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Based on medical record review and review of EMTALA policies, the facility failed to ensure the policies for the provision of the Medical Screening Examination (MSE) with sufficient assessment and/or testing to determine if the patient has an Emergency Medical Condition (EMC) was followed for 1 of 30 sampled patients (Patient 15). The sample was drawn from 3/4/17 through 5/4/17. This failure places all emergency patients requesting to be seen at risk of harm due to being discharged with an untreated/stabilized EMC. Based on facility provided data from 11/2016 to 4/2017 the facility saw an average of 2,600 emergency patients per month. Findings are:

A. Record review of the facility policy titled " Policies and Procedures for the Examination, Treatment, and Transfer of Individuals who "come to the the Emergency Department" last revised 11/2016 under the section titled "Medical Screening Examination" notes that a MSE will be provided to all unscheduled patients requesting examination or treatment for a medical condition or who has had a request made on their behalf or if based on the individual's appearance or behavior, the individual appears to need an examination or treatment for a medical condition. The MSE is to be performed by a physician or Qualified Medical Person (QMP) identified as a Physician, Nurse Practitioner, or Physician Assistant for those who presented to the Emergency Room (ER) for treatment. The QMP will determine with reasonable clinical confidence if the patient has an EMC utilizing the services within the capabilities of the hospital. The policy notes that the MSE is an "ongoing process." Monitoring of the individual will continue until the individual is stabilized, admitted to the hospital , transferred if the patient requires care and treatment that exceeds the hospital capabilities, is discharged or expires. The policy states "The MSE process must be documented in the medical record."

B. Review of the Electronic Medical Record for Patient 15 revealed the patient came to the ER on 3/3/17 at 5:05 AM with a chief complaint of "being poisoned" by previous spouse. The initial vitals at admission demonstrated an elevated BP of 171/105. Temperature was 98.4 F, Pulse elevated at 111 and Respirations of 20. Advanced Practice Registered Nurse (APRN) B documented the patient was not taking any medications. Laboratory testing and a urine drug screen were done. The patient was noted to be acutely paranoid, delusional, anxious with rapid speech, and wringing her hands. The medical record did not contain evidence APRN B performed a mental health evaluation or requested a mental health professional conduct a mental health evaluation prior to the patient's discharge. The patient's Blood Pressure was not reassessed prior to discharge to determine if the patient had an emergency medical condition. Refer to A 2406 for details.

Based on record review, staff and provider interviews and review of the facility EMTALA policies, the facility failed to ensure 1 of 30 sampled patients (Patient 15) received a Medical Screening Examination (MSE) with sufficient assessment and/or testing to determine if the patient had an Emergency Medical Condition (EMC). The sample was drawn from 3/4/17 through 5/4/17. This failure places all emergency patients requesting to be seen at risk of harm due to being discharged with an untreated/stabilized EMC. Based on facility provided data from 11/2016 to 4/2017 the facility saw an average of 2,600 emergency patients per month. Findings are:


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A. Review of the medical record showed Patient # 15 presented to the Emergency Department (ED) on 3/3/17 at 5:05 PM stating that her ex-husband and her entire family were working together to try and poison her, she states her family was trafficking diamonds, money, and drugs. Vital signs (VS) obtained during the triage process showed an abnormaly elevated blood pressure 171/105 (normal 120/80) and a higher than normal heart rate 111 (normal 70-100).

At 5:34 pm, the Advanced Practice Registered Nurse (APRN)-B examined patient # 15 and documented the patient was very delusional and at times anxious, but was agreeable to be evaluated in the ED for possible underlying intentional poisoning. Further documentation showed the patient requested that staff contact law enforcement so she could file a report of suspicious activity and items stolen from her apartment. ARNP B documented patient # 15 stated she was in a psychiatric facility and a group home while living in a different State and that "they were trying to kill me when I was there too." The patient denied any medication use or any medical problems. Under the medical record heading "Review of Systems", ARNP B documented "When specifically asked, patient denies delusions or paranoia." Under the medical record heading "Physical Exam", "Psychiatric:", ARNP B documented "Patient exhibits very grandiose and paranoid behavior." "Patient denies homicidal or suicidal thinking." "Patient is currently obsessing about others trying to harm her by poisoning."

At 5:56 pm, the ED nurse documented contact with local law enforcement who stated that they had been called to patient # 15's address twice that day. The ED nurse further documented she explained that the patient requested reports to be filed and that ED staff were concerned that she may need a psychiatric evaluation but that "we don't feel she will be willing to accept it."

At 6:16 pm, results of the lab tests showed that patient # 15 tested positive for Cannabinoid (marijuana). At 6:30 pm, the ED nurse noted police had come to the ED to speak with patient # 15.

At 7:33 pm, documentation in the medical record indicated patient # 15 was diagnosed with "Paranoia" and discharged with instructions to locate a primary care doctor for follow-up.

Patient education at discharge included: The patient was to follow up with a primary care provider in one to two days for re-evaluation, and that she should return to the emergency department for any other emergent concerns or worsening condition. APRN-B informed the patient that she may have pre-hypertension or hypertension (high blood pressure) based on a blood pressure reading in the emergency department.

Review of the Nurses' Notes and the Vital Sign flow sheet revealed no further blood pressure or pulse checks other than the check performed during triage were obtained on 3/3/17.

B. Interview with Registered Nurse (RN)-C on 5/9/17 at 1:50 PM acknowledged that the patient's blood pressure and pulse was elevated during the triage process. RN-C verified that Patient 15's VS should have been re-checked before discharge.

Interview with APRN-B on 5/10/17 at 9:55 AM revealed that Patient 15's chief concern was that she had been poisoned. The patient was very anxious with rapid speech, sitting forward and wringing her hands. Patient 15 was cooperative with the testing and with the police department. The police department determined that the patient was not eligible for emergency protective custody (EPC) and the patient was not deemed a danger to self or others. The APRN-B reviewed the patient's VS and discussed the possibility of pre-hypertension/ hypertension with the patient and reviewed the patient's case with the Emergency Department physician in charge. The patient was agreeable to follow up with a primary care physician. APRN-B verified that repeat VS would be necessary if the patient's condition deteriorated or at discharge. APRN-B was unable to find another set of VS for Patient 15 before discharge and stated that the patient's blood pressure was elevated and should have been rechecked before discharge.

Interview with RN-D, Patient 15's Primary Nurse, on 5/10/17 at 10:20 AM revealed that after Triage the nurse assumed care of Patient 15. The RN stated the patient was not screened for depression or suicide even though the patient exhibited anxious/ paranoid behaviors. The patient was restless and pacing even into the hallway. RN-D stated that normally VS were reassessed at the time of discharge. RN-D did not assist Patient 15 back into the examination room on discharge to reassess her VS because she was unsure if the patient would talk to the nurse and her attitude was aloof towards RN-D.

According to the Mayo Clinic Website dated 11/10/15 revealed that a Normal Blood Pressure reading was the top number (systolic) 120 and the bottom number or (diastolic) of below 80. A top number of 160 or more and a bottom number of 100 or more may indicate a Stage 2 hypertension.

C. Review of the facility completed Data Base Worksheet showed the hospital's capabilities and capacity included emergency psychiatric services, Adult inpatient and Adult outpatient psychiatric services. The facility had a Psychiatric inpatient facility which included on-call psychiatrists for evaluation and treatment in their dedicated emergency department. The evidence in the medical record indicated patient # 15 did not receive within the hospital's capabilities and capacity, a medical screening examination sufficient to determine whether an emergency medical condition existed. The hospital failed to re-evaluate patient # 15's elevated blood pressure prior to discharge, her stated history of mental health illness while living in another state, the factors contributing to her persecutory delusions, the conviction or veracity of her delusions, her intent to take adverse action or her risk for deterioration including harm to self or others, sufficient to determine whether or not an emergency medical conditon existed.