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Based on policy review, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

1. The hospital failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 1 sampled patients discharged to jail (Patient #12).

Cross refer to A2406

2. The hospital failed to ensure stabilizing treatment was provided as required to stabilize an emergency medical condition for 1 of 1 sampled patients who was discharged to jail (Patient #12).

Cross refer to A2407

Based on policy and procedure review, medical record review, and staff and physician interviews, the hospital failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 1 sampled patients discharged to jail. (Patient #12).

The findings include:

Review on 10/22/2019 of the "EMTALA - Medical Screening and Treatment of Emergency Medical Conditions" approved 08/31/2018 revealed " ...L. Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in labor. Such screening must be done within the facility's capability and available personnel, including on-call physicians. The Medical Screening Examination must be performed by a Physician or other Qualified Medical Personnel. The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred ..."

Review on 10/22-24/2019 revealed Patient #12 presented to Hospital A's DED via EMS on 9/12/2019 at 0006. Review of the triage notes at 0008 revealed " ...EMS sts (states) pt wasn't acting right but couldn't provide specifics. Spoke with (Staff Member at ALF-Assisted Living Facility) and she sts the pt (patient) walked to the med room holding a blanket and asked 'why did you leave me?'. (Staff member) sts she walked him back to his room and he shoved her. (Staff member) then sts her RA (Resident Assistant) then took the patient to his room, and he was stating, 'I don't want to die here.', and minutes later he ran out of the room and attempted to run out of the facility. Pt able to tell me his birthday at this time but refuses to speak to me anymore at this time. Pt resp (respirations) even and unlabored with NADN (No apparent distress noted) ..." Vital Signs were recorded as T (temperature) 98.9, P (pulse) 102, R (respirations) 17, BP (Blood Pressure) 154/118, and SpO2 97% on room air. A pain score of 0 was documented and Patient #12 was triaged as level 3, urgent. Further review of triage notes revealed "pt sts ht (height) and weight and sts the girls were trying to smother me. Pt sts after his brother left the two girls were on top of him and saying that this is reality. Pt sts he just wanted outside where the air was and they wouldn't let him up. 'They let me get so weak, I couldn't get up' pt sts her name was (Staff member at ALF) ..." Review of MD #1's documentation at 0156 revealed " ...PATIENT IS A 57-YEAR-OLD GENTLEMAN WHO IS SENT TO THE EMERGENCY ROOM FROM HIS LOCAL NURSING HOME FOR EVALUATION OF AGITATION AND VIOLENT BEHAVIOR. THIS IS PATIENT'S 4TH VISIT SINCE THE 1ST OF THE MONTH FOR A VARIETY OF COMPLAINTS. PATIENT TONIGHT BECAME VERY AGITATED WITH THE STAFF AT THE NURSING HOME. HE REPORTEDLY WALKED TO THE NURSING STATION MAKE IT (sic) AND AFTER BEING WALKED BACK TO HIS ROOM SHOT UP (sic) TO THE STAFF. THEY REPORT HE IS ACTING MORE AGITATED THAN NORMAL. THEY WOULD LIKE PATIENT TO BE EVALUATED FOR 5TH FLOOR COMMITMENT. PATIENT REPORTS THAT HE NEEDS TO BE IN THE HOSPITAL BECAUSE THE STAFF AT THE NURSING HOME WAS TRYING TO KILL HIM. REPORTS THAT THEY HAVE BEEN TRYING TO HOLD DOWN ELBOW NOT LETTING GET OUT OF THE BED. PATIENT WILL BE EVALUATED BY PSYCHIATRY ...Review of Systems ...Psychiatric: Anxiety, Paranoia, Other (AGGRESSIVE BEHAVIOR). Negative: Thoughts of Hurting Yourself or Others, Visual Hallucinations, Auditory Hallucinations ...Physical Exam ...Psychiatric: Judgement/Insight Impaired, Depressed Mood, Anxiety. negative: Suicidal Thoughts, Homicidal Thoughts, Visual Hallucination(s), Auditory Hallucination(s) ....Revaluation Time 1st Reeval: 0245 ...Other (PATIENT REPORTS HE HAS NOT BEEN ABLE TO URINATE AND HE DOES HAVE A DISTENDED BLADDER SO FOLEY WAS PLACED AND OVER 500 CC URINE RELEASED.) ..." Review revealed Patient #12's home medications were " ...Sinemet 25/100 (Medication used to treat Parkinson's Disease symptoms), Lexapro 10mg (medication that can treat depression and anxiety), Vistaril 50mg (medication that can treat anxiety and tension), Remeron 15mg (antidepressant), Miralax 1 packet (laxative), Azilect 1mg (medication used to treat Parkinson's Disease), Trazadone 50mg (sedative and antidepressant) ..." Review revealed a Foley catheter was placed at 0248 and a urinalysis resulted at 2138 on 09/12/2019 that was negative with no abnormal results. Review revealed the Foley catheter was discontinued at 1226 on 09/12/2019 and Patient#12 was able to void after the removal of the catheter. Review of the physician orders revealed an order on 09/12/2019 at 0156 for " ...Psych Social Services Consult [Behavioral Health SW (Social Worker) Consult] ...Reason for Consultation Parkinsons Confusion Agitation ..." Review of a behavioral health nursing note on 09/12/2019 at 0253 revealed " ...Attempted to assess pt. Pt refuses to answer questions and is evasive. Pt only states that he wants to stay at hospital because staff at nursing home is trying to kill him, that they held him in the floor and that he couldn't breathe. When he was asked if incident was after he shoved a nurse while naked, he refused to speak anymore. Will let pt rest and ask that day shift psych reassess patient at a later time ..." Review revealed on 09/12/2019 at 1117 another behavioral health nurse attempted to assess Patient #12 and wrote " ...Behavioral Health nurse in to talk with pt but pt refused to acknowledge her. Pt noted to be shaking (Parkinson disease). Pt stopped shaking a few minutes and turned his head to the other side. Several attempts have been made last night and today but pt will not respond. Ed doctor will send pt back to (Assisted Living Facility) at this time ..." Review of a behavioral health nurse note on 09/12/2019 at 1256 revealed " ...Pt did not appear angry, suicidal or homicidal when this nurse was assessing pt. Previous nurses state that he stated he didn't like being at (ALF) and didn't want to go back there. Otherwise no complaints of any kind noted ..." Review revealed on 09/12/2019 at 1650 Patient #12 was set for discharge and the nurse called the ALF for pick-up. Review revealed the ALF and Patient #12's family refused to pick Patient #12 up. Review revealed on 09/12/2019 at 2034 a consult order for the hospitalist for admission was placed. Review of the hospitalist note on 09/12/2019 at 2213 revealed " ...The patient was apparently sent to our emergency department after he became violent with a nurse at his skilled nursing facility. The patient has had a prolonged course in the emergency department with no acute issues identified. The patient has known chronic issues related to Parkinson's. The emergency room staff indicates to me that the patient has been in the hospital multiple times in the emergency department for various complaints and generally has a foul temper. I was contacted by the nurse administrator on-call at night after discussion she had with administration regarding potential admission of the patient to the hospital secondary to social issues the patient was having. The emergency room providers and Psychiatry have already cleared the patient to be discharged back to his skilled nursing facility but because of his violent outburst they refused to take him back. Additionally, the patient's family was requested to come care for the patient and they have refused to do so ...Past Medical History Psychiatric: Anxiety, Depression Other History: insomnia, aggressive behavior ...Plan: 1. Violence towards staff. Apparently the patient had been somewhat confused and violent towards staff at a skilled nursing facility. During my interview and exam of the patient exhibited no violent activities or behavior towards me. The patient was occasionally confused during interview as he was somnolent, but when I roused the patient he would become clear answer questions appropriately. The patient was even able to independently look at the clock and know that it was time for his nighttime medications ...The patient seems to have a host of social issues complicating his care and I defer to the emergency department and nursing administrator on at night to continue working with DSS (Department of Social Services) regarding the patient's care ..." Review revealed on 09/13/2019 at 0633 a consult order for Case Management for "Rest Home Placement." Review of PA #1's note on 09/13/2019 at 1304 revealed " ...Patient presents to the emergency department after aggressive behaviors at assisted living facility ...Patient was medically evaluated and cleared with hospitalist consultation. Patient has been, cooperative in the emergency department and was also evaluated by psychiatrist and cleared. The assisted living facility is refusing to accept patient back into the facility and family members are not currently picking up the patient as they are unable to care for him at home. Case management was consulted this morning with hospital administration involved as well. DSS was called likely by case management who spoke with RN and patient. Patient has been medically and psychiatrically cleared and is awaiting safe disposition ..." Review on 09/13/2019 at 1427 revealed the ALF delivered an "immediate discharge paperwork" and would not be taking Patient #12 back to the ALF. Review of a case management note on 09/13/2019 at 1501 revealed "..Consult from ER for placement on discharged Pt that facility refuses to let return. Spoke with (family) by phone and ...has made calls to find placement and Pt has appt at (Facility name) next week for a psych eval and medication eval ...states Pt's medications can cause the behaviors ...states there is no one in the family to take Pt at this time ...Spoke with (Staff member at ALF) states, they can not take Pt back due to the fact he 'assaulted a staff member while naked.' She stated that he shoved a staff member against the wall and she hit her back and head ...there will be no charges pressed, however, the police was called and he was taken to the ER ..." Review revealed case management made a referral to two gero-psych units on 09/13/2019 at 1648 and Patient #12 was denied placement at both. Review of PA #1's note on 09/14/2019 no time documented revealed " ...57 year old male patient has been awaiting placement after medical and psychiatric clearance. Dss, case management, and hospital administration are involved and family refuses to take patient home as well. Patient has been ambulating without difficulty and had an intentional fall today without injury. Patient assessed afterward by myself and attending physician (MD #2) without pain, difficulty ambulating, or signs of trauma after fall while RN was in room ..." Review of PA #1's note on 09/15/2019 no time documented revealed " ...57 year old male patient remain in ED awaiting placement after medical and psychiatric clearance. Patient has been ambulatory, eating and drinking, with complaint of constipation. Patient denies abdominal pain and was prescribed Magnesium Citrate. Patient was given a phone and spoke to family members in his room. Patient continues to voice his wishes to be discharge and is aware of awaiting placement ..." Review of PA #1's note on 09/16/2019 no time documented revealed " ...57-year-old male patient with a history of Parkinson's disease continues to await disposition and nursing facility placement. Patient has been cooperative and ambulatory today without complaints ..." Review revealed the case manager contacted a DSS social worker on 09/16/2019 to assist with finding placement for Patient #12. Review revealed referrals were sent to group homes, assisted living facilities and psychiatric units by case management on 09/16/2019. Review of MD #1's progress note on 09/17/2019 at 0030 revealed " ...PATIENT HAS BECOME AGGRESSIVE INTACT 1 (sic) THE ER NURSES FOR NO REASON. PATIENT IS AWAKE ALERT AND ORIENTED. PATIENT WILL BE DISCHARGED IN THE CUSTODY OF POLICE FOR ASSAULT ON HEALTHCARE WORKER ...Discharge Diagnosis (1) Aggressive behavior Status: Acute ...Disposition Type: Discharge (IN CUSTODY OF POLICE DEPARTMENT) Condition: Stable ..." Review of the nursing note on 09/17/2019 at 0115 revealed "...Pt wandered around ER. Nurse to pt stating 'I have some medicine to give you.' Pt came toward nurse and grabbed nurse's chest and would not release nurse's chest and clothing leaving an abrasion and redness to chest. pt placed in prt (physical restraint technique) taught by handle with care. (Police) called; pt contained by (police) and taken to jail..." Review revealed on 09/17/2019 at 0045 Patient #12 was discharged in police custody. Review revealed Patient #12 was not seen by a psychiatrist while in the ED.

Interview on 10/24/2019 at 1530 with PA #1 revealed she rounded on Patient #12 multiple days while he was in the ED. Interview revealed Patient #12 was waiting for placement because the ALF he was staying at and his family refused to pick him up. Interview revealed Patient #12 wanted to go home and was "somewhat agitated" when she took care of him. Interview revealed PA #1 had no concerns that Patient #12 needed to be IVCed (involuntarily committed) or had psychiatric issues. Interview revealed Patient #12 had no suicidal ideations and was easily redirected when agitated. Interview revealed Patient #12 had a psychiatric evaluation by the psychiatric nurse who would then talk to the psychiatrist and ED physician. Interview revealed patients did not always see a psychiatrist. Interview revealed PA #1 explained the providers in the ED were trying all options to find Patient #12 placement including consulting the hospitalist for admission.

Interview on 10/24/2019 at 1719 with MD #3 revealed he recalled Patient #12. Interview revealed Patient #12 was not aggressive when he took care of him. Interview revealed for psychiatric consults a social worker or behavioral health nurse would evaluate the patient first and then report their findings to the psychiatrist and ED physician. Interview revealed MD #3 had no concern that Patient #12 needed to be IVCed. Interview revealed MD #3 was concerned Patient #12's ALF was trying to get rid of him because they would not pick him up. Interview revealed when MD #3 took care of Patient #12 he had no behaviors that would warrant making him IVC. Interview revealed MD #3 would not IVC Patient #12 based on the behaviors at the ALF because he did "not trust" that report. Interview revealed Patient #12 was cleared psychiatrically based on the ED MD's assessment and BH RN assessment.

Interview on 10/24/2019 at 2030 with MD #1 revealed he recalled Patient #12. Interview revealed when Patient #12 first arrived he was told that the ALF wanted him to have a psychiatric screening. Interview revealed MD #1 put in an order for a psychiatric consult. Interview revealed the psychiatric nurse would evaluate the patient and report to the psychiatrist and ED physician their assessment. Interview revealed a hospitalist consult was placed when the ALF refused to take Patient #12 back, to see if Patient #12 could be admitted while waiting on placement. Interview revealed Patient #12 did not meet IVC criteria and was not suicidal when MD #1 cared for him. Interview revealed Patient #12 was stable at discharge and a complete medical screening exam had been completed.

Interview on 11/07/2019 at 1318 with RN #4 revealed she was a behavioral health nurse who assessed Patient #12. Interview revealed normally when the physician put a consult order in the behavioral health nurse would respond to the consult. Interview revealed if a behavioral health nurse was not there then the social worker on the behavioral health unit would be called. Interview revealed RN #4 went to see Patient #12 on 09/12/2019 after she had heard from a previous behavioral health nurse that he was not cooperative with the assessment and still needed a RARF (regional assessment and referral form) screening. Interview revealed normally RN #4 would do a RARF screening on the patients she assessed but it depended on how much patients told her during the assessment. Interview revealed when RN #4 went to see Patient #12 the first time he would not look or talk to RN #4. Interview revealed RN #4 left and attempted to assess Patient #12 again later, but he would still not talk to her. Interview revealed RN #4 spoke to the ED MD about Patient #12 and him not talking to RN #4. Interview revealed that was why in her note RN #4 wrote "did not appear." Interview revealed sometimes RN #4 would call the psychiatrist about the assessment but since Patient #12 did not say anything she was "pretty sure" she did not talk to the psychiatrist.

In summary, Patient #12 arrived to Hospital A's DED on 09/12/2019 at 0006 from his ALF for being aggressive to staff and pushing a staff member. Patient #12 was seen by a provider on 09/12/2019 and a consult for psychiatric social services was placed. Patient #12 was seen by a behavioral health nurse on 09/12/2019 at 0253, 1117, and 1256 and would not respond to their questions or assessment. Patient #12 was determined cleared by psychiatry although a psychiatrist never saw the patient. The ALF where Patient #12 came from refused to take the patient back and the case manager was searching for placement for Patient #12 from 09/13/2019 until 09/17/2019 when Patient #12 was discharged from the hospital's ED to jail for assaulting a emergency department staff member. The facility failed to ensure their policy was followed as evidenced by failing maintain an ongoing medical screening examination for patient #12's 09/12/2019 Emergency Department visit as evidenced by the patient was never evaluated by a psychiatrist.

Based on policy and procedure review, medical record review, and staff and physician interviews, the hospital failed to ensure stabilizing treatment was provided within the capability of the staff available at the hospital as required to stabilize the emergency medical condition for 1 of 1 sampled patients who were discharged to jail. (Patient #12).

The finding include:

Review on 10/22/2019 of the "EMTALA - Medical Screening and Treatment of Emergency Medical Conditions" approved 08/31/2018 revealed "...If the Medical Screening Examination reveals an Emergency Medical Condition, then the Hospital must provide stabilizing treatment within its capacity and capabilities....necessary to stabilize the patient or must appropriately transfer the patient to another facility. ..."

Review on 10/22-24/2019 revealed Patient #12 presented to Hospital A's DED via EMS on 9/12/2019 at 0006 from his Assisted Living Facility for evaluation of agitation and violent behavior. Review of the physician orders revealed an order on 09/12/2019 at 0156 for "...Psych Social Services Consult [Behavioral Health SW (Social Worker) Consult] ...Reason for Consultation Parkinsons Confusion Agitation ..." Review of a behavioral health nursing note on 09/12/2019 at 0253 revealed "...Attempted to assess pt. Pt refuses to answer questions and is evasive. Pt only states that he wants to stay at hospital because staff at nursing home is trying to kill him, that they held him in the floor and that he couldn't breathe. When he was asked if incident was after he shoved a nurse while naked, he refused to speak anymore. Will let pt rest and ask that day shift psych reassess patient at a later time..." Review revealed on 09/12/2019 at 1117 another behavioral health nurse attempted to assess Patient #12 and wrote "...Behavioral Health nurse in to talk with pt but pt refused to acknowledge her. Pt noted to be shaking (Parkinson disease). Pt stopped shaking a few minutes and turned his head to the other side. Several attempts have been made last night and today but pt will not respond. Ed doctor will send pt back to (Assisted Living Facility) at this time..." Review revealed on 09/12/2019 at 1650 Patient #12 was set for discharge and the nurse called the ALF for pick-up. Review revealed the ALF and Patient #12's family refused to pick Patient #12 up. Review revealed on 09/12/2019 at 2034 a consult order for the hospitalist for admission was placed. A hospitalist note on 09/12/2019 at 2213 stated "...The patient was apparently sent to our emergency department after he became violent with a nurse at his skilled nursing facility. The patient has had a prolonged course in the emergency department with no acute issues identified. The patient has known chronic issues related to Parkinson's.... The patient seems to have a host of social issues complicating his care and I defer to the emergency department and nursing administrator on at night to continue working with DSS (Department of Social Services) regarding the patient's care ..." Review of PA #1's note on 09/13/2019 at 1304 revealed "...Patient presents to the emergency department after aggressive behaviors at assisted living facility ...Patient was medically evaluated and cleared with hospitalist consultation. Patient has been, cooperative in the emergency department and was also evaluated by psychiatrist and cleared....Patient has been medically and psychiatrically cleared and is awaiting safe disposition ..." Review revealed hospital case managers searched for placement without success during Patient #12's ED stay. On 09/17/2019 at 0030, a physician progress note revealed Patient #12 became aggressive and assaulted a nurse. Review revealed the patient was "...AWAKE ALERT AND ORIENTED. PATIENT WILL BE DISCHARGED IN THE CUSTODY OF POLICE FOR ASSAULT ON HEALTHCARE WORKER...Discharge Diagnosis (1) Aggressive behavior Status: Acute ...Disposition Type: Discharge (IN CUSTODY OF POLICE DEPARTMENT) Condition: Stable ..." Record review revealed Patient #12 was cleared for discharge but failed to reveal a psychiatrist had evaluated the patient during the ED stay or prior to discharge. Review revealed Patient #12 was discharged in police custody to jail potentially delaying stabilization.

Interview on 10/24/2019 at 1530 with PA #1 revealed the PA rounded on Patient #12 multiple days while he was in the ED. Interview revealed Patient #12 was waiting for placement because the ALF he was staying at and his family refused to pick him up. Interview revealed Patient #12 wanted to go home and was "somewhat agitated" when the PA took care of him. Interview revealed PA #1 had no concerns that Patient #12 needed to be IVCed (involuntarily committed) or had psychiatric issues. Interview revealed Patient #12 had no suicidal ideations and was easily redirected when agitated. Interview revealed Patient #12 had a psychiatric evaluation by the psychiatric nurse who would then talk to the psychiatrist and ED physician. Interview revealed patients did not always see a psychiatrist. Interview revealed PA #1 explained the providers in the ED were trying all options to find Patient #12 placement including consulting the hospitalist for admission.

Interview on 10/24/2019 at 1719 with MD #3 revealed he recalled Patient #12. Interview revealed Patient #12 was not aggressive when he took care of him. Interview revealed for psychiatric consults a social worker or behavioral health nurse would evaluate the patient first and then report their findings to the psychiatrist and ED physician. Interview revealed MD #3 had no concern that Patient #12 needed to be IVCed. Interview revealed MD #3 was concerned Patient #12's ALF was trying to get rid of him because they would not pick him up. Interview revealed when MD #3 took care of Patient #12 he had no behaviors that would warrant making him IVC. Interview revealed MD #3 would not IVC Patient #12 based on the behaviors at the ALF because he did "not trust" that report. Interview revealed Patient #12 was cleared psychiatrically based on the ED MD's assessment and BH RN assessment.

Interview on 10/24/2019 at 2030 with MD #1 revealed he recalled Patient #12. Interview revealed when Patient #12 first arrived he was told that the ALF wanted him to have a psychiatric screening. Interview revealed MD #1 put in an order for a psychiatric consult. Interview revealed the psychiatric nurse would evaluate the patient and report to the psychiatrist and ED physician their assessment. Interview revealed a hospitalist consult was placed when the ALF refused to take Patient #12 back, to see if Patient #12 could be admitted while waiting on placement. Interview revealed Patient #12 did not meet IVC criteria and was not suicidal when MD #1 cared for him. Interview revealed Patient #12 was stable at discharge and a complete medical screening exam had been completed.

Interview on 11/07/2019 at 1318 with RN #4 revealed she was a behavioral health nurse who assessed Patient #12. Interview revealed normally when the physician put a consult order in the behavioral health nurse would respond to the consult. Interview revealed if a behavioral health nurse was not there then the social worker on the behavioral health unit would be called. Interview revealed RN #4 went to see Patient #12 on 09/12/2019 after she had heard from a previous behavioral health nurse that he was not cooperative with the assessment and still needed a RARF (regional assessment and referral form) screening. Interview revealed normally RN #4 would do a RARF screening on the patients she assessed but it depended on how much patients told her during the assessment. Interview revealed when RN #4 went to see Patient #12 the first time he would not look or talk to RN #4. Interview revealed RN #4 left and attempted to assess Patient #12 again later, but he would still not talk to her. Interview revealed RN #4 spoke to the ED MD about Patient #12 and him not talking to RN #4. Interview revealed that was why in her note RN #4 wrote "did not appear." Interview revealed sometimes RN #4 would call the psychiatrist about the assessment but since Patient #12 did not say anything she was "pretty sure" she did not talk to the psychiatrist.