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.

WESTERN MISSOURI MEDICAL CENTER 403 BURKARTH ROAD WARRENSBURG, MO 64093 June 15, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interview and record review of Emergency Department (ED) logs, 72 Hour Return logs, Medical Records, Staffing and Physician On-Call Schedules, the facility failed to provide a psychiatric screening examination within its capacity and capability for one patient (#1) of 22 patient records reviewed, who presented to the hospital ED for emergency care. The patient presented to the hospital in police custody with a self inflicted wound and the facility did not provide a psychiatric examination to determine if a psychiatric emergency condition existed.

The hospital had the capacity and capability to complete a thorough psychiatric screening examination, to ensure that the patient was not a danger to himself and others. The average monthly census in the ED over the past six months was 1,668. The facility census was 31.

Please refer to A2406 for details.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interview, record review and policy review, the facility failed to provide a Psychiatric screening examination for one patient (#1) of 22 patient records reviewed, who presented to the hospital Emergency Department (ED) for emergency care. The patient presented to the hospital in police custody with a self inflicted wound and the facility did not provide a psychiatric screening examination to determine if a psychiatric emergency condition existed.
This failure had the potential to increase the risk for a negative outcome for all patients in need of psychiatric treatment within the ED. The ED average census over six months was 1,668. The facility census was 31.

Findings included:

1. Record review of the facility's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act, which requires hospitals with EDs to provide a medical screening examination to any individual who comes to the ED): Transfer to Another Facility," dated 03/20/2015, showed the following:
- Any individual who presented to the facility with an emergency medical condition shall be provided a medical screening examination performed by a physician.
- An Emergency Medical Condition (EMC) was a medical condition that manifested itself by acute symptoms of sufficient severity (psychiatric disturbances) such that the absence of immediate medical attention could reasonably be expected to place the health of the individual in jeopardy.
- A Medical Screening Examination (MSE) was based on the capability of the hospital which included the physician and ancillary services (contracted psychiatric services) available to the ED.

Record review of the facility's policy titled, "Triage, Comprehensive," dated 01/26/2012, showed that all patients presenting to the ED shall be initially triaged/assessed by the Triage RN or Physician to determine the priority of care needed based on physical, social and psychological condition.

2. Record review of the facility's policy titled, "Rules and Regulations of the Medical Staff," dated 06/28/2013, showed that care and treatment provided to any patient who presents to the ED will comply with the Emergency Medical Treatment and [Active] Labor Act (EMTALA), its regulations and Interpretive Guidelines, and the Medical Center's EMTALA policies and procedures.

3. Record review of the facility's contracted services agreement with Hospital B, a psychiatric provider, dated 10/01/2014 through 09/07/2017 showed that mental health evaluation services were available remotely via telemedicine technology or on-site, on request.

4. Record review of the MSE, performed by Staff F, Doctor of Osteopathy (DO), ED Medical Director, on 06/06/16 at 5:48 PM showed:
- Patient #1 presented to the ED ambulance bay, accompanied by law enforcement.
- Patient was not triaged, no vitals signs obtained and no lab tests performed to determine if patient was intoxicated or had attempted an overdose.
- Patient remained in the police car in handcuffs when examined by Staff F.
- Staff F documented the patient was hostile, non-communicative, uncooperative, and belligerent during the exam.
- Patient had a laceration of his left forearm and suicidal ideations (thoughts about how to kill oneself).
- Laceration of patient's left forearm was cleaned and a gauze dressing was placed.
- Patient expressed suicidal intent to police officers before arrival.
- Patient stated that he cut himself on the left forearm with a blunt knife.
- Staff F documented the police said they may take the patient in for a psychatric assessment but did not tell him where they were going.
- Staff F failed to order, or perform a psychiatric screening examination. This failure resulted in a delay in the patient's psychiatric care.
- Staff F documented he discharged the patient to police custody at 5:53 PM.

During a telephone interview on 06/15/16 at 11:25 AM, Staff F, DO, stated that:
- Patient presented with police, in the ambulance bay, where he assessed the patient's physical condition.
- Police officers asked him for a medical clearance for the patient.
- He did not ask the patient if he wanted to harm himself.
- He did not perform a psychiatric screening examination on the patient, but in retrospect this was not the right decision.
- He did not contact Hospital B for a mental health evaluation via telemedicine technology.
- ED was very busy, but we could have found the patient a bed if needed.
- Police officers told him that potentially the patient would be taken to a psychiatric facility.

During an interview on 06/15/16 at 9:13 AM, Staff E, ED Emergency Medical Technician and Unit Secretary, stated that:
- Staff K told her they needed a medical clearance on the patient.
- She called police dispatch and retrieved the patient's information for registration and then notified the Registered Nurse (RN) for triage.
- She told Staff F, DO, that Patient #1, was there for medical clearance and suicidal ideations.
- Triage RN did not assess patient.

During a telephone interview on 06/15/16 at 8:50 AM, Staff G, Police Officer, Supervisor, stated that it was his decision to bring the patient to the ED, due to the cuts on his arms.

During a telephone interview on 06/15/16 at 7:15 PM, Staff K, Police Officer, stated that he went in to ED lobby to notify medical staff of his arrival with the patient. Staff K did explain to Staff E, that the patient had suicidal ideations and cuts from a pocket knife.

During an interview on 06/14/16 at 3:15 PM, Staff D, Director of the ED, stated that it was not a normal process for the police officers to bring the patient to the ED, before they took them to a psychiatric facility.

During an interview on 06/15/16 at 8:45 AM, Staff A, Chief Nursing Officer, stated that at the time Patient #1 arrived at the ED, it was very busy, but they could have accommodated the patient. She stated that the ED employees did not have any formal behavioral health training and that they didn't have a policy related to psychiatric patients that come to the ED.

Unsuccessful attempts were made by the surveyor to contact the patient and/or his family for telephone interview.

5. Record review of Patient #1's medical record from Hospital C, psychiatric receiving hospital (facility police transported patient to), showed that:
- On 06/06/16 at 8:38 PM, patient arrived with the police, for suicidal ideations with attempts to cut wrists with a knife.
- Patient stated that if the knife were sharper, he would have cut himself.
- Patient admitted that he had suicidal ideations.
- Patient was admitted to Hospital C's Psychiatric Unit for treatment of a psychiatric emergency.