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Based on interviews, policy review, document review, medical record review and observation, the hospital failed to meet the provider's agreement and comply with 42-CFR 489.24 requirements of EMTALA. There was deficient practice in FA-2406, Medical Screening Exam related to ACTs #11635. Due to the nature and extent of the noncompliance, an immediate jeopardy for failure to provide a medical screening exam (MSE) for one patient (P)1, of a sample size of one.

P1 was a minor, whose mother made the request for treatment on his behalf when she brought him to the Hospital for emergency exam and treatment. As a result of this deficient practice, she drove P1, whose behavior was unstable to another hospital for care, which put her and the occupants of the car, as well as others on the road, at high risk for serious harm or death.

Findings Include:

A federal EMTALA survey (Y17B11) which included ACTs #11451, was conducted in conjuction with this survey 04/09/2025 through 04/11/2025 and 04/14/2025, after authorization by The Centers of Medicare and Medicaid Services (CMS) San Francisco Regional Office. That investigation revealed an Immediate Jeopardy (IJ) with deficient practice in A-2406 Medical Screening Exam, but no deficient practice related to ACTs #11554, due to the fact the complaint included minimal information and the patient could not be identified.

Further investigation post survey identified the patient (P)1, a minor, who was brought to the Hospital (H)1 Emergency Department (ED) by his mother for treatment on 03/09/2025 . At that time, ACTs #11635 was initiated and the OHCA received authorization by CMS for a second EMTALA investigation (3BDS11).

Cross Reference F-A-2406- Medical Screening Examination
On 03/09/2025, a mother took her minor son, P1, to the Emergency Department by to be treated for mental health/ behavioral issues. On arrival to the hospital, the minor left the car, the mother entered the ED registration area alone, and requested that her son be seen in the ED. After the minor returned to the car, with the mother, there was a discussion with hospital staff in the parking lot, that the hospital did not have adolescent behavioral health services. The mother then drove her son to another facility (H2) that had inpatient adolescent behavioral health, for emergency treatment.

Based on interviews, medical record/document review and observations, the facility failed to comply with the EMTALA obligation to provide a medical screening examination (MSE-determines the presence or absence of an emergency medical condition and must be done in accordance with policy and medical standards) for one (P)1, a minor, brought to the Hospital (H)1 by his mother seeking examination and treatment on his behalf, due to change of behavior.

Although the mother informed ED registration she would like her son to be seen, and he was on the Hospital property in the parking lot, he did not receive a MSE. Instead, she drove approximately 10 miles for treatment to H2, which placed everyone in the car and on the road at high risk of serious harm or death due to P1's unstable and unpredictable behavior.

Findings include:

1 ) P1 was a 14-year-old male with past psychiatric history significant for ADHD (attention-deficit disorder/hyperactivity, a mental health disorder that includes problems, such as paying attention, hyperactivity and impulsive behavior). On 03/09/2025, his mother brought him to H1 to be seen in the ED for increased erratic behavior, but did not receive a MSE. She was informed H1 did not have an adolescent psychiatric unit and her son would likely be transferred to H2 for care. The mother drove P1 to H2 for treatment. On arrival to H2, P1 received a MSE by the ED provider and was admitted to the adolescent behavioral health unit for further care. P1 was discharged home on 03/13/2025.

2) Reviewed the ED Provider Notes from H2, dated 03/09/2025 at 05:09 PM. The notes included: "14-year-old male with ADHD, possible oppositional defiant disorder, now presenting with behavioral changes. ...Got into argument with mom today, more aggressive with mom, punched mom in the arm. Also more aggressive behavior towards younger sister. Was making statements of self-harm like "I do not want to live anymore. ...Patient presents with behavior change and escalation at home with concern for self-harm as well as harm of those around him including mom and younger sister. ... Discussed case with psychiatry who felt that inpatient admission was safe for this time to stabilize and ensure safety. ..."

Reviewed P1's History and Physical by the Psychiatrist (MD1) at H2 dated 03/10/2025 at 08:33 AM. The record included: "He (P1) states he was brought to the hospital after getting into an argument with his mother. ...Patient clarified that he was with his mother and little sister in the car on the way to his karate class yesterday when the argument started... Patient's mother ended up driving patient to the H1 parking lot, where the argument became physical after patient threw a cup of water at his family and then punched his mother "on the arm." Per patient, H1 staff/security came up to their car upon hearing the commotion and recommended that the patient be brought to the H2 instead, as patient was a minor and would likely get admitted to the adolescent psychiatric ward if admitted. Patient proceeded to run out of the car into the roadway, but was able to be de-escalated by police officers who happened to be passing by and patient eventually agreed to go back to his mother's car and come to H2 for treatment of his depression."

On 04/22/2025 at 02:00 PM, conducted a telephone interview with P1's mother. She said on 03/09/2025, she drove her son to H1, with the intent to have him seen in the emergency room because of his behavior. She said they were parked in the parking lot in front of the emergency room, when he punched her in the forearm, got out of the car and ran down the road. She said she thought "staff must of seen the commotion outside, and that I was stressed out, because two males in their mid 30's came out, and were saying they (H1) were not the right facility for people that age (14), and that H2 had a unit for kids." The mother said she did express to them she did not feel safe driving to the other hospital in the car. Inquired why, and she said on the way to H1, she and her son were arguing, when he jumped out of the car, and then he did it again when they got to H1. She described her son's behavior as "unstable and irate." The mother stated her young daughter was with them in the car, and on the way to H2, P1 was "screaming and crying, unbuckled his seat belt, jumped from the back seat to the front seat, and threw the phone out."

On 04/23/2025 at approximately 01:15 PM, interviewed H2's Registered Nurse (RN), in the conference room at H2. She said she recently encountered a child brought in by his mother, who said they went to another hospital, and "they wouldn't see him." The RN said when they arrived, "Security (H2) helped watch the child because he was agitated, while the mom parked the car." The RN said "the mom was very concerned and upset," but did not share specific details of what occurred at the other hospital. She remembered the mom being "very distraught,"and said her son had been aggressive toward his sibling and her. The RN stated again, the mom took him to H1 and they said they wouldn't see him. She said she tried to check in, and they refused to allow her to check him in. The RN confirmed this occurred on the day shift 03/09/2025, sometime in the afternoon.

On 04/23/2025 at 03:30 PM, conducted a phone interview with the MD1, who cared for P1 at H2. He said from his understanding the mom and son were arguing and fighting in the parking lot on the windward side hospital parking lot, and staff saw and approached them. The mother told them her son was having behavioral issues, and wanted to bring him to the hospital. Someone told her they didn't have a child psychiatric unit there, and sometimes have to wait in the emergency room a long time. MD1 was not clear on who it was they talked to. When asked if he had heard this directly from the the patient, he said yes, but also heard it separately from the mom, and the stories were consistent. He said they were in H1's parking lot and redirected here (H2). The mom said from what she understood, H1 didn't have the kind of ward for her son, and would have to hold him in the ER (ED) until sent to H2.

3) On 04/25/2025 at 08:30 AM, toured the premises of H1, and observed the parking lot, ED entrance and registration area. It was noted there were surveillance cameras outside the entrance. The waiting room area had windows with views of the parking lot entrance, ED entrance and part of the parking lot. When sitting at the Registration desk, staff are able to see someone approaching the entrance and a portion of the parking lot.

On 04/25/2025 at 10:33 AM, concurrent observation and interview was conducted with Security Manager (SM) in his office. At that time, the recorded surveillance video from Emergency Department (ED) entrance camera on 03/09/2025 between 12:00 PM to 03:00 PM was viewed with the SM. Upon reviewing recorded images/video, observed two male staff running toward the entrance of the ED heading outside, between 02:15 PM and 02:40 PM. They were later identified as the Security Supervisor, and ER Technician (seen wearing scrubs and putting on gloves). There was a third staff, a female nurse was in the waiting room area, a short distance from the ED entrance walking away from the door toward the waiting area. When asked the SM if he could pause the video and identify the staff, he was able to identify all three. Observed no recorded images between 01:00 PM and 02:20 PM. When SM was asked, he stated sometimes that happens when no activities are detected.

On 04/25/2025 at 01:15 PM, concurrent observation and interview was conducted with SM and Risk Manager (RM) in the security office. SM and RM agreed the staff were responding to something that was going on outside the ED, by the parking lot.

4 ) On 04/25/2025 at 11:50 AM, conducted a phone interview with the assigned ED Charge RN on 03/09/2025. When inquired if she was aware of any unusual incident that occurred in the parking lot that day, she said she had a vague memory of something happening, and heard there was some kind of commotion, but had no direct involvement, or interaction with the patient or the mom.

On 04/25/2025 at 12:35 PM, interviewed the Patient Access Representative (PAR) that was scheduled on 03/09/2025, in the conference room. She said there was a mother that came in by herself, and wanted to "check in her son." The PAR stated the mother was "flustered" and apparently the son got combative. When the PAR asked where the son was, she pointed outside. The PAR said she could remember, because he had a red shirt on and could see him walking away toward the road. The PAR stated she let the mother know she couldn't check him in until he was there. She asked the mother if she wanted to be seen, and her response was "no, I want my son to be seen." The PAR said the mom was at the desk when she said she had to go get him and went outside.

On 04/25/2025 at 01:21 PM, conducted a telephone interview with the Security Supervisor (SS), identified in the video. He said he saw a male teenager walking down the road and appeared upset and restless. SS stopped the teenager and asked if he was ok. SS said he observed the teenager walk back to his mother's vehicle parked nearby, and that he (SS) proceeded to talk to them. He said he noticed another female child was inside the vehicle. He went on to say the mother wanted to check-in son to ER for "mental health" issues. SS explained that he did not remember if mother went inside to get some assistance. SS stated he mostly spoke with the son to calm him, while the ER tech spoke with the mother. He confirmed the vehicle was parked in the first row in front of the Emergency Room.

On 04/25/2025, the Registered Nurse and ER tech seen in the video, were interviewed prior to being identified in the video, and both said they did not recall any unusual incident involving a mother bringing her teenage son to the ED for behavioral issues, or any incident occurring in the parking lot.

4) Reviewed the HI's Systemwide Model Policy number 12117 titled "EMTALA-Medical Screening Examination (MSE) and Stabilization, last review date 03/18/2025. The policy included:
Policy Intent: "A. To ensure that all individuals who Come to the Hospital (as defined in the Compliance with EMTALA policy) seeking or in need of Emergency Services and Care receive an appropriate Medical Screening Examination and further examination and Stabilizing treatment in accordance with applicable laws and hospital policies."
Policy Compliance:
"A. ...The Dedicated Emergency Department , must provide for an appropriate Medical Screening Examination within the Capability of the Dedicated Emergency Department, ...to determine whether or not an individual has an Emergency Medical Condition. ..."
"1. In the Dedicated Emergency Department. The individual has presented at the Hospital's Dedicated Emergency Department and requests or has a request made for his/her behalf for examination or treatment for a medical condition, or a prudent layperson observer would believe, based on the individuals appearance or behavior, that the individual needs examination or treatment for a medical condition;"
"2. On Hospital Property. The individual has presented on Hospital Property other than a Dedicated Emergency Department, and request made on his/her behalf for examination or treatment for what may be an Emergency Medical Condition who or a prudent layperson observer would believe, based on the individuals appearance or behavior, that the individual needs emergency examination or treatment. ..."
"H ...2. Psychiatric Condition: A Psychiatric Emergency Medical Condition is considered Stabilized when the Treating Physician has determined, within reasonable clinical confidence, that the individual is protected from injuring or harming himself/herself or others."