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Based on hospital policy review, medical record review, and staff interviews, the hospital failed to comply with 489.24 by failing to provide an appropriate medical screening examination and stabilization for 1 of 30 sampled patients presenting to the hospital's dedicated emergency department (#16).

The findings include:

~cross refer to Tag A2406 and Tag A2407.

Based on hospital policy review, medical record review and staff interviews, the hospital failed to provide an appropriate medical screening examination with ongoing monitoring for a patient with an emergency medical condition in 1 of 30 sampled patients presenting to the hospital's dedicated emergency department (#16).

The findings include:

A review of the facility policy "COBRA/EMTALA Compliance" (Reviewed date 09/2009) revealed "When an individual presents or is brought to the Emergency Department of __(hospital name) and request is made on the individual's behalf for examination and treatment of a medical condition, a physician/physician assistant will provide a medical screening examination within capabilities of the Hospital, including ancillary services routinely available to the Emergency Department, for the purpose of determining the presence or absence of an Emergency Medical Condition. An individual with an Emergency Medical Condition will receive either such further medical examination and treatment within the capabilities of the staff and facilities available as may be required to stabilize the Emergency Medical Condition, or appropriate transfer to another facility."

A closed medical review on 09/30/2010 for patient #16 revealed that the patient a 19 year old female that presented to the hospital's dedicated emergency department (DED) on the dates of 09/13/2010 and 09/14/2010 for treatment related to behavioral issues. The review of the patient's medical record for 09/13/2010 revealed that the patient presented to the DED at 1528 with a chief complaint of "Not wanting to take her medications and was banging head on cement"and had a past medical history of seizures and mental illness. The patient was triaged by the hospital's DED registered nurse with reports of having "psych problem"as official complaint documented. The documentation revealed that the patient had vital signs obtained with reassessments noted. The documentation further revealed that a mental status examination was completed by the hospital's nursing staff both in the DED and from the DED mental health staff working at the hospital. Documentation was found where the patient was placed on the hospital's "Emergency Department Psychiatric Suite Patient Safety Checks" with staff documenting 15 minute checks of the patient's safety and condition.

The medical record review revealed that DED physician documented an "Emergency Department Report" for the patient on 09/13/2010 at 1720. The physician documentation revealed that the patient had a medical history of seizures and mental illness with reported complaint of "psych problem." The physician further documented that the patient's mother took out a petition of involuntary commitment because the patient had been difficult at home, not wanting to take her medications, and she started banging her head on the cement when she got angry." There were no concerns about the patient being suicidal. There are no concerns about homicidal ideation." The documentation review revealed that the physician conducted a physical examination for the patient as part of the emergency department report. The documentation from the physician revealed " There is no evidence of suicidal or homicidal ideation or evidence of visual or auditory hallucinations. I do not believe that the patient is a threat to herself of others. The patient is going to be discharged with her mother. The patient did receive Tylenol and I do feel she is safe for discharge. She does not have any evidence of head injury. She is going to follow up with her primary doctor. I talked with the mom about signs and symptoms to look out for as well as indications to return. The patient's mother voiced a clear understanding and had no further questions or concerns." The documented discharge diagnosis was "Closed head trauma, nonfocal exam and Conduct disturbance" with the physician's disposition as "The patient was discharged in improved condition."

The medical record review of the hospital's emergency department nurse's notes revealed documentation from the hospital's mental health nursing staff as "Mental Health Exam checklist: The patient's appearance can be described as "poor eye contact." The patient's level of consciousness can be described as: alert, awake. The patient's level of orientation can be described as: orientated to time, place and person. The patient's psychomotor function can be described as: agitated. The patient's behavior can be described as: "childlike irritable, anxious." The documentation from the mental health nursing staff further described the patient's thought process as goal-directed with no delusions evident. The documentation revealed no hallucinations from the patient as well as the patient having "poor judgment." Risk factors were described as the "patient acts out physically when not getting her way." Patient's affect is described as blunted and her insight is described as poor as relates to MR. The medical record documentation revealed that the patient's mental screen examination was completed at 1736 by the hospital's mental health staff. The psych assessment further indicated on 9/13/10 that the patient was a suicide risk....risk factor reveals that the patient acts out physically when not getting her way.

Documentation from the hospital's "Emergency Department Nursing Notes" revealed that the patient had a discharge order from the physician on 09/13/2010 at 1736. The documentation in the medical record revealed from the DED nursing staff at 1832 that "Plan of care discussed with patient and significant other/family." " States that expectation for assessment, treatment and plan of care have been met. Discharged to home ambulatory, with family. Condition Stable. Disposition assessment: alert and patient is ready to learn. Discharge instructions given to family. Encouraged to engage case management in establishing more intensive home services during the interim period prior to placement, encouraged to contact prescribing physician to re-evaluate medications." Documentation revealed that the patient left the DED at 1846 on 09/13/2010 with parents.

An interview on 09/30/2010 at 1315 with the hospital's mental health staff revealed that the patient was assessed by the hospital's psychiatric staff on 09/13/2010 while in the emergency department. The interview revealed that the patient was not assessed as being homicidal or suicidal. The interview further revealed that the patient's mother was not happy with the hospital's plan for discharge and not admitting the patient. The interview revealed that the mental health staff discussed the patient's condition with the DED physician. The DED physician for the patient on 09/13/2010 was not available for interview during the survey.

A review of the medical record for the patient on 09/14/2010 ( 2nd DED visit) revealed that the patient presented to the DED via the local police at 1231. The documentation by the DED registered nurse in triage revealed "Patient states I didn't want to go to school today. My head was hurting this morning. The mother stated "She was trying to sit in the road trying to get cars to run over her, banging her head on the cement, hitting people, scratching herself with sticks, threatening animals." "The patient also admitted to cutting herself in the past and spitting at the police." The patient was documented by the nurse as having a chief complaint of "Suicidal ideations, patient has tried to harm herself and others today." Documentation revealed that the facility's staff documented the medications that the patient had been taking. Documentation from the patient's mother also revealed "That ___ (outpatient clinic) wanted the patient to be admitted and she was told to bring the patient to the emergency department until she was admitted."

Documentation revealed that the patient was seen by the DED psychiatric assessment staff with a mental status exam again conducted. The documentation revealed that the patient denied suicidal or homicidal ideation's during the assessment. The documentation further revealed that the patient's mother wanted the patient to be admitted to the hospital's psychiatric unit so that the behavior would improve. The disposition documentation from the staff revealed that "The patient was evaluated in the DED but does not require further psychiatric intervention at this time, and should be discharged home. A referral was done with outpatient mental health staff. The case was discussed with the on call psychiatrist."

A review of the DED physician's examination on 09/14/2010 revealed that a physical examination was documented for the patient. The documentation from the DED physician revealed that the patient was denying any suicidal or homicidal ideations. The documentation revealed "At this time, I do not believe that the patient poses a threat to herself or to anyone else. She has been evaluated by (outpatient mental health agency) and they have been attempting to get placement for her for inpatient treatment for her aggressive behavior, but the family states that the (outpatient mental health agency) asked her to come and stay here and sit until she gets admitted. We discussed this with the outpatient agency and they state that they did not say any such things and have asked the patient's family to make certain changes in order to help her behavior, but they have not complied with this at this time. I did discuss this with the mom and dad and I have asked them to follow up with the outpatient agency again in the next few days to see if they can hasten her placement, however, at this time again, I do not believe that she poses a treat to herself or to anyone else." The documentation revealed that the DED physician gave the patient a diagnosis of "Conduct Disorder with aggressive tendencies." The documentation revealed that the patient was treated and discharged home with her parents at 1722.

An interview on 09/30/2010 at 1315 with the hospital's mental health staff revealed that the patient was assessed by the hospital's psychiatric staff again on 09/14/2010 while in the emergency department. The interview revealed that the patient was not assessed as being homicidal or suicidal. The interview further revealed that the patient's mother was not happy with the hospital's plan for discharge and not admitting the patient. The interview revealed that the mental health staff discussed the patient ' s condition with the DED physician and for a second time decided that the patient did not need inpatient treatment. The DED physician for the patient on 09/13/2010 was not available for interview during the survey. The interviews did not reveal any reason as to why the hospital's physicians thought that the patient was stable, other than they thought she was stable for discharge home. The interviews also revealed no reasons other than the physician's documentation as to why the patient did not have any head injuries. The interviews revealed that the physicians examined the patient and felt that no other injuries to the patient warrented an admission to the hospital.

A review of a medical record from hospital (B) for patient #16 revealed that the patient presented to the DED of that hospital on 09/17/2010 at 1936 with a chief complaint of "Suicidal". The documentation summary from that hospital's record revealed that the patient was involuntarily committed and kept in the DED until 09/19/2010 where she was documented as no longer needing the involuntarily commitment and was discharged to home for outpatient treatment. The patient was never admitted to the hospital, but rather was held in the DED while the hospital was attempting to involuntarily commit to another acute care facility.

Consequently, the patient presented to the hospital's DED on 09/13/2010 and again on 09/14/2010 with her family after banging her "head on cement and not taking with her medications used for behavior" and suicidal ideations." The patient was not admitted to the hospital's behavioral health unit and sent home with her family for outpatient follow up and treatment. The hospital failed to provide an appropriate and ongoing medical screening examination in order to determine if the patient had an emergency medical condition.

Based on hospital policy review, medical record review and staff interviews the hospital's Dedicated Emergency Department (DED) failed to provide stabilizing treatment within its capability and capacity for 1 of 30 sampled DED patients that presented to the hospital with an emergency medical condition (#16).

The findings include:

A review of the facility policy "COBRA/EMTALA Compliance" (Reviewed date 09/2009) revealed "When an individual presents or is brought to the Emergency Department of __(hospital name) and request is made on the individual's behalf for examination and treatment of a medical condition, a physician/physician assistant will provide a medical screening examination within capabilities of the Hospital, including ancillary services routinely available to the Emergency Department, for the purpose of determining the presence or absence of an Emergency Medical Condition. An individual with an Emergency Medical Condition will receive either such further medical examination and treatment within the capabilities of the staff and facilities available as may be required to stabilize the Emergency Medical Condition, or appropriate transfer to another facility."

A closed medical review on 09/30/2010 for patient #16 revealed that the patient a 19 year old female that presented to the hospital's dedicated emergency department (DED) on the dates of 09/13/2010 and 09/14/2010 for treatment related to behavioral issues. The review of the patient's medical record for 09/13/2010 revealed that the patient presented to the DED at 1528 with a chief complaint of "Not wanting to take her medications and was banging head on cement."The patient was triaged by the hospital's DED registered nurse with reports of having "psych problem"as official complaint documented. The documentation revealed that the patient had vital signs obtained with reassessments noted. The documentation further revealed that a mental status examination was completed by the hospital's nursing staff both in the DED and from the DED mental health staff working at the hospital. Documentation was found where the patient was placed on the hospital's "Emergency Department Psychiatric Suite Patient Safety Checks" with staff documenting 15 minute checks of the patient's safety and condition.

The medical record review revealed that DED physician documented an "Emergency Department Report" for the patient on 09/13/2010 at 1720. The physician documentation revealed that the patient had a medical history of seizures and mental illness with reported complaint of "psych problem." The physician further documented that the patient's mother took out a petition of involuntary commitment because the patient had been difficult at home, not wanting to take her medications, and she started banging her head on the cement when she got angry." There were no concerns about the patient being suicidal. There are no concerns about homicidal ideation." The documentation review revealed that the physician conducted a physical examination for the patient as part of the emergency department report. The documentation from the physician revealed " There is no evidence of suicidal or homicidal ideation or evidence of visual or auditory hallucinations. I do not believe that the patient is a threat to herself of others. The patient is going to be discharged with her mother. The patient did receive Tylenol and I do feel she is safe for discharge. She does not have any evidence of head injury. She is going to follow up with her primary doctor. I talked with the mom about signs and symptoms to look out for as well as indications to return. The patient's mother voiced a clear understanding and had no further questions or concerns." The documented discharge diagnosis was "Closed head trauma, nonfocal exam and Conduct disturbance" with the physician's disposition as "The patient was discharged in improved condition."

The medical record review of the hospital's emergency department nurse's notes revealed documentation from the hospital's mental health nursing staff as "Mental Health Exam checklist: The patient's appearance can be described as "poor eye contact." The patient's level of consciousness can be described as: alert, awake. The patient's level of orientation can be described as: orientated to time, place and person. The patient's psychomotor function can be described as: agitated. The patient's behavior can be described as: "childlike irritable, anxious." The documentation from the mental health nursing staff further described the patient's thought process as goal-directed with no delusions evident. The documentation revealed no hallucinations from the patient as well as the patient having "poor judgment." Risk factors were described as the "patient acts out physically when not getting her way." The medical record documentation revealed that the patient's mental screen examination was completed at 1736 by the hospital's mental health staff.

Documentation from the hospital's "Emergency Department Nursing Notes" revealed that the patient had a discharge order from the physician on 09/13/2010 at 1736. The documentation in the medical record revealed from the DED nursing staff at 1832 that "Plan of care discussed with patient and significant other/family." " States that expectation for assessment, treatment and plan of care have been met. Discharged to home ambulatory, with family. Condition Stable. Disposition assessment: alert and patient is ready to learn. Discharge instructions given to family. Encouraged to engage case management in establishing more intensive home services during the interim period prior to placement, encouraged to contact prescribing physician to re-evaluate medications." Documentation revealed that the patient left the DED at 1846 on 09/13/2010 with parents.

An interview on 09/30/2010 at 1315 with the hospital's mental health staff revealed that the patient was assessed by the hospital's psychiatric staff on 09/13/2010 while in the emergency department. The interview revealed that the patient was not assessed as being homicidal or suicidal. The interview further revealed that the patient's mother was not happy with the hospital's plan for discharge and not admitting the patient. The interview revealed that the mental health staff discussed the patient's condition with the DED physician. The DED physician for the patient on 09/13/2010 was not available for interview during the survey.

A review of the medical record for the patient on 09/14/2010 ( 2nd DED visit) revealed that the patient presented to the DED at 1231. The documentation by the DED registered nurse in triage revealed "Patient states I didn't want to go to school today. My head was hurting this morning. The mother stated "She was trying to sit in the road trying to get cars to run over her, banging her head on the cement, hitting people, scratching herself with sticks, threatening animals." The patient was documented by the nurse as having a chief complaint of "Suicidal ideations, patient has tried to harm herself and others today."

Documentation revealed that the patient was seen by the DED psychiatric assessment staff with a mental status exam again conducted. The documentation revealed that the patient denied suicidal or homicidal ideation's during the assessment. The documentation further revealed that the patient's mother wanted the patient to be admitted to the hospital's psychiatric unit so that the behavior would improve. The disposition documentation from the staff revealed that "The patient was evaluated in the DED but does not require further psychiatric intervention at this time, and should be discharged home. A referral was done with outpatient mental health staff. The case was discussed with the on call psychiatrist."

A review of the DED physician's examination on 09/14/2010 revealed that a physical examination was documented for the patient. The documentation from the DED physician revealed that the patient was denying any suicidal or homicidal ideations. The documentation revealed "At this time, I do not believe that the patient poses a threat to herself or to anyone else. She has been evaluated by (outpatient mental health agency) and they have been attempting to get placement for her for inpatient treatment for her aggressive behavior, but the family states that the (outpatient mental health agency) asked her to come and stay here and sit until she gets admitted. We discussed this with the outpatient agency and they state that they did not say any such things and have asked the patient's family to make certain changes in order to help her behavior, but they have not complied with this at this time. I did discuss this with the mom and dad and I have asked them to follow up with the outpatient agency again in the next few days to see if they can hasten her placement, however, at this time again, I do not believe that she poses a treat to herself or to anyone else." The documentation revealed that the DED physician gave the patient a diagnosis of "Conduct Disorder with aggressive tendencies." The documentation revealed that the patient was treated and discharged home with her parents at 1722.

An interview on 09/30/2010 at 1315 with the hospital's mental health staff revealed that the patient was assessed by the hospital's psychiatric staff again on 09/14/2010 while in the emergency department. The interview revealed that the patient was not assessed as being homicidal or suicidal. The interview further revealed that the patient's mother was not happy with the hospital's plan for discharge and not admitting the patient. The interview revealed that the mental health staff discussed the patient ' s condition with the DED physician and for a second time decided that the patient did not need inpatient treatment. The DED physician for the patient on 09/13/2010 was not available for interview during the survey.

A review of a medical record from hospital (B) for patient #16 revealed that the patient presented to the DED of that hospital on 09/17/2010 at 1936 with a chief complaint of "Suicidal". The documentation summary from that hospital's record revealed that the patient was involuntarily committed and kept in the DED until 09/19/2010 where she was documented as no longer needing the involuntarily commitment and was discharged to home for outpatient treatment. The patient was never admitted to the hospital, but rather was held in the DED while the hospital was attempting to involuntarily commit to another acute care facility.

Consequently, the patient presented to the hospital's DED on 09/13/2010 and again on 09/14/2010 with her family after banging her "head on cement and not taking with her medications used for behavior" and "suicidal ideations." The patient had documentation for the DED's physician and mental health assessment nurses that revealed that the patient had behavior issues but was not harmful to self or others. The patient was not admitted to the hospital's behavioral health unit and sent home with her family for outpatient follow up and treatment. The hospital failed to stabilize a patient presenting with an emergency medical condition by discharging from the hospital before the emergency medical condition was resolved.