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JPS HEALTH NETWORK 1500 S MAIN ST FORT WORTH, TX 76104 April 12, 2019
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interview and record review, the hospital failed to abide by the provider's agreement that required a hospital to comply with 42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements in that, 1 of 1 patient (Patient #1) who presented in the emergency department on the night of 04/03/19 with a chief complaint of suicide ideation was discharged on the same night and was not appropriately transferred.

Cross Refer to Tag A409 - 489.24(e)(1) and (2) Appropriate Transfer/Discharge
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the hospital did not appropriately transfer 1 of 1 patient (Patient #1) that presented in the emergency department (ED) on the night of 04/03/19. Patient #1's chief complaint was suicidal ideation. Patient #1 was discharged on the same night at 11:57 PM. Patient #1 was brought back to the ED on 04/04/19 at 1:01 AM after an incident in the hospital's property. Patient #1 expired on [DATE] at 1:58 AM.

Findings included:

Patient #1 presented in the ED on 04/03/19 at 10:05 PM with "Arrival complaint: Suicidal." At 10:10 PM the patient scored a "1" in the "brief suicide risk." A "Follow-up Suicide Risk Screen" was conducted in which the patient scored a "5." "Follow-up Action Steps for Suicide Risk" indicated the patient was "high risk" to act on the suicide ideation. The physician was notified by the triage RN (registered nurse) regarding the result of the suicide risk screen.

The Behavioral Health Assessment Specialist (BHAS) Note at 10:18 PM reflected "Recommendations/Plan: PEC status VOL (voluntary) for further EVAL (evaluation)..." and a referral was made to PEC (psychiatric emergency clinic).

The ED physician noted "Disposition & Condition. Final Impression/Diagnosis: 1. Suicidal ideation. 2. Polysubstance abuse. Patient Progress: Patient presents with passive suicidal ideation..." Patient #1 was discharged at 11:57 PM and escorted to urgent care where behavioral health evaluation unit was located. Patient #1 did not proceed to go and left the hospital.

After an incident in the hospital's property, Patient #1 was brought back to the ED on 04/04/19 at 1:01 AM. The patient expired at 1:58 AM.

In an interview on 04/11/19 at 1:16 PM Personnel #8 said he reviewed the patient's medical record together with the ED leadership staff. Personnel #8 stated after the patient was discharged , there was a confusion as to where the patient would be escorted to. At this time the facility had 2 locations in obtaining behavioral health evaluations. The facility had a PEC (psychiatric emergency clinic) in tower 10 and another one located by the urgent care unit. Personnel #8 stated the patient should have been transferred to tower 10 (PEC).

In an interview on 04/11/19 at 2:15 PM Physician #9 was asked if she reviewed Patient #1's medical record. She replied she did. The Physician #9 was asked why the patient was discharged . Physician #9 replied the medical record appeared to look as if the patient was discharged but the patient was escorted to the behavioral health unit for further evaluation.

In an interview on 04/12/19 at 10:02 AM Personnel #15 who was on duty the night of 04/03/19 stated she interacted with Patient #1 during the time when Patient #1 was escorted to the urgent care unit. Personnel #15 saw Patient #1 sitting on the floor. Personnel #15 was told that they (escorts) were having a difficult time letting Patient #1 to stand-up and sit back in the wheelchair. Personnel #15 asked the escorts about the status of Patient #1. Personnel #15 was told Patient #1 was voluntary. Personnel #15 said she then spoke to Patient #1 and stated to get back in the wheelchair so the escorts could transport her to the behavioral health triage located next to Urgent Care Services. And if she did not want, she (Patient #1) was free to go home since her disposition was "discharge."

Hospital policy PC 1900 Emergency Medical Treatment and Active Labor Act (EMTALA) effective 12/18/2015 reflected "...is to provide services in accordance with the applicable Federal and State laws...regarding the appropriate medical screening examination, stabilization of treatment, and the transfer of patients between hospitals in a medically appropriate manner..."