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.

CHI HEALTH IMMANUEL 6901 NORTH 72ND ST OMAHA, NE 68122 Nov. 7, 2019
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on record reviews, staff interviews, and EMTALA policy review, the facility failed to ensure staff followed the policies for offering all patients coming to the emergency room (ER) a Medical Screening Examination to ensure the patient does not have an Emergency Medical Condition (EMC). 1 of 20 sampled patients failed to be offered a MSE (Patient 20) and also failed to be entered into the Central Log per policy. Patient 20 presented to the emergency department and was denied a psychiatric examination because she had recently been discharged from the inpatient psychiatric unit. The hospital's failure to provide patient 20 with an appropriate MSE had the potential to leave the patient with an untreated EMC which could lead to harm and or death. The total sample was 20. The facility provided data that showed that from May 2019 through October 2019 the ED saw an average of 3,248 patients per month.

Findings are:

A. The facility policy titled "Examination, Treatment, and Transfer of Individuals who Come to the Emergency Department" last revised 1/2018, notes the hospital will provide to any individual who"comes to the Emergency Department" an appropriate MSE within the capabilities of the hospital to determine whether or not an EMC exists.

The policy further notes that if the individual, or person acting on their behalf, does not consent to a a MSE they will inform them of the risks/benefits of the exam and treatment. If they still refuse after all reasonable steps have been taken the staff will ask them to sign a "Refusal to Permit Medical Screening Examination or Transfer". If they refuse staff are directed to document the steps taken to secure the individual's written informed refusal. The staff are further directed to "open a medical record" and "log the individual into the Central Log".

B. Review of a closed medical record showed that staff on the inpatient adolescent psychiatric unit documented patient 20 was admitted on [DATE] due to worsening symptoms of depression and suicidal ideation. Documentation in the medical record showed that staff discharged patient 20 on 10/31/19 at 8:41 PM. An addendum filed at 10:14 PM showed that hospital security walked patient 20 to her foster parent's car because she did not want to leave the hospital. Further documentation showed "Pt (patient) does show defiance leaving unit, on elevator and when getting into car." "Foster mother requests patient (pt) put seatbelt on and pt refuses and got out of non-moving car in front of the hospital." "Security continues to inform family and pt that pt has been DC'd (discharged )." "Law enforcement was called as pt refusing to get into car." "Foster mother calls unit (adolescent psychiatric unit) to report that she plans to take pt back to ED to be admitted ." "Foster mother continues to be upset about DC as it is reported that pt states she was unaware that she was be DC'd today." Further documentation showed that nursing staff contacted the psychiatrist about patient 20 not wanting to be discharged .

C. During a phone interview on 11/7/19 at 9:30 AM, Security Officer (SO) D recalled walking discharged Patient 20 to her foster mother's car in the evening on 10/31/19. SO D stated patient 20 was crying and refused to go with the foster mother. The patient got into the back seat of the car and refused to put on her seat belt. The foster mother got out of the car and so did Patient 20. The Patient told us she "did not want to go with Mom, crying upset." The foster mother wanted us to take patient 20 back upstairs to the Adolescent inpatient psychiatric unit. We could not as she was discharged . The police were called by the foster mother. Later we saw the patient, foster mother and the Police in the ED. SO D spoke with ED RN A telling her the prior events. ED RN A said she had called up to Adolescent Psychiatric Unit and was told by their nurse that the Psychiatrist would not readmit the patient. SO D recalled he and ED RN A then went to talk to the foster mother. SO D stated ED RN A told the foster mother "we can see her for Medical reasons in the ED but she would not get a psychiatric admission."

D. Review of facility Security Video of the ED for Thursday 10/31/19 showed Patient 20 arriving at the ED in the Police car at 9:13 PM. The foster mother's car arrived separately. The foster mother went to the Registration Desk at 9:14 PM. SO D and ED RN A are seen talking with the foster mother at 9:16 PM. The patient is not taken to triage but remained in the lobby. The Police and foster mother are seen making phone calls. The Police left with Patient 20 at 10:08 PM.

E. Review of Hospital B's medical record showed that patient 20 presented to the ED at approximately 11:34 PM on Thursday 10/31/19. Documentation in the medical record showed that patient 20 had recently been discharged from the adolescent psychiatric ward at CHI Health Immanuel. Further documentation showed that after providing patient 20 with an examination, arrangements were made for transfer to another hospital for psychiatric care for treatment of an emergency medical condition, active suicidal ideation and significant concern for the patient's safety.

Refer to tag C 2406 for further details.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on record reviews, staff interviews, and EMTALA policy review; the facility failed to ensure staff offered all patients presenting to the Emergency Department (ED) a Medical Screening Examination (MSE) to ensure the patient does not have an Emergency Medical Condition (EMC) and if medically necessary, hospital admission. 1 of 20 sampled patients failed to be offered a MSE (Patient 20). Patient 20 was offered a conditional MSE, medical only with no evaluation of her psychiatric condition. This failure has the potential to leave the patient with an untreated EMC which could lead to harm and / or death. The total sample was 20. The facility provided data that showed that from May 2019 through October 2019 the ED saw an average of 3,248 patients per month.

Findings are:

A. Review of a closed medical record showed that patient 20 had been admitted on [DATE] for treatment of worsening symptoms of depression and suicidal ideation. Further documentation in the medical record showed that staff on the inpatient adolescent psychiatric unit noted that patient 20 was discharged on [DATE] at 8:41 PM. An addednum to the discharge noted filed at 10:14 PM indicated that hospital security walked patient 20 to her foster parent's car because she did not want to leave the hospital. Further documentation showed "Pt (patient) does show defiance leaving unit, on elevator and when getting into car." "Foster mother requests patient (pt) put seatbelt on and pt refuses and got out of non-moving car in front of the hospital." "Security continues to inform family and pt that pt has been DC'd (discharged )." "Law enforcement was called as pt refusing to get into car." "Foster mother calls unit (adolescent psychiatric unit) to report that she plans to take pt back to ED to be admitted ." "Foster mother continues to be upset about DC as it is reported that pt states she was unaware that she was be DC'd today."

B. Review of the 10/31/19 ED log indicated staff did not enter information indicating patient 20 presented to the ED with family seeking medical care or that patient 20 received a medical screening examination as required.

C. During a phone interview on 11/7/19 at 10:30 AM, emergency department (ED) Registrar B recalled ED Registered Nurse (RN) A told her on 10/31/19 that if [name of patient 20] comes in "do not register her, call me." ED Registrar B stated that the foster mother came in with the Patient and stated "I want to check her in." The Registrar called ED RN A immediately. ED Registrar B stated she heard ED RN A tell the foster mother the reason we could not register her was "Doctor's orders." ED Registrar B said she heard ED RN A tell the foster mother that they could check patient 20 in for medical reasons but what she was here for was clear, wanting to be admitted to the psych [psychiatric unit]. ED Registrar B said the patient was offered a medical screening examination for medical issues but not for psychiatric issues. ED Registrar B stated the moster then said "so you want me to take her home and if she hurts herself, then come back?" The ED Registrar stated that since 10/31/19 she was told by her boss to register all patients regardless of nursing instructions.

D. During a phone interview on 11/6/19 at 3:10 PM, ED RN A recalled Patient 20 coming to the ED on 10/31/19 with the foster mother. ED RN A stated she was the Charge Nurse. The RN stated she got a call from the Inpatient Adolescent Psychiatric Unit RN. The patient had just been discharged and the foster mother wanted her immediately readmitted . The Adolescent Psychiatric RN told her the patient denied suicidal ideations, homicidal ideations and that the Psychiatrist "was not interested in seeing [Patient 20] again." ED Registrar B called ED RN A when they arrived. ED RN A recalled speaking with the foster mother. ED RN A stated she told the foster mother they would be happy to register her and have the ED Medical Doctor see her. The foster mother was not interested in that, she wanted patient 20 admitted upstairs. Security and the Police were in the lobby with the patient who was standing off to the side in the waiting room. The foster mother then told the ED RN that she was 'just going to take her home."

ED RN A stated that since 10/31/19 she has been re-educated that she should have gotten the patient registered in the Central Log, gotten an Against Medical Advice form signed and noted if foster mother refused to sign it. The nurse failed to identify the need to try and get the patient to stay for a medical screening examination, including a psychiatric examination, and the need to explain the benefits of an examination as well as the risks of refusing an examination. Telling the patient/responsible party they will only evaluate the patient's medical needs but not their psychiatric needs may encourage a patient to leave the ED prior to receiving an examination.

E. During a phone interview on 11/7/19 at 9:30 AM, hospital Security Officer (SO) D recalled walking discharged Patient 20 to the car with the foster mother. The patient was crying and refusing to go with the foster mother. The patient got into the back seat of the car and refused to put on her seat belt. The foster mother got out of the car and so did Patient 20. The Patient told us she "did not want to go with Mom, she was crying and upset." The foster mother wanted us to take her upstairs back to the Adolescent Inpatient Psychiatric Unit. We could not as she was discharged . The police were called by the foster mother. Later we saw the patient, foster mother and the Police in the ED. SO D spoke with ED RN A telling her the prior events. ED RN A said she had called up to Adolescent Psychiatric Unit and was told by their nurse that the Psychiatrist would not readmit the patient. SO D recalled he and ED RN A then went to talk to the foster mother. SO D stated ED RN A told the foster mother "we can see her for Medical reasons in the ED but she would not get a psychiatric admission." The foster mother then mentioned patient 20's self harming behavior.

F. During a phone interview on 10/31/19 at 12:00 PM, Psychiatrist E confirmed being the on call psychiatric physician for Adolescent Inpatient Psychiatic Unit as well as the ED on 10/31/19. Psychiatrist E recalled being called about Patient 20 on 10/31/19 by the floor nurse. The Police were involved at discharge. Psychiatrist E asked if the patient was suicidal or homicidal and was told she was not. The foster mother was willing to take her home. Psychiatrist E also consulted with the Adolescent House Supervisor and everyone felt she was appropriate for discharge. ED MD then thought the DC was completed. Despite being the on call psychiatric physician for Adolescent Psychiatry for the ED, Psychiatrist E had no information the patient came to the ED, stating "no-one from the ED called." The Psychiatrist further stated that "if kids are discharged and need readmission we take that seriously." "If they are not safe at home and escalate, they can always come back to ED for re-processing [a medical screening examination].

G. Review of facility Security Video of the ED on 10/31/19 showed Patient 20 arriving in the ED in the Police car at 9:13 PM. The foster mother's car arrived separately. The foster mother went to the Registration Desk at 9:14 PM SO D and ED RN A are seen talking with the foster mother at 9:16 PM. The patient is not taken to triage but remained in the lobby. The Police and foster mother are seen making phone calls. The Police left with Patient 20 at 10:08 PM.

H. Review of Hospital B's medical record showed that patient 20 presented to the ED at approximately 11:34 PM on Thursday 10/31/19. Documentation in the medical record showed that patient 20 had recently been discharged from the adolescent psychiatric ward at CHI Health Immanuel. Further documentation showed that after providing patient 20 with an examination, arrangements were made for transfer to another hospital for psychiatric care for treatment of an emergency medical condition, active suicidal ideation and significant concern for the patient's safety.