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EAST MORGAN COUNTY HOSPITAL 2400 W EDISON ST BRUSH, CO 80723 April 6, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in 489.20 and 489.24 related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag A2406 - Medical Screening Examination - Based on interviews and document review, the facility failed to provide an appropriate Medical Screen Exam (MSE) in 6 of 7 emergency department patients reviewed who presented with psychiatric emergencies and were not admitted to the hospital (Patients #1, #2, #6, #19, #20, and #21). Specifically, the facility relied on an external mental health provider entity, who had no relationship with the hospital, to conduct psychiatric and behavioral health medical screening examinations for patients with psychiatric emergencies.
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record review, the facility failed to provide an appropriate Medical Screen Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation by Qualified Medical Personnel (QMP) in 6 of 7 emergency department patients reviewed who presented with psychiatric and behavioral health emergencies and were not admitted to the hospital (Patients #1, #2, #6, #19, #20, and #21). Specifically, the facility relied on an external mental health provider entity, who had no relationship with the hospital, to conduct psychiatric and behavioral health medical screening examinations for patients with psychiatric emergencies.

This failure created the potential for delays in diagnosis and treatment of emergency medical conditions and potential negative patient outcomes.

FINDINGS:

POLICY

According to the policy, EMTALA - Medical Screening Examination and Stabilization Treatment, the definition of an Emergency Medical Condition (EMC) is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain and/or a Psychiatric Emergency) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual in serious jeopardy.

A psychiatric emergency are those situations where a patient is a danger to himself or others by reason of aggressive conduct to inability to perceive or appreciate danger. Symptoms of substance abuse (drug and/or alcohol) requiring immediate detoxification are also considered within the definition of an emergency medical condition, and stabilizing treatment must be rendered.

A Physician or Qualified medical Personnel (QMP), as determined by the Board, will medically screen patients.

According to the policy, Qualified Medical Personnel Authorized to Perform Medical Screening Examinations, QMPs must be determined to be competent before performing medical screening examinations. Initial competency for performing medical screening examination will be validated at the time of orientation through a skills assessment or through the Allied Health Professional credentialing process. Competency will be periodically assessed thereafter.

According to the policy, Safety Precautions: Suicide, Danger to Self, Non-Behavioral Health Settings for Adults, Children, and Adolescents, the Columbia-Suicide Severity Rating Scale is the screening tool approved by Behavioral Health for use in the non-behavioral setting. If a patient is deemed High Risk actions include contact provider for Behavioral Health Consult/Assessment.

REFERENCE

According to Rules and Regulations of the Medical Staff, for purposes of compliance with EMTALA, the Board has designated the following as qualified medical personnel to perform an initial medical screening examination: Physician's Assistant (PA), Certified Nurse Practitioner (CNP) and Physician. An emergency medical condition is now defined in the regulations as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could be reasonably expected to result in placing the health of the individual in serious jeopardy.

1. The facility failed to ensure all patients who presented at the facility seeking emergency medical treatment received a medical screening examination by a QMP to determine if a emergency medical condition existed. Medical record review and interview revealed the facility used an external mental health provider entity to conduct MSEs for emergency department patients with psychiatric emergencies.

a) An interview was conducted with the Chief Executive Officer (CEO #2) and the Emergency Department Manager (Manager #8) on 03/30/17 at 2:00 p.m. Manager #8 stated the only QMPs in the facility were physicians. S/he stated the external mental health provider entity acted as a "consulting agency" for behavioral health evaluations. Manager #8 stated there were no guidelines around what the mental health provider entity would document and that they would use their own "tool." CEO #2 stated the facility would like to receive the external mental health provider's documentation before they left the facility but that did not always occur.

b) During an interview, with CEO #2 on 03/29/17 at 12:10 p.m., s/he stated there was no contract with the external mental health provider entity. S/he stated once a patient was medically stabilized, the external mental health provider was contacted and asked to come assess the patient and provide recommendations for care and treatment. If psychiatric hospitalization was recommended, the mental health provider was the entity that made the referral to the hospital and coordinated admission and transportation to the psychiatric hospital. If outpatient psychiatric services were recommended, those services would be provided by or coordinated by the external mental health entity. CEO #2 stated the facility did not have a business associate agreement or contract with the mental health entity, did not reimburse the mental health entity for the services provided, and did not have a process for vetting, monitoring or evaluating the services provided by the mental health provider. CEO #2 confirmed the mental health providers who conducted the behavioral health assessments were not employed by the facility.

c) During an interview with the Medical Director of the Emergency Department (MD #3) on 03/29/17 at 3:30 p.m., s/he stated when patients with psychiatric emergencies or behavioral issues presented to the emergency department, s/he would medically stabilize the patient and call the outside mental health provider entity to request a mental health assessment. The facility staff would provide for the safety of the patient while waiting for the mental health provider to arrive and assess the patient. MD #3 stated s/he did not know the credentials of the personnel providing the mental health assessments. When asked if s/he was aware the facility had no contract or other agreement with the mental health service provider, MD #3 stated s/he was "surprised to hear that."

d) On 03/30/17 at 11:00 a.m. an emergency department physician (Physician #4) was interviewed. S/he stated when patients with mental health emergencies presented for care, s/he would conduct an examination and interview the patient to obtain a history of psychiatric conditions or concerns. Once the patient was medically stable, the external mental health provider entity would be contacted and requested to come to the facility to conduct a face to face assessment of the patient. The mental health provider would conduct a thorough psychiatric and behavioral evaluation of the patient and would make recommendations to the physician for placement or referral if needed. Based on the recommendations of the mental health provider, a transfer or discharge plan would be developed and executed.

Physician #4 stated if a patient needed a plan developed for remaining safe at the facility while transfer or discharge arrangements were made, the plan would be developed by the external mental health provider. Physician #4 stated "I don't see the safety plan." Physician #4 was asked if s/he knew the credentials of the individuals from the external mental health provider entity who were relied upon to provide the psychiatric evaluation and s/he stated s/he did not.

2. Record review showed multiple examples where the external mental health entity conducted the behavioral health portion of the medical screening examination to determine if an emergent medical condition existed and decided treatment plans for patients who were currently receiving emergency services at the hospital. As example,

a) Patient #2 (MDS) dated [DATE] at 11:51 p.m. for a multiple sclerosis flare up and complaints of severe pain rated 10 of 10 (on a scale of 1-10). The patient was evaluated, medicated and discharged home on 01/28/17 at 12:50 a.m.

Patient #2 returned to the emergency department at 9:22 a.m. on 01/28/17 with complaints of severe pain in his/her back, arms and abdomen. Patient #13 had a history of multiple sclerosis with intractable pain that was worsening and s/he was expressing suicidal ideation due to the severity of the pain. According to the Pain Assessment, conducted on 01/28/17 at 9:26 a.m. by Registered Nurse #5 (RN), Patient #2's pain was rated at a 10 of 10, worst possible pain, in his/her back. The patient's pain was reassessed at 11:50 a.m. and remained a 10 of 10.

Review of Progress Notes showed RN #5 answered the patient's call light to find him/her sitting on the floor with oxygen tubing loosely wrapped around his/her neck twice. The patient was flushed and crying, but difficult to understand with crying. The patient was moved to a room with no cords with direct observation put in place. There was no time documented as to when the event occurred.

Subsequently, the patient was assessed by RN #6. When asked if the patient "wished self dead or to not wake up", the patient responded "yes". The patient answered "yes" when asked if s/he actually thought about killing yourself. The patient stated "just today, because I hurt so bad." Further documentation showed the patient stated s/he had only ever wished to be dead today while in the hospital's care because his/her pain was so great. At 11:50 a.m., RN #6 documented the patient was put on suicide precautions.

The external mental health service provider entity was contacted and requested to come evaluate the patient due to the suicidal gesture. The RN caring for Patient #2 documented the mental health provider was in to evaluate Patient #2 at 3:15 p.m. The patient was discharged and driven home by the mental health provider at 3:35 p.m.

Review of a handwritten Safety Plan, dated 01/28/17 with no time noted, was signed by the patient and the unaffiliated mental health provider. There was no documentation to show the facility, or a QMP evaluated and agreed with the safety plan. There was additional documentation in the medical record which showed Patient #2 was evaluated by the mental health service provider; however, there was no documentation as to who the evaluator was and their credentials. Additionally, there was no documentation the facility reviewed and approved of the evaluation and the recommendations.

Later in the evening on 01/28/17, Patient #2 committed suicide at home by a self inflicted gunshot wound to the head.

Of note, the handwritten Safety Plan and evaluation conducted by the unaffiliated mental health provider was faxed to the facility on [DATE] at 4:43 p.m., 3 days after the patients emergency department visit and subsequent suicide, for inclusion in the facility's medical record.

There was no documentation Patient #2 received a medical screening exam, by a QMP, for his/her suicidal gestures prior to being discharged from the facility.

b) Patient #21 was brought to the emergency department on 12/13/16 with acute alcohol intoxication and suicide ideation. According to the ED Reports the patient's risk factors consisted of multiple psychiatric disorders including ADD (attention deficit disorder) and bipolar disorder. The physician documented the patient had significant agitation and threatened to leave against medical advice (AMA) and with his/her acute alcohol intoxication and suicidal ideation s/he was placed on a mental health hold (M-1).

According to the Psychosocial Assessment, using the Columbia Suicide Rating Score, conducted on 12/13/16 at 12:11 p.m. by RN #8, Patient #21 had a score of 12 which indicated s/he was at a high risk for suicide and a behavioral health evaluation should be conducted pursuant to the policy noted above.

The medical record indicated that once Patient #21 was medically stabilized, a representative from the outside mental health provider entity came to the facility to assess him/her. The ED notes stated the external mental health provider entity evaluated the patient and did not find any evidence of him/her being at acute risk of suicide.

However, there was no documentation of the mental health provider's evaluation, findings or recommendations in the medical record. Additionally, there was no documentation the mental health provider was qualified as a QMP to conduct the behavioral health evaluation.

There was no documentation the mental health hold (M-1) had been discontinued prior to the patients discharge. Further, the mental health hold was not in the medical record and the facility was unable to locate a copy during the survey process.

Patient #21 was discharged home from the facility with no documentation s/he received a MSE by a QMP after being placed on a mental health hold for suicidal ideation.

c) Record review revealed Patient #6 (MDS) dated [DATE] for suicidal ideation. According to the physician's ED Reports, the patient presented with suicidal ideation and had a history of suicide attempts in the past.

On 03/02/17 at 3:42 p.m. RN #9 conducted a Psychosocial Assessment using the Columbia Suicide Rating Scale. Patient #6 scored an 8 which indicated s/he was at a high risk for suicide and a behavioral health evaluation should be conducted.

According to the ED reports the external mental health provider entity came to the ED and evaluated Patient #6 for his/her suicide risk. Review of a document, titled My Safety and Action Plan, dated 03/02/17, showed Patient #6 met with an individual from the external mental health provider entity and signed the safety plan. However, there was no documentation from the the mental health provider entity on the patient's evaluation, findings or clinical decision making. Additionally, there was no documentation Patient #6 received a psychiatric or mental health evaluation from the facility or a QMP to ensure s/he did not have an emergent medical condition. The patient was discharged home on 03/02/17 at 7:16 p.m.

d) Patient #19 (MDS) dated [DATE]. Review of the ED Reports showed the patient did not have any money and was planning to rob a store. The patient called the police who picked him/her up and brought him/her to the CAH. The patient denied suicidal ideation but "feels [s/he] may hurt someone." The notes stated the patient was medically stable for the external mental health provider entity to evaluate. The patient was "evaluated" by the mental health provider and it was decided the patient could be safely discharged with his/her mother. Follow-up was arranged through the mental health provider.

Review under the section, titled Outside Records, showed an undated Safety and Action Plan, signed by the patient. However, there was no documentation from the mental health provider entity on the safety plan and the patient's evaluation, findings or clinical decision making. Additionally, there was no documentation the individual who conducted the behavioral health evaluation was qualified and a designated QMP.

There was no evidence Patient #19 received a psychiatric or mental health evaluation from the facility or a QMP to ensure s/he did not have an emergent medical condition and was safe for discharge. The patient was discharged home on 03/20/17 at 11:59 p.m.

e) Patient #20 (MDS) dated [DATE]. The pediatric patient stated s/he had been having suicidal ideation almost every day but it got worse over the last week. The patient was brought to the ED after "trying to commit suicide by ingesting prevacid."

On 03/25/17 at 8:33 p.m., RN #10 conducted a Psychosocial Assessment using the Columbia Suicide Rate Scale. Patient #20 scored 12 which indicated s/he was at a high risk for suicide. The patient answered "yes" when asked if s/he wished him/herself dead, actually thought about killing yourself, thinking how you might kill yourself, do you intent to act on these thoughts and started or prepared to end your life. The assessment noted the patient reported suicidal ideations and the external mental health provider entity was consulted.

Further review of the ED Reports revealed the external mental health provider was contacted and "they evaluated [the] patient and made a plan to have patient go home with grandmother." The Discharge Comment stated the mental health provider made a safety plan with grandma and the pediatric patient. Both felt comfortable with the plan.

However, there was no evidence the mental health provider was a QMP for the facility. There was no documentation Patient #20 received a psychiatric or behavioral health medical screening by a QMP to determine if an emergent medical condition existed or if the patient was safe for discharge home. Additionally, there was no documentation from the external mental health provider entity on the patient's evaluation, findings or clinical decision making in the medical record.

f) Medical record review showed Patient #1 came to the emergency department on 12/26/16 with concerns that s/he had a neuro transmitted in his/her ear. Patient #1 had been diagnosed with a history of schizoaffective disorder and was using methamphetamine on a daily basis. The medical record indicated that a representative from the outside mental health entity had been in to evaluate Patient #1 and had arranged for admission to a behavioral health facility.

However, there was no documentation in the medical record from the mental health entity who conducted the mental health assessment and clinical decision making. There was no evidence the mental health provider was a QMP.

3. The facility maintained no personnel records on any of the external mental health providers who conducted behavioral health evaluations and decided treatment plans for patients who present to the CAH with psychiatric and behavioral health emergencies. There was no documentation the behavioral health evaluators were Qualified Medical Personnel.

The facility's standard practice of using the unaffiliated mental health provider entity to conduct medical screening examinations to determine if an emergent medical condition existed left all patients who presented to the emergency department with behavioral and psychiatric emergencies at risk for treatment delays and potential negative patient outcomes.