HospitalInspections.org

Based on interview and record review, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements when they did not provide an appropriate medical screening exam (MSE) for two out of 20 patients (Patient #1) and appropriate transfer for one of 20 patients.

The hospital failed to ensure a medical screening exam (MSE) was completed for two of 20 (Patient #1 and Patient #20) of 20 patients. Patient #1 presented with police to Facility A's emergency department on an apprehension by police officer without warrant (APOWW) due to suicidal ideation. Facility A did not complete the MSE due to police department indicating they only wanted medical clearance prior to transporting to a higher level of care at Facility B. Patient #1 was on 3/3/2024 with a diagnosis of suicidal and homicidal ideation and discharged on 3/6/2024. Patient #20 presented to the ED as a transfer due to syncopal episode, loss of consciousness and vomiting. Patient #20 was ordered to have a cardiac halter monitor placed with instructions to review telemetry results. Patient #20 was discharged from the ED without the cardiac halter monitor placed and did not have further follow up from cardiology.

Additionally, the facility staff, Facility A failed to perform an appropriate transfer for one of 20 patients (Patient #1) to an inpatient psychiatric treatment facility after staff learned Patient # 1 was going with the Police Officer to Facility B for inpatient psychiatric services. The facility failed to notify the receiving hospital of patient transfer, secure an accepting physician at the receiving hospital, send medical records to the receiving facility, and did complete a memorandum of transfer (MOT) form.

Cross reference to Tag A2406 CFR §489.24(c).
Cross reference to Tag A2409 §489.24 (e)(1)(i)

Based on review of documentation and an interview, the hospital failed to ensure a medical screening exam (MSE) was completed for two (Patient #1 and Patient #20) of 20 patients. Patient #1 presented with police to Facility A's emergency department on an emergency detention order due to suicidal ideation. Facility A did not complete the MSE due to police department indicating they only wanted medical clearance prior to transporting to a higher level of care at Facility B. Patient #1 was admitted inpatient to Facility B on 3/3/2024 with a diagnosis of suicidal and homicidal ideation and discharged on 3/6/2024. Patient #20 presented to the ED as a transfer due to syncopal episode, loss of consciousness and vomiting. Patient #20 was ordered to have a cardiac halter monitor placed with instructions to review telemetry results. Patient #20 was discharged from the ED without the cardiac halter monitor placed and did not have further follow up from cardiology.

The findings were:

Review of Record

Patient #1

Patient # 1 presented to the facility with a police officer under an Apprehension by Peace Officer Without Warrant (APOWW). The police officer requested a medical clearance for Patient # 1. The police officer told Staff # 1, he planned to take Patient # 1 to Facility B.

A review of the document titled "ED Care Timeline" by Staff # 3, Registered Nurse-Emergency Department (RN-ED) on 03/03/2024 at 6:48 PM revealed the "Suicide Prevention Suicide / Depression Screening": Patient # 1 refused to answer all questions.

A review of the document titled "ED Provider Notes" by Staff # 1, Registered Nurse-Pediatric Nurse practitioner (RN, PNP) on 03/03/2024 at 7:02 PM revealed in part the following:

"7:02 PM Patient #1 is a 16 y.o. male with no sig past medical history (PMH) who presents to the ED with complains of medical clearance by Dallas Police Department (DPD). Per police officer patient need to be medically cleared prior to taking him to Parkland under APOWW. Patient admits to taking 10 melatonin gummies around 5:45 p.m. Patient reports he wanted to go to sleep. Denies headache, chest pain, palpitations, abdominal pain, nausea or vomiting. Denies [suicidal ideation] SI or [homicidal ideation] HI. Treatments tried at home: none. Patient denies head injury or tazing by police. Parent states pt is [up to date] UTD on vaccinations. No other [symptoms] sx, complaints, or modifying factors at this time." ...
... "Review of Systems
Psychiatric/Behavioral: Positive for behavioral problems. Negative for self-injury. The patient is not hyperactive." ...
..."

A review of the document titled "ED Note" by Staff # 3, RN-ED on 03/03/2024 at 7:10 PM revealed the following: "Pt took melatonin gummies @1745 because he likes the way they taste. No endorsement of SI/HI at this time. Pt arrives in handcuffs with Dallas Police Department (DPD) officers #12364, #12365."


A review of the document titled "Provider Note-Discharge Instructions" by Staff # 1, Registered Nurse, Pediatric Nurse Practitioner (RN, PNP) on 03/03/2024 at 9:22 PM revealed the following:
"Discussed with the patient and the police that the patient is stable for medical clearance. Discussed that this is only a medically screening exam and that the patient still needs to follow-up for any other concerns that they may have and still needs to be re-evaluated in 2-3 days by PCP for recheck of any symptoms that the patient is having. Discussed the importance of having the patient evaluated further for any new, concerning, or worsening symptoms. Police stated verbal understanding of d/c instructions: s/s to return to ER, follow-up with PCP, and home medication management as well as the importance of having any new, concerning, or worsening symptoms evaluated. All questions answered prior to d/c."

Patient #1 was discharged with diagnosis of substance abuse, in custody of police.

A review of "Notification of Emergency Detention by Peace Officer" for Patient #1, dated 3/3/2024 at 9:42 PM revealed: I have reason to believe and do believe that the above-named person evidences a substantial risk of serious harm to himself/herself or others based on the following, "attempted to harm himself by taking multiple pills and mentioned he wanted to hurt others." The document indicated Patient #1 was restrained and was taken to Hospital B for inpatient treatment.

A review of Patient #1's medical record for Facility B, revealed

Patient # 1 arrived at Facility B Emergency Department (ED) on 03/03/2024 at 9:47 PM for psychosocial assessment. Patient #1 was triaged at 9:48 PM. Medical Screening exam was started at 10:23 PM.

"History: Here accompanied by police under emergency detention. SI, took melatonin earlier today. Was initially taken [Hospital A] and got labs, cleared, and brought here for psych.

2152 Patient states his name is "number 65" and refers to the police officer as "number 7"

2304 While being seen by psych social worker (SW), patient quickly escalated. Yelling "I don't give a fuck". Started throwing/punching items in the room - TV, monitor, scanner. Verbally threatened the sitter. Police came to bedside. Attempted to verbally deescalate. Still angry and yelling "you think I give a fuck" and about god's plan. IM meds ordered."

A review of the document titled "Psychiatric Attending Evaluation and Attestation Note" by Staff #1 on 03/04/2024 at 8:29 AM revealed the following:

"HPI: Patient is a(n) 16 year old Hispanic male with past psychiatric history including reported bipolar disorder and no past medical history brought under EmDet by DPD to [Hospital B] from [Hospital A] for SI/HI. Patient received medical workup at [Hospital A] for overdose on 10 melatonin gummies. Upon arrival to [Hospital B], patient noted to be agitated, destroyed property, and threatened harm to staff. He was emergently medicated and placed in restraints. XR of left hand noted boxer's fracture; a splint has been placed. Met with patient in Main ED; patient in 3 point restraints. Patient largely refuses to engage in assessment. He reports he took the 10 melatonin gummies yesterday with intent to "sleep forever." Reports he "doesn't care" about life. He declined to discuss recent stressors, mood, or information regarding sleep, appetite, energy, concentration. Patient then began threatening to kill treatment team, "I'm going to fuck you up; I'll fucking kill you." Attempted to redirect patient to which he responded, "I don't care if I catch a case." Assessment was stopped to prevent further escalation.

Reviewed collateral attained from SW. Per mother, patient has been having anger management issues over the past several months, including aggression towards others (physical violence towards mother, siblings, threatening to shoot up the school), aggression towards property (destruction of property), and aggression towards self (threatening to kill self). Mother indicates he makes threats of harm to self/others when his needs are not immediately met or when he is angry. Per mother, stressors include break up with girlfriend and being expelled from school."

A review of the document titled ED Notes at 3/3/2024 11:43 PM revealed the following:

"SW called [Hospital B] PD to inform them of reports in collateral interview about patient threatening to "shoot up the school." SW informed by dispatch that PD will be in contact.

... "PLAN OF CARE:

Patient is under an Emergency Detention and will need to be seen by a psychiatric provider to determine further plan of care."


Patient # 1 was transferred to Hospital D on 3/6/2024 at 12:10 AM for inpatient admission.

Patient # 20:

Summary:
Patient #20 presented to the ED as a transfer from Facility C to Facility A due to syncopal episode, loss of consciousness and vomiting. While on a monitor in Facility C's ED, Patient #20 had pauses on his electrocardiogram (EKG). After evaluation at Facility A, Patient #20 was ordered to have a cardiac halter monitor placed with instructions to review telemetry results. Patient #20 was discharged from the Facility A's ED on 3/7/2027 at 7:00 AM without the cardiac halter monitor placed and did not have further follow up from cardiology. Patient #20 was subsequently called by cardiology to return to the ED for further cardiac monitoring and treatment. Patient #20 was admitted to in-patient was at on 3/7/2024 at 1:23 PM and discharged on 03/08/2024 at 4:00 PM to home.

The findings were:

Review of Record

A review of the document titled "ED Provider Note" by Staff # 10, Medical Doctor-Emergency Department (MD-ED) on 3/7/2024 at 12:14 AM revealed the following:
Patient # 20 "is a 14 y.o. male with [past medical history] PMH of depression on Zoloft presenting from OSH[Facility C] due to x2 episodes of [loss of consciousness] LOC. Mom reports for the 1st LOC episode, the pt fell off a chair and hit his head for ~30 seconds. Pt states everything went white, his eyes felt heavy, before he woke up confused for several minutes and vomited. Pt was taken to OSH when he had a 2nd episode lasting 30 seconds while an IV was being placed. At OSH, pt was Flu A positive, CT head unremarkable. No family hx of cardiac issues or other sick symptoms. Of note, a 10 second pause on monitor was noted while the pt was awake, and pt was transferred to ED for cardiology consult."

"ED Course as of 03/07/24 0557
Thu Mar 07, 2024
0236 Cardiology recommended patient to be monitored on Telemetry until 7 AM. They will be discharged with Holter monitor."

A review of the document titled "Attending Physician Accept Note" by Staff # 4, MD-ED on 3/7/2024 at 6:26 AM revealed the following:
"I have received sign out for [Patient # 1] from [Staff # 10], MD at 3/7/2024.
Pt is a 14 y.o. male with a PMH of depression and currently taking Zoloft presenting from an OSH for 2 episodes of LOC and head injury. At OSH pt was Flu A positive, CT head normal. Pt has received an ECG and a cardiology consult." ...
... "Update:
7:51 am
Patient was discharged at 7am per sign out instructions. Called by cardiology due to concern that patient was discharged without holter or review of [telemetry] tele. They state that Holter was not placed at 2am as understood by ED and the patient's tele information is lost. After discussing with the cardiology fellow and attending, they would now like the patient to return to the emergency department for further evaluation. I have contacted the ED referral line to recall the patient and will page cardiology upon arrival."

A review of the document titled "ED Notes" by Staff # 5, RN-ED on 03/07/2024 at 6:48 AM revealed the following:
"0747-Received call from [Staff # 4] who states child was just seen and discharged and that he just spoke with cardiology and child needs to return to ED for further testing.
0749-Message left for mother to return call.
0753-Spoke to mother who states she is still in parking lot with patient and will return to ED now."

Policy Review

A review of documentation related to facility corrective action or training related to EMTALA revealed the following:
2. Assessment and Care of Patients under Emergency Detention in the Emergency Department revealed the following:
If the Law Enforcement Officer presents with the patient under Emergency Detention or a Patient Under Guard but requests a medical clearance only, then the Notification of Emergency Detention by Law Enforcement Officer form will not be signed, but the Law Enforcement Officer will need to sign the "Refusal of Medical Screening Exam" section of the Emergency Department Patient Decisions form.
o This form must be scanned into the patient's medical record and maintained as part of
the medical record.
3. Attachment A: Minor Patients Arriving with a Law Enforcement Officer (LEO). Attachment A is a guideline for staff when a minor patients arrive with a Law Enforcement Officer. The guideline does not address a medical screening exam.

5. APOWW Training: Education Points-
EMTALA requirements in cases when the patient is in police custody under an APOWW.
o The distinction between completion of an appropriate medical screening examination versus a police officer requested medical clearance of a patient.

o The ED workflow process of a patient under an APOWW.
The facility noted in the APOWW training the requirements of EMTALA:
The hospital must provide an appropriate medical screening examination ("MSE") within its capabilities and capacity to any individual who comes to the emergency department (ED) requesting examination or treatment for a medical condition, including a behavioral or mental health condition."

Although the facility provided a corrective action plan with the above information, the policy indicates unless the patient comes in under APOWW, a medical screening exam is not completed and only medical clearance is provided.


A review of the policy "AD 2.29.01 Emergency Medical Treatment (EMTALA) and Patient Transfer -Dallas" reveals the following: page 4/18
PROCEDURE:
A. Patient's Rights and General Provisions
1. Medical Screening. The Hospital recognizes the right of an individual to receive,
within the capabilities and capacity of the Hospital:
a. An appropriate MSE, including ancillary services routinely available to the
Emergency Department, diagnostic testing and procedures and physician
consultative services to determine whether or not an emergency medical condition
exists ;
b. If an emergency medical condition exists, necessary stabilizing treatment
(including treatment for an unborn child); and
c. If necessary, an appropriate transfer of an individual with an emergency medical
condition to another facility even if the individual cannot pay, does not have
medical insurance or is not entitled to Medicare or Medicaid.
The Hospital should not move individuals off-campus for the MSE.

A review of the document titled "Rules and Regulations of the Medical/Dental Staff" revealed the following: page 4 # 1.9
"1.9. Any patient who is evaluated in the Emergency Department (ED) or is being admitted to
or is already an inpatient at Children's Dallas, and who is known or suspected to be suicidal,
has taken a chemical/drug overdose, or is otherwise suspected to exhibit intentional self harm
behavior, shall have a mental health assessment. The assessment may be performed
by a mental health clinician (LCSW, LPC, LMFT, PhD, MD or DO) who will provide the
findings of that assessment to the ED attending or the patient's treating physician. The
attending will determine if additional psychiatric consultation is needed. If this assessment
is refused by the patient, parent or other authorized party, the medical record shall indicate
that the assessment was recommended, offered, and refused. A referral shall be made by
the physician to Child Protective Services, if appropriate, and necessary suicide prevention."

Related to the facilities failure to follow their own Rules and Regulations of the Medical/Dental Staff. Patient # 1 arrived at Facility A with a police officer after he ingested 10 melatonin gummy bears at home. ED Provider Notes by Staff # 1, RN, PNP on 03/03/2024 at 7:02 PM documented: Diagnosis: substance abuse. "Psychiatric/Behavioral: Positive for behavioral problems." A review of the document titled "ED Care Timeline" by Staff # 3, RN-ED on 03/03/2024 at 6:48 reveals the "Suicide Prevention Suicide / Depression Screening" documented: Patient # 1 refused to answer all questions. No further mental health was performed by a mental health clinician at Facility A.

Interviews

In an interview with on 4/16/2024, Staff # 1, RN, PNP stated they assessed Patient #1 after they were brought in by Dallas Police Department on an APOWW to clear the patient medically for an admission to Hospital B for a higher level for a psychiatric emergency. Staff #1 indicated the patient was hesitant to talk to them at first but later told admitted to taking 10 melatonin gummies. He wanted to go to sleep. When asked about suicidal ideation or homicidal ideation the patient said no. "Patient denied all." Labs were taken for the patient and Patient #1 was discharged the patient to the police officer.

In an interview with Staff # 8, Senior Director of Patient Safety and Service Excellence on 04/16/2024, Staff #8 acknowledged Patient #20 did not receive a complete exam prior to being discharged. Staff #8 indicated a plan of correction would be completed as a result of the incident with Patient #20.

Based on review of documentation and interviews with the facility staff, Facility A failed to perform an appropriate transfer for one of 20 patients (Patient #1) to an inpatient psychiatric treatment facility after staff learned Patient # 1 was going with the Police Officer to Facility B for inpatient psychiatric services. The facility failed to notify the receiving hospital of patient transfer, secure an accepting physician at the receiving hospital, send medical records to the receiving facility, and did complete a memorandum of transfer (MOT) form.


The findings were:

Review of Record

Patient # 1 presented to the facility with a police officer under an Apprehension by Peace Officer Without Warrant (APOWW). The police officer requested a medical clearance for Patient # 1. The police officer told Staff # 1, he planned to take Patient # 1 to Facility B.

A review of the document titled "ED Care Timeline" by Staff # 3, Registered Nurse-Emergency Department (RN-ED) on 03/03/2024 at 6:48 PM revealed the "Suicide Prevention Suicide / Depression Screening": Patient # 1 refused to answer all questions.

A review of the document titled "ED Provider Notes" by Staff # 1, Registered Nurse-Pediatric Nurse practitioner (RN, PNP) on 03/03/2024 at 7:02 PM revealed in part the following:

"7:02 PM Patient #1 is a 16 y.o. male with no sig past medical history (PMH) who presents to the ED with complains of medical clearance by Dallas Police Department (DPD). Per police officer patient need to be medically cleared prior to taking him to Parkland under APOWW. Patient admits to taking 10 melatonin gummies around 5:45 p.m. Patient reports he wanted to go to sleep. Denies headache, chest pain, palpitations, abdominal pain, nausea or vomiting. Denies [suicidal ideation] SI or [homicidal ideation] HI. Treatments tried at home: none. Patient denies head injury or tazing by police. Parent states pt is [up to date] UTD on vaccinations. No other [symptoms] sx, complaints, or modifying factors at this time." ...
... "Review of Systems
Psychiatric/Behavioral: Positive for behavioral problems. Negative for self-injury. The patient is not hyperactive." ...
..."

A review of the document titled "ED Note" by Staff # 3, RN-ED on 03/03/2024 at 7:10 PM revealed the following: "Pt took melatonin gummies @1745 because he likes the way they taste. No endorsement of SI/HI at this time. Pt arrives in handcuffs with Dallas Police Department (DPD) officers #12364, #12365."


A review of the document titled "Provider Note-Discharge Instructions" by Staff # 1, Registered Nurse, Pediatric Nurse Practitioner (RN, PNP) on 03/03/2024 at 9:22 PM revealed the following:
"Discussed with the patient and the police that the patient is stable for medical clearance. Discussed that this is only a medically screening exam and that the patient still needs to follow-up for any other concerns that they may have and still needs to be re-evaluated in 2-3 days by PCP for recheck of any symptoms that the patient is having. Discussed the importance of having the patient evaluated further for any new, concerning, or worsening symptoms. Police stated verbal understanding of d/c instructions: s/s to return to ER, follow-up with PCP, and home medication management as well as the importance of having any new, concerning, or worsening symptoms evaluated. All questions answered prior to d/c."

Patient #1 was discharged with diagnosis of substance abuse, in custody of police.

A review of "Notification of Emergency Detention by Peace Officer" for Patient #1, dated 3/3/2024 at 9:42 PM revealed: I have reason to believe and do believe that the above-named person evidences a substantial risk of serious harm to himself/herself or others based on the following, "attempted to harm himself by taking multiple pills and mentioned he wanted to hurt others." The document indicated Patient #1 was restrained and was taken to Hospital B for inpatient treatment.

A review of Patient #1's medical record for Facility B, revealed

Patient # 1 arrived at Facility B Emergency Department (ED) on 03/03/2024 at 9:47 PM for psychosocial assessment. Patient #1 was triaged at 9:48 PM. Medical Screening exam was started at 10:23 PM.

Facility A did not fill out a Memorandum of Transfer, contact Facility B for acceptance, notification or doctor to doctor communication about Patient # 1.

Policy

A review of the policy titled "AD 2.29.01 Emergency Medical Treatment (EMTALA) and Patient Transfer - Dallas" revealed the following: pg. 3
Facility A failed to follow their own policy. The policy reads:
"Transfer means the movement (including the discharge) of an individual outside a hospital's facilities at the direction of any person employed by (or affiliated or associated with) the hospital but does not include such a movement of an individual who has been declared dead or leaves the facility without the permission of any such person. (Pursuant to state hospital licensing regulations, the movement of a stable patient from the hospital to another medical facility is not considered to be a transfer if it is the understanding and intent of both hospitals that the patient is going to the second hospital only for tests, the patient will not remain overnight at the second hospital, and the patient will return to the first hospital, provided that the patient remains stable during the transfer.) An appropriate transfer occurs when:
a. The transferring hospital provides treatment within its capabilities to minimize risks to
the Patient (and to the unborn child if the Patient is pregnant)
b. The receiving facility agrees to the transfer and has the capability and capacity (bed and staff) to treat the Patient
c. The transferring hospital sends pertinent medical records
d. The transfer occurs with qualified personnel and equipment.


Interview

In an interview with on 4/16/2024, Staff # 1, RN, PNP stated they assessed Patient #1 after they were brought in by Dallas Police Department on an APOWW to clear the patient medically for an admission to Hospital B for a higher level for a psychiatric emergency. Staff #1 indicated the patient was hesitant to talk to them at first but later told admitted to taking 10 melatonin gummies. He wanted to go to sleep. When asked about suicidal ideation or homicidal ideation the patient said no. "Patient denied all." Labs were taken for the patient and Patient #1 was discharged the patient to the police officer.