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Based on record review and interview, the hospital failed to ensure compliance with the requirements of CFR 489.24 as evidenced by the hospital:

1) failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed for 1 (#2) of 20 patients reviewed that presented to the emergency room. This deficient practice is evidenced by Patient #2 eloping from the emergency department after being PECd on 3/29/19 for suicidal ideation. Patient #2 returned to the emergency department on 3/31/19 requesting to be seen by the physician for continued psychiatric problems and the physician refused to conduct a medical screening examination.. On 4/2/19, the hospital was notified by family members of Patient #2 that Patient #2 committed suicide on 4/2/19 (see findings tag A- 2406); and

2) failing to maintain an accurate and complete Emergency Department Central (patient) Log on each individual who came to the Emergency Department as evidenced by failing to document in the central log a patient who had eloped from the ED on 2/29/19 and presented back to the ED 3/31/19 seeking to see the physician while still under the Physician's Emergency Certificate (see findings tag A-2405).

Based on observation and interview, the hospital failed to ensure signs were posted conspicuously in places likely to be noticed by all individuals entering the emergency department (ED) specifying the rights of individuals under section 1867 of the Emergency Medical Treatment and Active Labor Act (EMTALA) with respect to examination and treatment for emergency medical conditions and women in labor, and to post conspicuously information indicating whether or not the hospital participated in the Medicaid program under a State plan approved under Title XIX. The hospital did not have signs posted in the area where patients presented to the ED by ambulance.

Findings:

Observation of the ED on 4/8/19 at 10:30 a.m. revealed signs related to examination and treatment for emergency medical conditions and women in labor and that the hospital participated in the Medicaid program were posted in the lobby where ambulatory or wheelchair-bound patients entered the ED. Further observation revealed there were no signs posted in any area within the ED where patients were treated and could be seen by patients brought to the ED by ambulance.

In an interview on 4/8/19 at 10:30 a.m. S1CNO (Chief Nursing Officer) and S2DirED confirmed no signs related to EMTALA were posted within the patient care areas of the ED that could be seen by patients arriving in the ED by ambulance. They confirmed EMTALA signs were only located in the ED lobby where ambulatory or wheelchair-bound patients arrived to be registered.

Based on record review and interviews, the hospital failed to maintain an accurate and complete Emergency Department Central (patient) Log on each individual who came to the Emergency Department as evidenced by failing to document in the central log a patient who had eloped from the ED on 2/29/19 and presented back to the ED 3/31/19 seeking to see the physician while still under the Physician's Emergency Certificate.

Findings:

On 4/8/19 at 11:30 a.m. a review of the Emergency Room Register revealed Patient #2 checked into the ED on 3/29/19 at 2:56 p.m. for trouble sleeping.
A review of Patient #2's medical record revealed the following time line from 3/29/19:
a. 3:00 p.m. Triaged,
b. 3:00 p.m. MD examination per the PEC,
c. 3:35 p.m. Eloped the first time after being told he was going to be PECd,
d. 4:00 p.m. Returned to the ED by the police at 4:00p.m.,
e. 4:15 p.m. PEC Sitter watching Patient #2,
f. 4:30 p.m. PECd due to being suicidal,
g. 6:00 p.m. Eloped again.

On 4/8/19 at 1:50 p.m. a review of the BHS PEC Sitter Flow Sheet dated 3/29/19 revealed at 6:15 p.m. Patient #2 began hitting and kicking, impulsive behavior, patient left AMA@ 6:15 p.m. and notified Deridder Police Department. "ELOPED!" Noted at the bottom of the record.

In an interview on 4/8/19 at 2:00 p.m. S1CNO stated on 3/31/19 Patient #2 was returned to the ED via a family member on 3/31/19 and the staff returned his belongings to Patient #2.

On 4/8/19 a review of the Emergency Department Central Log from 3/29/19 through 4/2/19 failed to reveal Patient #2 on the register on 3/31/19, the date Patient #2 returned to the ED with family.

In an interview on 4/9/19 at 10:25 a.m. S2DirED stated they did not interview the ED Admission clerk S8RegClk about Patient #2 returning to the ED and asking to see the doctor. She also verified S8RegClk was the clerk on duty and seen in the video when Patient #2 returned to the ED on 3/31/19 and was given his belongings.

In an interview on 4/9/19 at 12:15 p.m. S8RegClk stated she was an ED registration clerk working on 3/31/19 when Patient #2 returned to the ED. S8RegClk said she walked over to meet Patient #2 and asked if she could help with anything. She said Patient #2 stated, I would like to speak with the physician. I'm the one that ran. Patient #2 said he was there with family and his family wanted to try and get him put somewhere to try and help him. S8RegClk stated she walked, back to the nurses' station and announced Patient #2 was back in the ED and I think he was the one who ran. She also stated Patient #2 wanted to talk to the physician S8RegClk stated that S7MD said, "I'm not going talk to him".
S8RegClk admits not adding Patient #2 to the ED Central Log or registering him as an ED patient. She said it was a situation she had never encountered before. She further admits she adds patients to the log who presented to the ED and stated they are sick or ask to see the physician. She acknowledged being aware that Patient #2 was under a PEC prior to him returning to the ED on 3/31/19 and receiving his belongings.

In an interview on 4/9/19 at 1:20 p.m. S7MD stated he was the physician who PECd Patient #2 on 3/29/19. He further stated he was working on 3/31/19 when Patient #2 returned and was given his belongings. S7MD stated he remembered someone walking into the nurses' station stating that Patient #2 was in the ED and wanted to see him. S7MD admitted to stating that he was not going to see Patient #2. He further stated he did not feel comfortable going to see Patient #2 because, "he ran twice before and the patient's behavior". He further stated that he decided to have the staff call the police. S7MD confirmed he was the treating physician who had completed the PEC on Patient #2 on 3/29/19.

In an interview on 4/9/19 at 2:20 p.m. S2DirED verified Patient #2 was not listed on the ED Central Log as a patient to be seen by the ED physician on 3/31/19.

Based on record review, video review and interviews, the hospital failed to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed for 1 (#2) of 20 patients reviewed that presented to the emergency room. This deficient practice is evidenced by Patient #2 eloping from the emergency department after being PECd on 3/29/19 for suicidal ideation. Patient #2 returned to the emergency department on 3/31/19 requesting to be seen by the physician for continued psychiatric problems and the physician refused to conduct a medical screening examination. On 4/2/19, the hospital was notified by family members of Patient #2 that Patient #2 committed suicide on 4/2/19.

Findings:

A review of the hospital's policy titled Medical Screening Examination, effective 8/2011 and revised/ reviewed 7/2013 revealed in part:
Purpose: To establish Beauregard Memorial Hospital's (BMH) obligation under federal law to provide patients who present to the ED with a medical screening examination and indicated stabilizing treatment. The purpose of the medical screening examination is to determine if an "emergency medical condition" exist in order to provide stabilizing treatment.
Objective: All individuals presetting to the Emergency Department at BMH will receive a medical screening examination to determine if an emergency medical condition exist and will receive any indicated stabilizing treatment.
Definitions:
1. Presenting to the ED is defined as when a person presents anywhere on the hospital campus and request emergency services, has a request made on his/her behalf, or who would appear to a reasonably prudent person to be in need of medical attention.
3. Emergency medical condition is defined as any medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
Process:
1. A medical screening examination will be performed on all patients presenting to the ED, regardless of age, race, gender, or ability to pay.
2. The medical screening examination determines if the individual has an emergency medical condition or if the patient is in active labor. The medical screening examination must be performed by a licensed independent practitioner and will consist of any exam or test deemed necessary and within the capabilities of BMH to provide.

A review of the hospital's policy titled Psychiatric Patient Treatment/ Behavior Management approved 7/6/19 revealed in part:
Purpose:
To develop guidelines for the care of patients who present with psychiatric illness.
PEC: Physician Emergency Commitment. A legally binding document completed by a physician that places a patient in a 72 hour hold for psychiatric evaluation and treatment when the patient is thought to be a danger to self and or others and is unwilling or unable to seek treatment on his own.
Policy:
Patients accessing BMH through the ED will receive a medical screening exam and necessary stabilization. If the patient meets legal criteria for PEC, the appropriate documents will be completed by the ED physician.
When a PEC is in place, the patient will be monitored continually observed by a trained, dedicated staff member and/ or member of law enforcement until transfer to a psychiatric facility.
Patient safety and dignity will be maintained at all times.

On 4/8/19 at 11:30 a.m. a review of the Emergency Room Register revealed Patient #2 checked into the ED on 3/29/19 at 2:56 p.m. for trouble sleeping.
A review of Patient #2's medical record revealed the following time line from 3/29/19:
a. 3:00 p.m. Triaged,
b. 3:00 p.m. MD examination per the PEC,
c. 3:35 p.m. Eloped the first time after being told he was going to be PECd,
d. 4:00 p.m. Returned to the ED by the police at 4:00p.m.,
e. 4:15 p.m. PEC Sitter watching Patient #2,
f. 4:30 p.m. PECd due to being suicidal,
g. 6:00 p.m. Eloped again.

On 4/8/19 at 1:50 p.m. a review of the BHS PEC Sitter Flow Sheet dated 3/29/19 revealed at 6:15 p.m. he began hitting and kicking, impulsive behavior, patient left AMA@ 6:15 p.m. and notified Deridder Police Department. "ELOPED!" Noted at the bottom of the record.

In an interview on 4/8/19 at 4:40 p.m. S3RN stated someone from admissions called the nurses station saying there was a patient who had been PECd and was there to get his belongings. She also stated PECd patients forget their belonging and come back latter to get them. S3RN said she heard staff talking about the patient needing his belongings so she went to the soiled utility room to look. S3RN stated she heard someone say the patients name but denies remembering who said the patient's name. She then went bring Patient #2 his belongings. S3RN said the family member asked if Patient #2 needed to stay. S3RN then asked if Patient #2 was checked into the ER and the family said no. S3RN said she then told them "I don't know why he has to stay then". She then went back to the ED and someone said he had been PECd. S3RN said S11RN checked and discovered the PEC was still active and then called the local police department. S3RN denied anyone going outside to see if Patient #2 was still in the parking lot after they discovered the PEC was still in effect. She also denied anyone giving her report as to Patient #2 eloping days before.

In an interview on 4/9/19 at 12:15 p.m. S8RegClk stated she was working on 3/31/19 when Patient #2 returned to the ED with family. She stated she walked over to meet Patient #2 and asked if she could help with anything. She said Patient #2 stated, I would like to speak with the doctor. I'm the one that ran. Patient #2 said he was there with family and his family wanted to try and get him put somewhere to try and help him. S8RegClk stated she walked, back to the nurses' station and announced Patient #2 was back in the ED and I think he was the one who ran. She also stated that Patient #2 wanted to talk to the doctor. S7RegClk said S7MD said, "I'm not going talk to him."
S8RegClk acknowledged being aware that Patient #2 was under a PEC prior to him returning to the ED on 3/31/19 and receiving his belongings.

In an interview on 4/9/19 at 1:20 p.m. S7MD stated he was the physician who PECd Patient #2 on 3/29/19. He further stated he was working on 3/31/19 when Patient #2 returned and was given his belongings. S7MD stated he remembered someone walking into the nurses' station stating that Patient #2 was in the ED and wanted to see him. S7MD acknowledged that he said he was not going to see Patient #2. He further stated he did not feel comfortable going to see Patient #2 because "he ran twice before and the patient's behavior". He further stated that he decided to have the staff call the police. S7MD confirmed he was the treating physician who had completed the PEC on Patient #2 on 3/29/19.

In an interview on 4/9/19 at 1:45 p.m. S1CNO stated S7MD was the physician who completed Patient #2's PEC on him and she was not sure why he wouldn't have gone to the lobby to see him.

In an interview on 4/9/19 at 2:00 p.m. S1CNO confirmed the Medical Screening Examination and Psychiatric Patient Treatment/ Behavior Management policies presented as approved and up to date.

In an interview on 4/9/19 at 10:30 a.m. S2DirED stated on 4/2/19 at around 3:00 a.m. Patient #2's mother called the ED and notified them Patient #2 had hung himself. S2DirED stated the staff called her around 7:00 a.m. and informed her that Patient #2 had committed suicide.

On 4/9/19 this surveyor along with S1CNO and S2DirED watched the recorded interview conducted on 4/2/19 by the local police department of the female family member who returned to the ED with Patient #2 on 3/31/19. During the interview the family member stated Patient #2 told her Sunday evening, 3/31/19 he was ready to go to the ED. She said Patient #2 had been hearing voices and acting weird. The family member stated she brought Patient #2 to the ED thinking they were going to keep him. She said they approached the desk in the ED and said this is Patient #2 who escaped. She said she told them he is still hearing voices and feeling crazy. She said the ED staff then returned with Patient #2's belongings and said here is his stuff. The family member then asked if the ED was going to keep Patient #2. The family member said hospital staff said that Patient #2 was already discharged and there was nothing else they could do. They could not give him a prescription and he would have to see his doctor for that.
The female family member then stated Patient #2 was found dead in his aunt's closet.