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Based on interview, record review, and review of video surveillance, the hospital failed to enter into the Emergency Department (ED) log and provide a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#26) of 27 ED patients records reviewed. The hospital's ED average monthly census over the past six months was 3,252.

The hospital's failure to enter Patient #26 into the ED log, and provide Patient #26 with a MSE within the capability and capacity of the hospital, could have resulted in possible injury or death to patients who required immediate medical care.

Please refer to A-2405 and A-2406 for details.

Based on interview, record review, and review of video surveillance, the hospital failed to enter into the Emergency Department (ED) log one patient (#26) of 27 patients' medical records reviewed who presented to the hospital's ED seeking care, out of sample selected from April 2018 to September 2018. This failure had the potential to affect all patients who presented to the ED.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act-EMTALA Requirements," revised 07/08/15, showed that:
- A covered person means a person who comes to the facility for emergency care.
- The Emergency Department maintains a log of all covered persons.
- The initial log entry is required to be made at the first point of contact.
- The entry in the log shall include: the covered person's name, disposition, whether the person refused treatment, was refused treatment by Mercy, transferred, admitted, treated, stabilized, or was discharged.
- If a patient refuses to be examined, Mercy personnel shall encourage the patient to be examined and explain the risk of refusal and the benefits of a Medical Screening Examination (MSE).
- When the patient refuses in spite of efforts to convince him or her to remain for the MSE, refusal shall be documented on a Mercy approved Patient Consent/Refusal of Treatment Form, and the form forward to the ED for inclusion in the ED log.

During a telephone interview on 10/04/18 at 3:46 PM, Patient #26 stated that:
- He and his mother went to Mercy's ED because he needed to be hospitalized for suicidal thoughts (thoughts to harm self.)
- He and his mother talked to registration (Staff N) and a nurse (Staff M) who gave them a card (identified as a behavioral health response card) and told them to leave.
- No staff had asked him any questions.

During an interview on 10/02/18 at 1:30 PM, Staff N, ED Registration Clerk, stated that:
- She was responsible for "checking in" all patients who presented to the ED for emergency care, which placed the patients on the ED log.
- She remembered that Patient #26 and his mother came to the registration desk on 09/21/18, and asked for psychiatric help.
- She did not obtain the patient's name or date of birth, and did not check the patient in; therefore, the patient was not placed on the ED log.
- She also stated that only the patients that were treated in the ED were placed on the ED log.

During an interview on 10/02/18 at 12:13 PM, Staff M, ED Registered Nurse (RN), stated that Patient #26 was not "checked in" to the ED. She had gave Patient #26 and his mother a behavioral health response card and the patient left.

Review of video surveillance dated 09/21/18, showed that at 9:57 AM, Patient #26 and his mother presented to the ED, spoke with staff members (identified by Mercy as Staff N, and Staff M), then turned and exited the ED at 10:04 AM.

Review of the ED log, dated 09/21/18, showed no evidence of Patient #26's arrival to the ED, that he requested care, or that he left the ED without receiving an examination.

During an interview on 10/02/18 at 11:45 AM, Staff L, ED Team Leader, stated that every patient that came to the ED should be placed on the ED log.

Based on observation, interview, record review, policy review and review of video surveillance, the hospital failed to provide a complete Medical Screening Examination (MSE), within its capacity and capability, to determine if an Emergency Medical Condition (EMC) existed for one patient (#26) of 27 patients who presented to the hospital's Emergency Department (ED) seeking care, out of sample selected from April 2018 to September 2018. This failure had the potential to affect all patients who presented to the ED.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act-EMTALA requirements," revised 07/08/15, showed that:
- A covered person means a person who comes to the facility for emergency care.
- An EMC means any condition that is a danger to the health and safety of the patient or any condition that may result in a risk of impairment or dysfunction to a bodily organ or part of the patient if not treated in the foreseeable future.
- A range of conditions including psychiatric disturbances (severe depression, insomnia [inability to sleep]), suicide attempt/ideation (attempt or thought to harm self) or inability to comprehend danger or care for one's self.
- A MSE is a process required in determining with reasonable clinical confidence whether or not an EMC exist.
- The screening must be completed within the capabilities of the hospital, must determine what if any further medical examinations and/or treatments may be required to stabilize the patient, or to determine that the patient needs to be transferred to a different facility once the patient is stabilized per the capabilities of the transferring facility.
- Mercy provides a MSE to any patient who comes to the hospital for emergency care.
-The MSE provided must be the same MSE that Mercy would provide on any patient with the same signs and symptoms.
- If prior to completion of the MSE, the patient expresses the intent to leave the hospital, either a Qualified Medical Personnel, triage nurse or other nurse in charge is responsible to encourage the patient to remain and explain to the individual the risk of leaving and the benefits of the MSE.
- The hospital staff may not take any action to suggest that the patient leave the hospital prior to completion of an MSE.

Review of the hospital's policy titled, "Psychiatric/Behavioral Health Patient Management," revised 03/2017, showed that Mercy Hospital Washington does not have inpatient psychiatric services. If a patient presenting to the ED or inpatient unit requires further psychiatric evaluation, the treating physician is to evaluate and determine the patient's need for transfer to the appropriate level of care.

Review of the hospital's ED protocol titled, "Emergency Department Adult Behavioral Health Protocol-Mercy Hospital-Washington," revised 08/2015, showed that nursing orders to implement for behavioral health patients were:
- Place the patient in a gown or paper scrubs.
- Place the patient in ED room 12 or an alternate room close to the nurses' station.
- If in the special room (room that can be converted to a psychiatric-safe room), pull down the garage door (garage style door that covers cabinets, equipment and supplies that would create an unsafe environment for a behavioral health patient) if the patient was suicidal or homicidal (thoughts of injuring others).

Review of the hospital's ED huddles (informal communication meetings) dated 04/20/18, 04/26/18, and 05/01/18, showed that EMTALA was very important. Communication included that the hospital must see and complete a MSE by a provider for anyone who presented to the ED, and that no one could be turned away or suggested that they could not be seen, regardless of reason for visit.

Observation on 10/01/18 at 3:35 PM in the ED, showed a dedicated psychiatric safe room available for treatment of patients with psychiatric EMCs.

During a telephone interview on 10/04/18 at 3:46 PM, Patient #26 stated that:
- He and his mother went to Mercy's ED because he needed to be hospitalized for suicidal thoughts (thoughts to harm self.)
- No staff examined him or asked him any questions.
- He and his mother had talked to registration (Staff N) and a nurse (Staff M) gave them a card (identified as a behavioral health response card) and told them to leave.
- Patient #26's mother called the behavioral health response number as they exited Mercy's ED.

During a telephone interview on 10/01/18 at 4:16 PM, Patient #26's mother stated that:
- She picked up Patient #26 from school because he was having suicidal thoughts.
- She took him to Mercy's ED, went to the registration window, and told the registration staff that she needed a psychiatric bed for her son because he was suicidal.
- The registration staff left for approximately 10 minutes, then the triage nurse came and gave her a behavioral health response card, that included a phone number, and told her to call them for help.
- Patient #26 had never had any psychiatric issues before; it was all new to her.
- No staff examined Patient #26, or asked him any questions.

Review of video surveillance dated 09/21/18, showed that at 9:57 AM, Patient #26 and his mother presented to the ED, spoke with staff members (identified by Mercy as Staff N, and Staff M), then turned and exited the ED at 10:04 AM.

The hospital did not have any documentation of Patient #26's presentation to the ED, treatment, refusal (if warranted), an appropriate MSE, transfer, discharge, or entry into the ED log.

During an interview on 10/02/18 at 1:30 PM, Staff N, ED Registration Clerk, stated that:
- She remembered that Patient #26 and his mother came to the registration desk on 09/21/18, and asked for psychiatric help.
- She asked Patient #26's mother if she wanted treatment for her son, but the mother never did give her a definite yes or no.
- She left the triage area to inform the triage nurse who was in the treatment area of the ED.

During an interview on 10/02/18 at 12:13 PM, Staff M, ED Registered Nurse, stated that:
- Mercy's ED had protocols for the treatment of psychiatric patients.
- Patient #26 was not "checked in" to the ED.
- She gave Patient #26 and his mother a behavioral health response card and the patient left.
- The mother never told her that Patient #26 was suicidal.
- She would never turn anyone away from treatment.

During a telephone interview on 10/02/18, at approximately 3:55 PM, Staff S, ED Medical Director, stated that a nurse could not determine whether or not an EMC exist and added that Mercy's ED could provide treatment for psychiatric EMCs.

Mercy hospital failed to provide an appropriate MSE to Patients #26 when they failed to follow psychiatric protocols, and further the evaluation of the patient who presented with a psychiatric presentation.

2. During a telephone interview on 10/02/18 at 3:20 PM, Behavioral Health Response Counselor T, stated that Patient #26's mother called on 09/21/18 at 10:05 AM (approximately the same time as Patient #26 and his mother left Mercy's ED) and stated that Patient #26 was suicidal and he needed help. The Behavioral Health Response Counselor offered outpatient care, but the mother stated that she did not feel safe to take Patient #26 home. The Behavioral Health Response Counselor gave directions to go to another nearby hospital for treatment.

Review of Patient #26's medical record from Hospital B (nearby hospital), showed that Patient #26, a 16 year old male, with no medical or psychiatric history, presented to the ED on 09/21/18 at 11:07 AM (approximately one hour after leaving Mercy's ED) with a chief complaint of suicidal thoughts. Patient #26 stated that he had thoughts to "slit his wrist in the bathtub." Patient #26 also stated that he had thoughts about it for a few weeks, but the thoughts he had got "bad" over the last week. The patient was medically cleared and admitted to inpatient psychiatric services for treatment.