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Based on interview and record review, the facility failed to ensure 1 of 21 sampled patients (Patient 19) received an MSE (Medical Screening Exam, medical examination performed to determine if an emergency situation exists) so that treatment could begin as soon as possible.

This deficient practice had the potential to result in delay of treatment, which may result in patient harm.

Findings:

During a review of the document "Daily Focus Assessment Report" with 'Entry Date 08/22/2021 03:44', this document indicated Patient 19 was in the Emergency Department lobby. The author of this document, Registered Nurse 1 (RN 1), wrote that at this time Patient 19 had been refusing treatment during his stay and was now refusing to leave the facility after being discharged. Patient 19 was stating that all he wanted to do was to be left alone and allowed to sleep; according to this report Patient 19 then made threatening statements toward staff and security personnel because, he stated, people would not leave him alone and let him sleep. This report indicated that NP was notified and no new orders were issued for Patient 19. This entry stated that Patient 19 then stated that he did not really want to follow through with his threats; he just wanted to be left alone so he could sleep. LAPD (Los Angeles Police Department) was then summoned for trespassing due to Patient 19 refusing treatment and making false statements of suicidal and homicidal ideation. Neither NP nor RN 1 were available for interview during this survey.

During a review of the document "Department of Emergency Medicine Rules and Regulations - Function of the Emergency Staff," this document indicated that all patients entering the emergency department must be given a medical screening examination to determine if a medical emergency exists. Physicians and other authorized persons can perform assessments to determine if a serious enough condition exists, e.g., severe pain, psychiatric disturbances, and/or symptoms of substance abuse, such that the lack of immediate attention could result in serious harm.

During an interview on 7/26/2023 at 9:15 a.m., ED Charge stated that any patient that enters the emergency department and needs medical attention should, minimally, be given an MSE to determine if an emergency situation exists so that treatment can begin. ED Charge then iterated that if there is a situation where the patient verbalizes a medical issue, after being discharged, the physician is to be notified and another assessment (MSE) should be performed.

During an interview on 7/26/2023 at 9:50 a.m., the ED Medical Director stated that the facility is supplied with an area in the emergency department with chairs for patients with psychiatric issues; have sitters for these patients; a 'psych' team comprised of social workers, physicians, and nurse practitioners is available to assess patients in the morning of each day. The ED Medical Director then stated that the attending physician is notified; if it is determined that a 5150 hold (section of the Welfare and Institutions Code, which allows an adult, who is determined to be a risk of harm to him/her self or others, can be involuntarily detained for a 72- hour psychiatric hospitalization) should begin and care transferred to an acute psychiatric facility. The ED Medical Director also stated that any complaint identified after discharge of a patient should be assessed.

Based on interview and record review, the facility failed to provide one of one sampled patients (Patient 11), medical screening exam (MSE-used to determine if there is an emergent medical condition occurring) in a timely manner.

This failure had the potential to result in Patient 11 not receiving appropriate treatment and led to patient leaving without being seen by ED physician.

Findings:

During a concurrent interview and record view on 7/27/2023 at 10:55a.m. with the Chief Nursing Officer (CNO), Patient 11's Emergency Department (ED) Triage (categorize patients based on the severity of their condition) Report dated 1/01/2023 was reviewed. The triage report indicated that Patient 11 arrived on 1/01/2023 at 20:15 (8:15p.m.) and was triaged on 1/01/2023 at 21:24 (9:24p.m.). The record also indicated that the last set of vital signs documented for Patient 11 was on 1/02/2023 at 04:16 (4:16a.m.).

A review of Patient 11's face sheet, dated 1/02/2023,?indicated that Patient 11 was discharged on 1/02/2023 at 07:15a.m. with discharge status of left without being seen. Patient 11 was in ED for total time of 11 hours and was not seen by a physician for MSE.

During an interview with CNO on 7/26/2023 at 3:15p.m., she (CNO) stated patients who left without being seen mean that they came to ED and got triaged by the nurse. However, they were not seen by provider for an MSE, then they (referring to patients) left.

During an interview with CNO on 7/28/2023 at 10:55a.m., the CNO said the expectation for the physician was to see the patient and document they saw the patient. CNO stated she was not able to find any documentation from physician that a MSE was done for Patient 11.

During a review of the facility's policy and procedure (P&P) titled, "Department of Emergency Medicine Rules and Regulations," dated 11/01/2018, the P&P indicated, "all patients entering the Emergency Room are to receive, within a reasonable period of time, a medical screening examination within the capacity of the Emergency Service Department to determine whether or not an emergency medical condition exists."

Based on interview and limited review, the facility failed to ensure three of three sampled patients (Patients 3, 4, 5) were made aware of the risks and benefits of the transfer as evidenced by incomplete physician certification for transfer form.

This failure resulted in Patients 3, 4, and 5 not receiving information regarding risks and benefits of transfer prior to going to other facilities for psychiatric (mental, emotional, and behavioral conditions) treatment.

Findings:

1. A review of Patient 3 ' s Emergency physician note dated 1/19/2023 indicated Patient 3 arrived at the Emergency department with past medical history of schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly), bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), polysubstance abuse, and presented with suicidal ideation (thinking about or planning skill self).

During a concurrent interview and record review, on 7/27/2023 at 10:03 a.m., with Chief Nursing Officer (CNO), Patient 3 ' s Authorization for and consent to transfer dated 1/20/2023 was reviewed. The risks and benefits in "Physician Certification for Transfer" section was blank. There was a physician signature but no date and time.

The CNO stated that the Emergency physician was supposed to speak with the patient (Patient 3) regarding the risks and benefits and alternatives prior to transfer. The CNO stated that she was not able to find any records to show if the Emergency physician spoke with the patient (Patient 3) regarding risks and benefits for transfer.

During a review of the facility ' s policy and procedure (P&P) titled, "Transfer of Patients from Emergency Department," dated 2019, the P&P indicated, "the transfer may occur if the individual or LRP (legally responsible person) consents to the transfer and his/her awareness of the risks and benefits of the transfer on the Transfer Summary Form."

2. A review of Patient 4 ' s Emergency physician note dated 4/01/2023 indicated Patient 4 presented to the Emergency Department with complaint of feeling suicidal with a plan to walk out into traffic.

During a concurrent interview and record review on 7/27/2023 at 10:32 a.m., with the Chief Nursing Officer (CNO), Patient 4 ' s Authorization for and consent to transfer dated 4/01/2023 was reviewed. The risks and benefits in "Physician Certification for Transfer" section was blank.

The CNO stated that the Emergency physician was supposed to speak with the patient (Patient 4) regarding the risks and benefits and alternatives prior to transfer. The CNO She stated that she was not able to find any records to show if the Emergency physician spoke with the patient (Patient 4) regarding risks and benefits for transfer.

During a review of the facility ' s policy and procedure (P&P) titled, "Transfer of Patients from Emergency Department," dated 2019, the P&P indicated, "the transfer may occur if the individual or LRP (legally responsible person) consents to the transfer and his/her awareness of the risks and benefits of the transfer on the Transfer Summary Form."

3. A review of Patient 5 ' s Emergency physician note dated 3/18/2023 indicated Patient 5 stating, "If I had a gun I would go back and shoot all those people."

A review of Patient 5 ' s Daily focus assessment report dated 3/18/2023 indicated that the social worker spoke with Patient 5 and Patient 5 agreed to voluntary hospitalization if needed.

During a concurrent interview and record review on 7/27/2023 at 10:32 a.m., with Chief Nursing Officer (CNO), Patient 5 ' s Authorization for and consent to transfer with no date was reviewed. The risks and benefits in "Physician Certification for Transfer" section was blank. With signatures but no date and time.

The CNO stated that this patient (Patient 5) volunteered to go to another hospital. The CNO agreed that there should be date and time for the signatures.

During a review of the facility ' s policy and procedure (P&P) titled, "Transfer of Patients from Emergency Department," dated 2019, the P&P indicated, "the transfer may occur if the individual or LRP (legally responsible person) consents to the transfer and his/her awareness of the risks and benefits of the transfer on the Transfer Summary Form."