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Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an ongoing assessment and reassessment during a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for two patients (#1and #25) of 31 Emergency Department (ED) records reviewed from 09/15/24 to 03/24/25. This failed practice had the potential to cause harm to all patients who presented to the ED.

Findings included:

Review of the hospital's policy, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC)," dated 10/01/24, showed when an individual comes to the ED and requests emergency care or treatment the hospital must provide an appropriate MSE, beyond medical triage (process of determining the priority of a patient's treatment based on the severity of their condition), by qualified medical personnel. A MSE is an examination sufficient to reasonably indicate the presence or absence of an "EMC" for an individual.

Review of the hospital's document, "Medical Staff Bylaws and Rules and Regulations," dated 01/01/2024, showed a MSE will be provided to all patients presenting for emergency services.

Review of the hospital's undated policy, "Suicide Prevention," showed:
- Patients who have had suicidal ideations (SI, thoughts of causing one's own death) or with suicidal behaviors (any action that could cause one's own death) need additional individualized precautions implemented to keep them safe from their own actions.
- Intervention will be applied based on the stratified risk level.
- Patients at a high-risk for suicide based on the screening will be assessed further by a Qualified Mental Health Provider (QMHP).
- Precautions for high-risk patients may not be removed or reduced until the QMHP has assessed the patient and the appropriate provider has determined the most appropriate level of care.
- High-risk suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) include immediate implementation of continuous one-to-one (1:1, continuous visual contact with close physical proximity) observation.
- Patients must have an assigned staff observer directly observing them 1:1 continuously.
- The staff observer must be close enough to the patient to immediately intervene in any self-harm act and must remain with the patient continuously until precautions are discontinued by a provider.
- Patients at high-risk for suicide will also be placed on elopement precautions (EP, interventions to prevent someone from leaving who may be at risk for self-harm or injury).

Review of the hospital's undated policy "Elopement (when a patient makes an intentional, unauthorized departure from a medical facility) Risk Assessment, Intervention and Response," showed:
- Patients determined to be at risk for elopement should not be permitted to leave.
- Patients who are observed to have SI are at risk for elopement.
- If a patient is a high-risk for suicide, they are automatically on EP.
- ED patients identified as an elopement risk at triage should be placed in a room as soon as possible, away from the exit doors. If waiting for a room, the patient is to be placed in a treatment area with 1:1 observation.
- Notify Public Safety and the Charge Nurse.

Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an ongoing assessment and reassessment during a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for two patients (#1 and #25) of 31 Emergency Department (ED) records reviewed from 09/15/24 to 03/24/25. This failed practice had the potential to cause harm to all patients who presented to the ED.

Findings included:

Review of the hospital's policy, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC)," dated 10/01/24, showed when an individual comes to the ED and requests emergency care or treatment the hospital must provide an appropriate MSE, beyond medical triage (process of determining the priority of a patient's treatment based on the severity of their condition), by qualified medical personnel. A MSE is an examination sufficient to reasonably indicate the presence or absence of an "EMC" for an individual.

Review of the hospital's document, "Medical Staff Bylaws and Rules and Regulations," dated 01/01/2024, showed a MSE will be provided to all patients presenting for emergency services.

Review of the hospital's undated policy, "Suicide Prevention," showed:
- Patients who have had suicidal ideations (SI, thoughts of causing one's own death) or with suicidal behaviors (any action that could cause one's own death) need additional individualized precautions implemented to keep them safe from their own actions.
- Intervention will be applied based on the stratified risk level.
- Patients at a high-risk for suicide based on the screening will be assessed further by a Qualified Mental Health Provider (QMHP).
- Precautions for high-risk patients may not be removed or reduced until the QMHP has assessed the patient and the appropriate provider has determined the most appropriate level of care.
- High-risk suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) include immediate implementation of continuous one-to-one (1:1, continuous visual contact with close physical proximity) observation.
- Patients must have an assigned staff observer directly observing them 1:1 continuously.
- The staff observer must be close enough to the patient to immediately intervene in any self-harm act and must remain with the patient continuously until precautions are discontinued by a provider.
- Patients at high-risk for suicide will also be placed on elopement precautions (EP, interventions to prevent someone from leaving who may be at risk for self-harm or injury).

Review of the hospital's undated policy "Elopement (when a patient makes an intentional, unauthorized departure from a medical facility) Risk Assessment, Intervention and Response," showed:
- Patients determined to be at risk for elopement should not be permitted to leave.
- Patients who are observed to have SI are at risk for elopement.
- If a patient is a high-risk for suicide, they are automatically on EP.
- ED patients identified as an elopement risk at triage should be placed in a room as soon as possible, away from the exit doors. If waiting for a room, the patient is to be placed in a treatment area with 1:1 observation.
- Notify Public Safety and the Charge Nurse.

Record review of Patient #1's medical record, dated 11/06/24, showed:
- At 7:04 PM, a 27-year-old male presented to the ED requesting mental health medication. He stated that he had suicidal thoughts and dreams.
- His past medical history included bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), depression (extreme sadness that does not go away), drug abuse, Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock) and schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly).
- At 7:36 PM, his Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) showed he was a high suicide risk.
- At 7:42 PM, orders were written for SP and EP.
- At 8:11 PM, he needed a mental health assessment. His significant other (SO) encouraged him to stay for treatment. He did not indicate he would attempt to elope and verbalized an agreement with the plan of care. The nurse left him in the company of his SO while she consulted with other staff members to develop a plan for a room placement. The ED room designated for mental health patients was occupied and the only place available was in the hallway. When the nurse returned to the triage room both the patient and his SO were gone. Security was contacted and video reviews were completed. The patient walked out of the hospital with the SO. The House Supervisor, Risk Management and the local police department were notified.
- At 8:37 PM, the disposition was set to eloped.

During a telephone interview on 03/26/25 at 1:34 PM, Staff I, Physician Assistant (PA, a type of mid-level health care that can serve as a principal healthcare provider), stated that he did not have contact with the patient. The patient eloped from triage and providers do not assess patients in the triage area. When there were no beds available, he expected every patient assessed to be high-risk for suicide to be placed in the hallway, with a 1:1 observer in place at all times. The goal was to keep the patients safe.

During a telephone interview on 03/26/25 at 4:01 PM, Staff J, Registered Nurse (RN), stated that she asked the C-SSRS questions specifically as they were written. The patient was able to answer the questions, and his answers seemed to be truthful. That night the hospital was "very busy," all of the beds were full, and patients were waiting in the hallway. She stepped out of the triage area to find a place for the patient and when she returned, he was gone. His SO encouraged him to seek treatment. She felt safe leaving the patient with the SO for a few minutes while she sought a bed. When she discovered he had eloped she notified the House Supervisor. She reviewed the video footage to identify which direction he traveled towards, contacted the local police department, informed them which direction he traveled and provided his home address. He did not return to the ED. She recognized all high-risk suicide patients required 1:1 observation, someone must always stay with the patient. She "would never do this again." In the future, she would call for a security officer to ensure the patient was safe if a 1:1 observer was not immediately available. The hospital had to look out for the safety of patients who expressed suicidal thoughts.

During an interview on 03/25/25 at 9:05 AM, Staff A, Clinical Excellence Director, stated that the triage door did not lock, and patients could leave the triage area without being seen.

Review of Patient #25's medical record, dated 03/07/25, showed:
- At 9:02 PM, a 38-year-old female arrived at the ED, stated she was on blood thinners, had bloody urine that day and blood in her stool for the last few days.
- She had a history of kidney stones, pulmonary embolus (PE, blood clot in the lung) and rectal hemorrhage (excessive bleeding).
- Orders included urinalysis (a laboratory examination of a person's urine) and blood tests.
- No stool tests were ordered.
- Urine and blood laboratory results confirmed bloody urine with a normal hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body) level.
- The medical decision-making indicated kidney stones possibly contributed; she was not in pain.
- She was advised to follow up with her physician and a urologist (a physician who specializes in diseases of the urinary system).

During a telephone interview on 03/26/25 at 1:20 PM, Staff E, ED Medical Director, stated that a patient at high-risk for suicide required 1:1 observation and was not allowed to elope from the hospital. He expected all high-risk suicide interventions to be maintained until a provider changed the intervention orders. Hospital staff should follow the policies and procedures for suicide and elopement prevention. He stated that stable patients with bloody urine who had no pain would not necessarily require a computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan. Laboratory results and the patient's presentation were helpful to determine if the patient had a bleeding emergency. The ED did not have stool sample tests for active bleeding. Rectal exams could be considered.

During a telephone interview on 03/26/25 at 1:38 PM, Staff F, Physician, stated that laboratory values and physical examinations helped to determine if a CT scan was necessary. ED staff ruled out emergencies.

During an interview on 03/26/25 at 12:28 PM, Staff H, ED Manager, stated that patients assessed to be at a high suicide risk required 1:1 observation and were not to be left alone. The hospital did not use SOs as a patient observer. She stated that diagnoses were not always achievable in the ED. Stable patients with non-obstructive kidney stones and no pain were discharged to follow up with their provider. If the patient's condition was not life-threatening, then they were stable.

During a telephone interview on 03/26/25 at 10:03 AM, Staff G, RN, stated that some patients with bloody urine did not require CT scans. CT scans were considered if patients were in pain or had a bad infection. Patients with blood in their stool were not tested with stool sample cards. Sometimes doctors did rectal exams. She expected blood tests to be ordered that indicated active bleeding and a consultation to a gastroenterologist (physician who specializes in the digestive system). Some doctors ordered CT scans if indicated.

During a telephone interview on 03/26/25 at 4:45 PM, Staff K, RN, stated that they did not use stool sample cards to detect blood in stool. Stool samples sent to the laboratory had delayed results. Doctors could order CT scans for patients with histories of kidney stones or gastrointestinal (GI) bleeds. Physicians weighed the risks versus the benefits of imaging radiation (the use of energy waves to diagnose or treat disease). Patients were not exposed to radiation if the test was not necessary to determine the presence of an emergency. Emergent patients showed symptoms such as significant blood loss, paleness, sweaty skin and dizziness. If a patient's condition was not life threatening, a CT scan was not always performed in the ED.