The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ESSENTIA HEALTH ST MARY'S MEDICAL CENTER 407 EAST THIRD STREET DULUTH, MN 55805 Dec. 12, 2013
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on documentation review and interview, the hospital failed to ensure compliance with the requirements of 42 CFR 489.24 as evidenced by the deficient practices cited at 489.24 (r) and 489.24 (c).
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on observation and interview, the hospital failed to post conspicuously in the emergency department (ED) waiting rooms, for those individuals waiting for examination, signs specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment in the emergency department and women in labor.

Findings include:

A tour of the ED was conducted with registered nurse (RN)-A at 9:28 p.m. on 12/12/2013. The hospital's ED had two separate waiting rooms, one for pediatric patients and their families and one for adult patients. The pediatric waiting room had no signs regarding EMTALA (emergency medical treatment and labor act) rights. The adult waiting room had one wall that had been removed for remodeling however, the other three walls of the waiting room had no signage regarding a patient's EMTALA rights.

During the tour, RN-A confirmed patient's EMTALA rights were not posted in the pediatric and adult waiting rooms.

Review of the hospital's EMTALA policy and procedure with a review/revision date of 7/2012, stated, the hospital must post appropriate signage notifying patients of their right to a medical screening examination and stabilization as specified under EMTALA.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on document review and interview, the hospital failed to maintain the emergency department (ED) central log for 1 of 1 (P21) patients that presented to the ED and was refused care by the hospital.

Findings include:

Interview with registered nurse (RN)-A on 12/12/2013, at 10:48 a.m. established on 12/4/13, at approximately 5:15 p.m. under consultation with a RN supervisor, a decision was made to divert or redirect mental health patients to other EDs. Rational for the decision to divert the patients was based on the hospital's ED already providing care for 10 psychiatric patients in the ED and a snow storm that was limiting the available transportation for patients being discharged from the mental health unit and the ED. A short time after the decision was made to divert mental health patients, a police car with P21 had arrived in hospital's ED garage. RN-A said the police officer and P21 entered the ED and were standing near the nurse station. The ED staff informed the police officer the ED was on diversion and could not provide care to mental health patients. The police officer told RN-B that the patient was requesting the hospital's ED and admission to the mental health unit utilized by the hospital. RN-A said the police officer and P21 left the ED. RN-A said the ED should have registered P21 into the ED log and arranged for a medical screening examination

Review of the hospital's ED log dated 12/4/2013, revealed P21 had not been entered into the ED log.

Review of the hospital's EMTALA (emergency medical treatment and labor act) policy and procedure with a review/revision date of 7/2012, stated, the hospital will maintain a central log to include information on each individual that comes on the premises requesting treatment.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the hospital failed to provide a medical screening examination (MSE) for 1 of 21 patients (P21) reviewed who presented to the emergency department (ED) for evaluation of an emergency medical condition (EMC).

Findings include:
Review of the hospital's ED log dated 12/4/2013, revealed no entry in the ED log for P21 and there was not a medical record for P21.

Interview with registered nurse (RN)-A on 12/12/2013, at 10:48 a.m. established on 12/4/13, at approximately 5:15 p.m. under consultation with a RN supervisor, a decision was made to divert or redirect mental health patients to other emergency departments. Rational for the decision to divert the patients was based on the hospital's ED already providing care for 10 psychiatric patients in the hospital's ED and a snow storm that was limiting the available transportation for patients being discharged from the mental health unit and the ED. A short time after the decision was made to divert mental health patients, RN-A was notified that a police car with P21 had arrived in the hospital's ED garage. RN-A said the police officer and P21 entered the ED. RN-B told the police officer the ED was on diversion and could not provide a medical screening examination (MSE) to mental health patients. RN-A said the police officer was asked whether he had contacted the hospital prior to the transport of P21. The police officier left the ED with the patient. No attempt was made by the hospital's ED staff to bring P21 back into the ED for a MSE. RN-A said the ED should have registered P21 and arranged for a medical screening examination (MSE) at the hospital's ED.

Interview with RN-B on 12/12/2013, at 11:21 a.m. established a police officer had driven into the hospital's ED garage accompanied by P21.RN-B said she was told by the police officer that P21 had requested to be seen at hospital's ED and had requested to be admitted to the mental health unit utilized by hospital's ED.

Interview with police officer-E on 12/16/2013, at 10:41 a.m. established he had been contacted by the police department's dispatch and spoke with P21 who had contacted 911 requesting assistance and transport to the hospital's ED for suicidal thoughts. P21 told police officer-E he had called the mental health unit normally used by the hospital's ED where he had previously been a patient, and was told to first be seen in the hospital's ED. Police officer-E said upon arriving in the ED garage, he was met by an unnamed staff person and told to stay in the garage until a charge nurse from the ED could speak to him. Despite that request, police officer-E escorted P21 into the hospital's ED. He said 4 to 5 unidentified staff told him and P21 that the hospital's ED was full and P21 would need to be taken to a different ED. Police officer-E said he told the ED staff that P21 requested to be seen at that hospital's ED for suicidal thoughts. After the ED staff refused to see P21, police officer-E said he escorted P21 to the police car and left for another hospital's ED. Police officer-E said the hospital's ED staff did not attempt to summon P21 back to the ED as they were leaving. Police officer-E revealed P21 stated he was concerned he wouldn't get medical attention and was crying during the one mile ride to another hospital's ED.

Interview with P21 on 12/17/2013, at 1:28 p.m. established P21 had called 911 because of suicidal thoughts and his "mental state just wasn't good". P21 refused an ambulance and was provided police transport to the hospital. P21 said upon arrival to the hospital's ED, he told the ED staff he preferred to be admitted to the mental health unit utilized by the hospital's ED. According to P21, the ED staff told him the mental health unit was full and he had to go to another hospital's ED. P21 said the hospital's ED staff did not ask him how he was doing or what the staff could do to help him. P21 said during the ride to the other hospital's ED, he was upset and crying because he wanted help for his mental condition.

Interview with RN-D established the hospital's ED remained in diversion status on 12/4/2013, from 5:15 p.m. until 8:30 p.m.

Review of the hospital's ED log dated 12/4/2013, revealed three patients that required a medical screening examination (MSE) and psychiatric evaluations received the MSE between 5:15 p.m. and 8:30 p.m. on 12/4/2013, during the diversion.

Review of the second hospital's ED record for P21 dated 12/4/2013, revealed P21 presented at the second hospital's ED at 6:25 p.m. The physician's dictated note established the patient had thoughts of harming self and/or the patient's spouse that evening. P21 had a history of anxiety had previously been hospitalized for suicidal ideation. P21 requested a psychiatric assessment, stabilization, and admission to a mental health unit. The second hospital's ED completed a breathalyzer test and urine toxicology screen and both were negative. Also, P21 had complaints of vomiting and left sided abdominal pain for the previous two day. Additional lab work was completed. The lab values were within normal limits and a urine sample was sent for culture. Once stabilized, P21 was admitted on [DATE], to the second hospital's mental health unit for suicidal thoughts.

Review of the hospital's EMTALA (emergency medical treatment and labor act) policy and procedures with a review/revision date of 7/2012, stated, an emergency medical condition is considered for psychiatric disturbances when individuals are expressing suicidal or homicidal thoughts or gestures and are determined to be a danger to self or others. The medical screening examination (MSE) for patients that present with psychiatric symptoms will consist of both a medical and psychiatric screening. For every person requesting emergency examination or treatment for a medical condition, the hospital will provide an appropriate medical screening. EMTALA obligations are triggered when a request for medical care has been made by an individual within a dedicated emergency department, when an individual requests emergency medical care on the hospital property, or when a layperson would recognize that an individual on hospital property required emergency treatment or examination though no request for treatment is made.