (MSE) within its capability and capacity, to determine if an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid serious harm or serious impairment) existed for one patient (#28) of 32 patient's records reviewed who presented to the Emergency Department (ED) for emergency care, out of a sample selected from 02/2022 through 07/2022. Patient #28 presented to the ED for suicidal ideations (SI, thought of causing ones' own death). This failed practice had the potential to cause harm to all patients who presented to the ED seeking care. The hospital's average monthly ED census over the past six months was 3,378.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," reviewed 02/16/2021 showed that the hospital was to provide an appropriate medical screening examination (MSE) and stabilizing treatment to any individual who presented and requested examination or treatment for a medical/psychiatric (relating to mental illness) condition. The MSE was a screening process to determine the presence or absence of an EMC.

Review of the hospital's policy titled, "Scope of Service-Inpatient Psychiatry: Child-Adolescent, Adult and Senior Adult Service," reviewed 12/03/20, showed that referral for mental health examinations were completed by the Psychiatric Intervention Team (PIT) Registered Nurse (RN) utilizing the pre-admission intake form and the findings were shared with a psychiatrist. The psychiatrist determined if inpatient admission was appropriate.

Review of the hospital's undated policy titled "Medically Necessary Hold," showed that when a patient exhibited moderate or high risk of harm to themselves, the physician may place a medically necessary hold order to prevent the patient from leaving a non-psychiatric setting. The medically necessary hold order was kept in place to keep the patient safe until a physician determined that the patient was no longer at risk for self-harm. The policy showed that a physician placed an order for a medically necessary hold and documented the reason for the hold. The policy included an Appendix titled "Medically Necessary Hold-Harm Risk Decision Tree," which showed that a patient with an order for medically necessary hold who received three consecutive assessments which indicated no risk for self-harm and the provider determined that there was no risk or low risk could have the medically necessary hold removed and could discontinue constant observation.

Review of the policy titled "Affidavit for Mental Health Hold," reviewed 06/15/21 showed that a patient with a moderate or risk of harm may require a medically necessary hold order in the ED.

Review of the ED medical record for Patient #28 showed that he presented to the ED on 07/05/22 at 12:34 AM. The record showed that Patient #28 was triaged (process of determining the priority of a patient's treatment based on the severity of their condition) by Staff M, RN at 1:00 AM with an acuity (the severity of a patient's illness and the level of service needed) of 2-Psych Patient. Documentation by Staff M showed a Harm Risk Assessment was completed at 1:00 AM with a score of seven, moderate level and that a sitter for constant observation was assigned. Patient #28's medical record showed an untimed, notarized affidavit dated 07/05/22 completed and signed by Staff J, ED Physician. Staff J which documented the concerning behaviors as quoted statements from Patient #28 referencing his despair and that the patient stated he needed help for his depression. Staff J documented that the patient verbalized suicidal ideations without delusions or hallucinations, an explanation of the patient's social and living situation and that the patient planned to neglect himself in order to kill himself. Staff J documented a physical examination that showed no abnormal findings and that the patient requested a mental health evaluation. Staff J signed an order for Medically Necessary Hold for Harm to Self at 01:12 AM. The ED Physician Notes showed that laboratory values and an electrocardiogram (ECG or EKG, test that checks for problems with the electrical activity within the heart) were completed and included blood alcohol level of <0.003% and a urine drug screen was positive for amphetamines (an addictive mood altering drug), methamphetamines (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) and cannabinoids (chemical compounds that are the active principles of marijuana). Staff J documented the ED disposition order of "Transfer" at 2:31 AM. Staff J documented that Patient #28's ED care was transitioned to Staff K, ED physician, at 3:00 AM. An untimed note by Staff K showed documentation that the patient requested to leave and a contract for safety (an agreement between the patient and clinician whereby the patient agrees not to harm him or herself) was made and the patient was "released" in stable condition to his own devices. Sitter documentation at 3:02 AM showed that the patient was anxious and agitated and that the sitter attempted verbal re-direction and notified the patient's caregiver. Staff P, Graduate Nurse (GN) documented at 3:06 AM that at 2:55 AM the patient was cursing at staff, demanded that his clothing be returned and that the patient wanted to leave the ED. Staff P's note showed that he notified Staff K, ED Physician and the charge nurse of the patient's statements. Staff J signed off on Patient #28's record at 2:49 AM and Staff K entered an order for discharge at 2:57 AM. Patient #28's ED Clinical Summary for 07/05/22 signed by Staff P, GN at 3:08 AM showed that the patient was discharged to home.

Patient #28 presented to the ED on 07/05/22 requesting psychiatric evaluation for SI. The patient's care was managed by Staff J, ED Physician, from 1:12 AM until 2:49 AM and then transitioned to Staff K, ED Physician. Staff K ordered Patient #28's discharge at 2:57 AM despite an affidavit on file, an order for Medically Necessary Hold and continued constant observation with recently reported escalated behavior. In a span of eight minutes, the patient was determined to be stable for discharge, contracted for safety and "released" without receiving an MHE to adequately determine if an EMC existed.

During an interview on 08/03/22 at 11:40 AM, Staff J, ED physician, stated that when a patient with psychiatric concerns presented to the ED, a PIT evaluation would be requested. Staff J stated that he could not recall if the MHE for Patient #28 was completed at the time he transitioned care to Staff K or if they had discussed the status of Patient #28's MHE.

During a telephone interview on 08/03/22 at 2:05 PM, Staff K, ED Physician, stated that he took over the care of Patient #28 just prior to 3:00 AM. He stated that he received a report from Staff J and then performed his own assessment of Patient #28. Staff K stated that when he assessed Patient #28, the patient reported to him that he wished to leave and entered into a verbal agreement with him as a contract for his safety. Staff K stated that he discussed at length with the patient his current psychiatric situation and the patient reported no intentions of hurting himself, did not have the means to hurt himself and that he was not going to kill himself.

Patient #28 presented to the ED on 07/05/22 at 12:34 AM with SI with an affidavit completed by Staff J, ED Physician, and an order to transfer for inpatient treatment with an ordered MHE. Patient #28 did not receive an MHE or the mental health resources that may have been available as a result of that evaluation. Patient #28 was discharged by Staff K at 3:08 AM and returned the next day with worsening SI, was evaluated by the PIT nurse with a Harm Risk Assessment of high risk, and admitted to the inpatient psychiatric unit.

Review of the hospital provided e-mail from the ED Clerk to Staff N, RN showed that the PIT nurse was notified of the need for a PIT evaluation for Patient #28 on 07/05/22 at 2:32 AM. The PIT nurse responded to the ED clerk on 07/05/22 at 2:41 AM requesting affidavits associated with the patient and notifying that a telephone call for the evaluation would be placed.

During a telephone interview on 08/03/22 at 6:18 PM, Staff N, RN, PIT nurse stated that she had received an e-mail from the ED technician requesting evaluation for Patient #28 on 07/05/22 and that the patient's name was listed on the worksheet of patients who needed a mental health assessment. Staff N stated that she did not perform a MHE on Patient #28 on 07/05/22. Staff N stated that in addition to determining the need for inpatient placement, the PIT nurse provided resources for the patient to utilize as an outpatient.

Review of the hospital provided e-mails showed that the inpatient adult psychiatric unit (APU) had blocked beds to a maximum of nine patients from 07/02/22 at 4:00 PM to 07/05/22 at 7:00 AM due to staffing limitations.

Review of the hospital-provided document showed that the census of the APU on 07/05/22 was nine inpatients until the evening shift.

Review of the hospital provided document titled, "Psychiatry Branson," showed that 24-hour coverage for psychiatry was available on 07/05/22.

During a telephone interview on 08/08/22 at 7:00 PM, Staff P, RN, stated that he was not Patient #28's primary nurse on 07/05/22 but he had noticed that Patient #28 was agitated, swearing and was "pressing" his sitter to give him his clothing. Staff P stated that he attempted to verbally de-escalate Patient #28 and reported the patient's behavior to Staff K, ED Physician. Staff P stated that Staff K then handed him discharge paperwork, told him that Patient #28 was ready for discharge and requested that Staff P perform nursing discharge of the patient. Staff P stated that he gathered the patient's clothing and the discharge paperwork and attempted to review the discharge paperwork with Patient #28. He stated that Patient #28 grabbed his clothing, refused to sign acknowledgement of discharge paperwork and left the ED.

During a telephone interview on 08/03/22 at 12:35 PM and interview on 08/04/22 at 10:50 AM, Staff M, ED RN, stated that the Harm Risk Assessment was completed upon presentation for all suicidal patients and repeated every twelve hours or if a significant change in the patient's condition occurred. Staff M stated that the Harm Risk Assessment could be repeated before a patient was discharged; but would be dependent upon the situation.

During an interview on 08/04/22 at 9:30 AM, Staff O, MD, Medical Director of the ED, stated that when ED physicians transferred patient responsibility there was a verbal exchange regarding each patient and their current status in the ED, including any psychiatric concerns. He stated that the timeline presented in review of a medical record could be "skewed" because the exchange between physicians generally began up to an hour before official shift change and if an electronic record was not "closed" after accessing, all documentation was timed at the time the record was originally opened. Staff O stated that the discharge process required reviewing discharge instructions with the patient and nursing duties which included discharge instructions being reviewed again. Staff O stated that discharging a patient from the ED was ultimately the decision of the ED physician who determined if the MSE including any psychiatric evaluation had been completed and if an EMC existed which required stabilization. Staff O stated that the MHE by the PIT occurs after all lab results were completed.

During an interview on 08/03/22 at 9:40 AM, Staff C, RN, ED Nurse Manager stated that when a patient entered into a contract for safety, the agreement would be reflected in a Harm Risk Assessment completed by nursing staff.

Patient #28 entered into a contract for safety with Staff K, ED Physician but a Harm Risk assessment was not repeated by nursing staff prior to the patient's discharge.

During an interview on 08/04/22 at 10:05 AM, Staff Q, Counselor from Facility C, stated that Patient #28 presented from the ED to Facility C on the morning of 07/06/22 in "crisis" and reported that he was scared he would harm himself or others. She stated that she drove the patient to the ED and stayed with him until the PIT team arrived for his evaluation. Staff Q stated that the PIT evaluator seemed familiar with Patient #28 and his psychiatric concerns.

Review of Patient #28's ED medical record showed that he presented to the ED on 07/06/22 at 10:16 AM. Documentation by the triage nurse showed that the patient was brought to the ED by Staff Q, a counselor from Facility C (a homeless shelter) who reported that the patient had reported that he was being reckless with ongoing thoughts of harming himself which were worsening. Staff Q had completed an affidavit and presented it upon arrival to the ED. The ED record showed that the triage nurse documented the patient's acuity level as 2-Psych Patient and he was placed on constant observation. A Harm Risk Assessment was completed at 10:25 AM, with a score of eight, moderate level Risk. Staff L, ED Physician documented at 10:27 AM that the patient had thoughts of harming himself and reported he had been seen previously for suicidal thoughts, but they were getting worse. The patient reported he did not have a plan, but wanted a MHE and wanted to receive inpatient care. Staff L documented that the patient was medically cleared for psychiatric evaluation and that PIT was notified. A PIT evaluation timed at 2:16 PM documented that the patient had presented to the ED for the fourth time in six days reporting suicidal and homicidal ideation without a specific plan. (Previous hospital visit dates for Patient #28 were requested from the hospital and showed three visits since 06/30/22. Patient #28 was seen in the ED on 06/30/22 and a PIT evaluation was completed, one ED visit on 07/05/22 that resulted in discharge without a PIT evaluation and the 07/06/22 ED visit which resulted in admission). The 07/06/22 PIT evaluation contained a Harm Risk Assessment with a score of 15, high risk. The PIT evaluation showed documentation at 4:00 PM that the patient was admitted to the hospital's APU on 07/06/22 at 4:20 PM.