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Based on document review and interview, the facility failed to provide documentation indicating an MSE (Medical Screening Exam) was performed for 1 of 20 patient medical records reviewed (P20); and failed to keep a log of each individual presenting to the emergency department for medical care for 1 of 20 patient medical records reviewed (P20).


Findings Include:

1. See findings cited at A2405, and A2406.

Based on document review and interview, the facility failed to keep a log of each individual presenting to the emergency department for medical care for 1 of 20 patient medical records reviewed. (P20)

Findings Include:

1. F4 (Acute Care Hospital) medical records for P20 dated 9/15/2024, indicated that the patient was accepted, had a transfer form, and report was called to F1 (Behavioral Health Hospital). The ambulance run sheet indicated that P20 left F4 at 2209 hours on 09/15/2024, and arrived at F1 at 2322 hours on 09/15/2024. Upon presentation at F1, the ambulance crew noted that F1 staff stated that P20 would not be accepted. The ambulance crew received orders to divert to F2 (Acute Care Hospital) from their command center.

2. Review of F1, Emergency Department, (ED) log did not indicate P20 was recorded seeking medical treatment on 09/15/2024.

3. In interview dated 10/30/2024 at approximately 1000 hours with S4, Corporate Project Admissions Director, indicated F1 does offer emergency services under federal guidelines for EMTALA. All persons who present at the facility will be logged on the facility EMTALA log. Even if an individual arrives from another facility without coordination the individual is listed on the emergency department (ED) log, and an MSE is to be conducted by a QMP, and level of care requirements will be determined for patient treatment. or appropriate transfer.

Based on document review and interview, the facility failed to ensure documentation indicating a MSE (Medical Screening Exam) was performed for 1 of 20 patient medical records reviewed. (P20)

Findings include:

1. Review of F1, Behavioral Health Hospital, policy titled "EMTALA" (Emergency Medical Treatment and Labor Act), last reviewed 01/2023, indicated on page 3, section 5, C. A medical screening examination (MSE) must be completed by a qualified medical professional (QMP) to anyone who presents at F1 for treatment to determine if an emergency medical condition exists.

2. Review of F1 "Medical Staff Bylaws" last approved 01/03/2022, page 86, indicated that a qualified medical professional (QMP) is designated as a Medical Doctor, Nurse Practitioner, Physician Assistant, or Registered Nurse.

3. Review of medical record (MR) for P20 indicated patient presented to F1 on 09/15/2024, no medical screening examination (MSE) by a qualified medical professional (QMP) was completed on 09/15/2024.

4. In interview dated 10/30/2024 at approximately 1000 hours with S4, Corporate Project Admissions Director, indicated F1 does offer emergency services under federal guidelines for EMTALA. Patients are accepted only for screening and assessment to determine suitability for inpatient acute psychiatric care. Any person presenting at F1 will receive a medical screening examination (MSE). The MSE is conducted by a qualified medical professional (QMP) during the intake process. All persons who present at the facility will be logged on the facility EMTALA log. Even if an individual arrives from another facility without coordination the individual is listed on the emergency department (ED) log, and an MSE is to be conducted by a QMP, and level of care requirements will be determined for patient treatment. or appropriate transfer.

5. In interview dated 10/30/2024 at approximately 1730 hours with S3, Chief Executive Officer, confirmed that no intake packet containing a medical screening examination (MSE) was found for P20 on 09/15/2024.