HospitalInspections.org

Based on policy and procedure review, medical record review, and medical staff interview the facility failed to follow their policy regarding medical screening exams for 1 (Patient (P)2) of 20 sampled medical records. This failed practice has the potential cause harm or even death to all patients who present to the Emergency Department (ED). According to facility provided information the ED averages 1,675 patients in the ED monthly.

See citation A2406 and A2407 that resulted in A2400 not being met.

Based on record review, facility call schedules, policy and procedure review and staff interviews the facility failed to provide 1 (P2) of 20 sampled patient records a complete medical screening exam (MSE) to rule out an emergency medical condition (EMC). This failed practice has the potential to cause harm or even death to all patients presenting to the ED. According to facility provided information the ED averages 1,675 patients in the ED monthly.

Findings include:

A. Review of facility policy "EMTALA (Emergency Medical Treatment and Labor Act) Medical Screening", approved 2/24/2023 revealed, a MSE is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation documented in the medical record prior to discharge or transfer.

Psychiatric MSE - Patients presenting with both psychiatric and other medical signs or symptoms shall receive a MSE broad enough to rule out both psychiatric and other medical EMCs. The medical record documentation should specifically address any psychiatric complaint, culminating in an evaluation of the complaint resulting in a finding of no EMC, or establishing an appropriate plan of care.

B. Review of Patient (P)2's medical record revealed, P2 presented to the ED on 9/4/24 at 12:16PM with the police per P2's guardian request for suicidal ideation. P2 had a piece of porcelain with a plan to cut their own neck. P2 admitted to increasing marijuana use to help numb the suicidal ideation. On 9/3/24 P2 laid down on the train tracks and called the police. Medical Doctor (MD)-A evaluated P2 in the ED and discussed admitting P2 to psychiatric service, however P2 refused and would prefer to be admitted at Behavioral Health Facility (BHF) - B. P2 states if I go home, I will attempt to commit suicide and perhaps will be successful. P2 had 1:1 (1 staff member per 1 patient) during the ED stay.

Labs ordered and completed included, Complete blood count (CBC, a blood test that measures the number and types of blood cells in your body.), comprehensive metabolic panel (CMP, a blood test that measures electrolytes, kidney and liver function, protein levels and provides information about your body's chemical balance and metabolism.), both were with in normal limits. Other labs included a pregnancy test that was negative, acetaminophen and salicylate levels (measure the levels of medication in body to rule out an overdose of medication) both in normal limits and a urine drug screen that was positive for marijuana.

Transfer communication with BHF-B was initiated at 3:24PM. The last phone call to follow up on referral for transfer was made at 8:09PM. BHF-B state they have been busy and are looking at referral. At 8:14PM P2 was requesting to go home. MD-C notified of the request. P2 was discharged from the ED at 8:29PM to home. Discharge instructions included that P2 has chosen to go home tonight. Please return if having thoughts of self-harm. Continue to take medications as prescribed. Follow a healthy lifestyle including exercising regularly and eating a healthy diet. Consider volunteer opportunities in the community. P2 was to follow up with a family medicine provider (no appointment scheduled prior to discharge), and education regarding suicide and depression.
The medical record lacks evidence of the MSE evaluation documentation prior to discharge by MD-C.
The medical record lacks evidence of psychology consultation.

C. During an interview on 10/17/24 at 11:45AM, MD-D revealed "we had a team meeting (Behavioral Health Services Providers) regarding P2." As a team it was decided to not admit P2 for inpatient stay in Behavioral Health as it was not beneficial for P2. However, we do expect to the ED to call us to assist in P2's plan of care.

Based on record review, policy and procedure review and staff interviews the facility failed to provide 1 (P2) of 20 sampled patient records stabilizing treatment for an EMC prior to discharge. This failed practice has the potential to cause harm or even death to all patients presenting to the ED. According to facility provided information the ED averages 1,675 patients in the ED monthly.

Findings include:

A. Review of facility policy "EMTALA (Emergency Medical Treatment and Labor Act) Medical Screening", approved 2/24/2023 revealed, Psychiatric MSE - Patients presenting with both psychiatric and other medical signs or symptoms shall receive a MSE broad enough to rule out both psychiatric and other medical EMCs. The medical record documentation should specifically address any psychiatric complaint, culminating in an evaluation of the complaint resulting in a finding of no EMC, or establishing an appropriate plan of care.
B. Review of Patient (P)2's medical record revealed, P2 presented to the ED on 9/4/24 at 12:16PM with the police per P2's guardian request for suicidal ideation. P2 had a piece of porcelain with a plan to cut their own neck. P2 admitted to increasing marijuana use to help numb the suicidal ideation. On 9/3/24 P2 laid down on the train tracks and called the police. Medical Doctor (MD)-A evaluated P2 in the ED and discussed admitting P2 to psychiatric service, however P2 refused and would prefer to be admitted at Behavioral Health Facility (BHF) - B. P2 states if I go home, I will attempt to commit suicide and perhaps will be successful. P2 had 1:1 (1 staff member per 1 patient) during the ED stay.
Transfer communication with BHF-B was initiated at 3:24PM. The last phone call to follow up on referral for transfer was made at 8:09PM. BHF-B state they have been busy and are looking at referral. At 8:14PM P2 was requesting to go home. MD-C notified of the request. P2 was discharged from the ED at 8:29PM to home. Discharge instructions included that P2 has chosen to go home tonight. Please return if having thoughts of self-harm. Continue to take medications as prescribed. Follow a healthy lifestyle including exercising regularly and eating a healthy diet. Consider volunteer opportunities in the community. P2 was to follow up with a family medicine provider (no appointment scheduled prior to discharge), and education regarding suicide and depression.
C. During an interview on 10/17/24 at 11:45AM, MD-D revealed "we had a team meeting (Behavioral Health Services Providers) regarding P2." As a team it was decided to not admit P2 for inpatient stay in Behavioral Health as it was not beneficial for P2. However, we do expect to the ED to call us to assist in P2's plan of care.