HospitalInspections.org

Based on interviews, review of the Emergency Medical Treatment & Labor Act (EMTALA) Log, Assessment & Referral Center (ARC-Intake) records, ByLaws and policies, the facility failed to:
- Develop an EMTALA compliant policy regarding the central log with required elements and ensured ARC Intake staff (Qualified Mental Health Professional - QMHP) entered every patient into the facility's EMTALA Log that presented to the facility and requested either a medical or psychiatric screening to rule out if an emergency condition existed for one (#20) patient out of 21 patients reviewed. Refer to A-2405 for additional information.
- Develop an EMTALA compliant policy regarding Medical Screening Exam (MSE) within the facility's capability and capacity to determine if an Emergency Medical Condition (EMC) existed for five (#20, #13, #1, #3 and #5) patients out of 21 patients reviewed. Refer to A-2406 for additional information.
The facility's ARC saw an average of 266 patients over the past six months. The facility census was 31.

Based on interviews, record review and policy review, the facility failed to ensure that the Assessment & Referral Center (ARC) Intake staff entered into the EMTALA (Emergency Medical Treatment & Labor Act) Log one (#20) patient out of 21 patients reviewed that presented to the ARC Intake for assessment. No ARC Intake record was found for Patient #20 who had presented and requested a medical/psychiatric screening to rule out if either a medical or psychiatric emergency condition existed. This failure had the potential to affect all patients that presented to the facility's ARC Intake seeking an assessment. The facility's ARC Intake saw an average of 266 patients monthly over the past six months. The facility census was 31.

Findings included:

1. Record review of the facility's policy titled, "Intake and Admissions," reviewed 08/17, showed the directives for ARC staff that if a patient walks into the facility, the person's name and other demographic information, and time of triage will be recorded on the EMTALA Log.

During an interview on 09/27/17 at 4:15 PM, Staff B, Interim Risk Manager/Executive Assistant, stated that the surveyors had all the policies and procedures related to EMTALA. Staff B stated that the EMTALA Log was included in the policy titled, "Intake and Admissions" and the facility did not have any other information that addressed the EMTALA Log.

During an interview on 09/27/17 at 10:45 AM, Staff I, RN, ARC Intake, stated that ARC Intake staff are responsible to log patients into the EMTALA Log when they presented to the facility.

2. Record review of the facility's EMTALA Log dated 09/17/17 showed that ARC staff did not enter Patient #20 into the log when she presented, accompanied by local Law Enforcement, for assessment to rule out if she had an emergency psychiatric condition related to her complaints of suicidal ideations (SI - thoughts of harming self).

During an interview on 09/26/17 at 4:25 PM, Staff G, Registered Nurse (RN), ARC Intake and House Supervisor (Qualified Mental Health Professional - QMHP, identified in the facility's ByLaws as a person capable of performing a medical screening exam to rule out if either a medical or psychiatric emergency condition existed) stated that:
- She was working in ARC Intake on 09/19/17.
- She did not recall a patient that presented and requested an assessment for SI that was accompanied by local Law Enforcement.
- She would inform a patient if the facility was at capacity and did not have an available bed for inpatient admission.
- All patients that presented or requested an assessment would be entered into the EMTALA Log.

During a telephone interview on 09/28/17 at 12:20 PM, Patient #20 stated that:
- She presented to the facility on 09/17/17 and told the receptionist that she was experiencing SI.
- The receptionist contacted ARC Intake staff (Staff G) that the patient was in the lobby.
- Staff G came to the lobby and informed her that the facility did not have any available beds and she (Staff G) could not help her.
- Staff G referred her to another psychiatric hospital for care and treatment.
- She was brought to the facility per the local Law Enforcement.
- Law Enforcement was with her in the lobby when Staff G informed her that the facility did not have any available beds and referred her to a local psychiatric hospital.

During an interview on 09/27/17 at 2:00 PM, Staff F, Licensed Clinical Social Worker (LCSW), Director of ARC stated that:
- Since the facility was a stand-alone psychiatric hospital, she did not consider the ARC Intake as a dedicated emergency department.
- She has not done any Quality Assessment Performance Improvement (QAPI) projects for the ARC Intake related to EMTALA.
- The expectation for ARC Intake staff was that if a patient presented to the facility even if on diversion or no bed available for inpatient admission, the patient would receive an assessment.
- ARC Intake staff received on-the-job training, the first couple of days the new staff would "shadow" staff and the facility did not have an "official" training manual for ARC Intake staff at this time.
- Most of her EMTALA training/education was received per a computer on-line course.

The facility failed to develop and implement an EMTALA compliant process related to the central log for staff to follow when a patient presents to the facility seeking a medical or psychiatric screening to rule out if an emergncy condition exists. The facility failed to enter the patient into the EMTALA Log after she presented and requested assistance for treatment and care.

Based on interviews, record review and policy review, the facility failed to provide a Medical Screening Examination (MSE) within its capabilities and capacity, and sufficient to determine whether or not an emergency medical condition existed prior to discharging five patients (#20, #1, #3, #5 and #13) out of 21 patient records selected from April 11, 2017 to September 25, 2017. This failed practice had the potential to affect all patients that presented to the facility seeking a MSE. The Assessment & Referral Center (ARC) Intake saw an average of 266 patients over the past six months. The facility census was 31.

Findings included:

1. Review of the facility's policy titled, "Scope of Service; ARC Department," dated 08/2016, showed the following directives for staff:
-The facility assesses individuals presenting to the Emergency Department. Emergency assessments include a medical screening evaluation from a Qualified Mental Health Professional (QMHP).
-ARC staff complete the assessment process for all persons that present to the hospital and in consultation with the on-call psychiatrist refer patients to the appropriate level of care.
-ARC staff will prepare all intake documentation for the patients chart.

2. Record review of the facility's policy titled, "Intake and Admissions," dated 08/2014, showed the following directives for staff:
-The facility will be staffed 24 hours per day by Assessment & Referral Center (ARC) staff or a House Supervisor to provide crisis assessment and admission services.
-ARC staff or the House Supervisor screen patients upon their arrival to the hospital to determine whether an emergency medical condition exists, and whether acute psychiatric symptoms are present. If a patient walks into the facility, the person's name and other demographic information, and time of triage will be recorded on the EMTALA Log.
-After the assessment, ARC staff contact the on-call Psychiatrist. Clinical information about the patient will be provided to the Psychiatrist so that a determination can be made by the Psychiatrist regarding disposition of the patient.

3. During a telephone interview on 09/28/17 at 12:20 PM, Patient #20 stated that:
-She presented to the facility on 09/17/17 and told the receptionist that she was experiencing suicidal ideation's (SI - thoughts of harming self).
-The receptionist contacted Intake staff (QMHP) that she was in the lobby.
-Intake staff came to the lobby and informed her that the facility did not have any available beds and she could not help her.
-Intake staff referred her to another psychiatric hospital for care and treatment.
-She was brought to the facility per local Law Enforcement.
-Law Enforcement was with her in the lobby when Intake staff informed her that the facility did not have any available beds and referred her to a local psychiatric hospital.

During an interview on 09/28/17 at 2:10 PM, Staff C, Receptionist/Administrative Assistant, stated that:
-She worked the afternoon shift on 09/17/17.
-A white female accompanied by local Law Enforcement presented to the facility's lobby and reported that she was experiencing SI.
-She contacted the ARC/Intake staff, Staff G, RN, (QMHP), that the patient was in the lobby.
-Staff G, RN, came out to the lobby area and spoke to Law Enforcement.
-She heard Staff G, RN, inform the Law Enforcement that the facility did not have any available beds.
-Staff G, RN, gave Law Enforcement referrals where he could take the patient.
-Staff G, RN, never took the patient back to the ARC/Intake area to perform an assessment on the patient.
-The patient accompanied with Law Enforcement left the facility after talking with Staff G, RN.
-She believed the process was that the patient would be assessed before leaving the facility.

During a telephone interview on 09/29/17 at 2:42, Staff P, Law Enforcement, stated that:
-The patient requested to be taken to the facility due to her SI and he took her to the requested facility.
-When they arrived at the facility, the receptionist was told the patient was there because she was having SI.
-The receptionist called the Intake staff and the Intake Specialist (ARC/Intake Staff RN - QMHP) came out to the waiting area.
-The Intake Specialist (QMHP) told him and the patient that the facility did not have any beds available and there was nothing else "I can offer you."
-They (Law Enforcement and patient) left the facility without the patient being seen and he took the patient to another local psychiatric hospital.

The facility failed to enter the patient on the ED log and failed to provide the patient with a psychiatric screening exam within its capability to rule out if a psychiatric emergency condition existed after the patient requested treatment and care.

4. Record review of the facility's "EMTALA Log" showed Patient #1 presented to the facility on 06/14/17 at 9:25 PM with Psychiatric complaints of SI and stated "I don't want to live with this pain anymore" and that she had diarrhea caused by Clostridium Difficile (C-Diff - a bacteria that causes diarrhea), vomiting and was weak. The MSE was stopped and the patient was returned by ambulance to Hospital C for medical clearance.

During an interview on 09/26/17 at 4:07 PM, Staff E, RN, stated that if a medical condition is recognized when screening a patient for a psychiatric emergency; the screening is stopped and the psychiatrist is called for direction to transfer the patient. The patient was then transferred for clearance of the medical concern.

Record review of the patients medical chart from Hospital C on 06/14/17 at 8:50 PM, showed that the sending facility (Hospital A) had expressed concern related to the patient's C-Diff status. Hospital C documented that the patient was likely a C-Diff "carrier". The patient had no loose stools "diarrhea" during the three hours in the ED. The receiving facility (Hospital A) accepted the patient for transfer for psychiatric treatment.

Record review of the patient's chart "Nursing Medical Clearance Form" dated 06/14/17 at 7:00 PM showed the reason for transfer was possible C-Diff with a "stool sample sent out this evening".

The facility failed to provide Patient #1 with a sufficient medical screening exam to rule out if an emergency medical/psychiatric condition existed within their capability and capacity prior to transfer. The facility had available 24 hour RN coverage, medical physician on call coverage dated 06/14/17 and laboratory services in order to test for C-Diff. The patient showed no signs or symptoms of C-Diff with no stools during her stay. The facility had the capability and capacity to admit the patient to a private room to provide infection control precautions until the results of the C-Diff test was returned.

5. Record review of Patient #3's medical chart showed that he arrived at the facility on 06/21/17 at 7:28 AM with complaints of Suicidal Ideation with plan to shoot himself or drive his car off the road. He was depressed. He had a history of heart transplant and had not been taking his heart medications.

Record review of the patient's medical screen dated 06/21/17 at 7:45 PM showed Staff J, Provisional Licensed Professional Counselor (PLPC) documented the following:
- history of heart transplant;
- suicidal idiation with a plan, not taking any medications;
- blood pressure 174/106 (normal range = 120/80 to 140/90); and
- pulse 145-150 (normal 60 - 100) beats a minute .

Record review of the facility's document titled, "Memorandum of Transfer" dated 06/21/17 at 8:06 PM showed the patient was transferred to Hospital B by ambulance for medical clearance related to his heart transplant, not being medication compliant, elevated blood pressure and elevated pulse.

During an interview on 09/27/17 at 11:10 AM, Staff J, Intake Provisional Licensed Professional Counselor, stated that he had initiated the MSE and when the patient had revealed that he had not been taking his heart transplant medication, the MSE was stopped and transportation was then arranged to Hospital B for medical clearance.

Record review of the medical chart from Hospital B showed the patient was in Atrial Fibrillation with rapid response (a rapid fluttering heart beat). The patient was admitted to Hospital B.

The facility failed to provide Patient #3 with a sufficient medical screening exam to rule out if an emergency medical/psychiatric condition existed within their capability and capacity prior to transfer. The facility had the appropriate medical equipment (blood pressure cuff/machine) to monitor and evaluate the patient's elevated blood pressure, available 24 hour RN coverage, and on-call medical physician coverage per the facility's on-call schedule dated 06/21/17.

6. Record review of Patient #5's medical chart showed that he arrived at the facility on 06/24/17 at 5:15 PM with complaints of Suicidal Ideation with a plan and had attempted suicide by drug overdose within the last 24 hours and Homicidal Ideation (HI-thoughts of harming others) with a plan but had made no attempt to harm anyone.

Record review of the facility document titled, "Medical Screen - Comprehensive Assessment - Adolescent/Child" dated 06/24/17 at 5:40 PM showed a Medical Screening Examination provided by Staff N, Licensed Professional Counselor (LPC), to determine if a a Emergency Medical Condition existed.

Record review of the facility's document titled, "Memorandum of Transfer," dated 06/24/17 showed the patient was transferred to Hospital B by ambulance for medical clearance related to monitoring of labs due to an intentional overdose. The documentation showed the patient was transferred to the receiving hospital but there was no documentation of the receiving hospital accepting the patient.

During an interview on 09/26/17 at 4:30 PM, Staff F, Director of Assessment/Referral, stated that the Intake Registered Nurse (RN) should call the RN at the receiving hospital.

Record review of the American Medical Response (ambulance) showed the patient returned to the facility at 11:55 PM.

The facility failed to provide Patient #5 with a sufficient medical screening exam to rule out if an emergency medical/psychiatric condition existed within their capability and capacity prior to transfer. The facility had available 24 hour RN coverage to monitor the patient, an on-call medical physician coverage per the facility on-call schedule dated 06/24/17 and laboratory capabilities to determine if the patient continued to be at risk for a poor outcome due to the intentional overdose.

7. Record review of Patient #13's Emergency Department (ED) record showed he presented to the facility's ARC on 04/28/17 with complaints of wanting to get off his narcotic pain medication.

Record review of the patient's Medical Screen dated 04/28/17 at 3:14 PM showed Staff E, Licensed Professional Counselor (LPC), documented the following:
-Blood Pressure: 190/102 (normal range = 120/80 to 140/90).
-Staff documented that the patient took high blood pressure medication at 2:45 PM and repeated the medication at 3:45 PM and his blood pressure read 193/115.
-The patient's current medical conditions included high blood pressure (hypertension - HTN).

Record review of the patient's Memorandum of Transfer dated 04/28/17 at 5:50 PM showed Staff E, LPC, documented the following:
-Benefits of Transfer:
-Specialized equipment is not available (the facility did have blood pressure equipment available to monitor the patient's blood pressure);
-Risks of delay in transfer outweigh the benefits of further diagnosis and treatment; and
-Medical Services are not available at this hospital: CHF (congestive Heart Failure - the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs) and HTN.
-Risk of Transfer:
-Patient is fearful of ambulance.
-Physician Certificate: As of 09/28/17 neither the psychiatrist nor medical physician had co-signed that they agreed with the assessment performed by Staff E, LPC, that the facility did not have capability to stabilize the patient's elevated blood pressure or that the patient required a transfer for further care of his elevated blood pressure.

During an interview on 09/26/17 at 4:10 PM, Staff E, LPC, stated that she would have an RN review the assessment to see if the patient had a medical issue. She would notify the psychiatrist or physician for acceptance or denial for a patient to be admitted to the facility.

Record review of the patient's medical record showed that Staff E, LPC, did not document that she consulted with an RN, psychiatrist or medical physician related to the elevated blood pressure or need for transfer to Hospital B for evaluation of high blood pressure.

Record review of Hospital B's Emergency Department record for Patient #13 showed he presented to the facility on 04/28/17 at 5:21 PM with complaints of wanting to be checked into drug rehab but had high blood pressure.

Record review of the patient's History and Physical-General Illness dated 04/28/19 at 5:24 PM showed ED staff from Hospital B documented that: The patient was checking himself into rehabilitation at the psych facility (Hospital A) today. The patient has a history of high blood pressure and today his blood pressure was higher than normal. He was sent to the ED for evaluation. The patient has no complaints on arrival and just wants to be cleared for the rehabilitation facility. He states he does have blood pressure medicine and has plenty of that medicine to take if needed. He thinks he was just anxious and nervous.

Record review of the patient's blood pressure dated 04/28/17 at 5:33 PM documented by ED staff from Hospital B showed the patient's blood pressure was 161/93.

Record review of the patient's Physical Exam - Psychiatric Exam documented by ED staff from Hospital B showed:
-EKG (electrocardiogram) showed normal sinus rhythm and no significant changes found.
-Re-Evaluation: The patient was taken to a room, interviewed and examined. The patient's blood pressure has improved. He stated his blood pressure at the psych facility was 190's over 110's. The patient had labs performed that showed no acute findings at this time. The patient has actually no complaints in the ER. He has been cleared medically.
-Primary Impression: Hypertension.
-The patient was discharged in stable condition.

8. During an interview on 09/27/17 at 9:35 AM, Staff O, Medical Physician, stated that in some cases the medical physician on-call would be contacted based on the seriousness of the patient and critical lab results for a medical concern.

9. Review of the facility's website showed that the facility put on their website the following information: Pre-admission, psychiatric assessments are offered 24 hours a day, 7 days a week. All assessors are licensed mental health professionals or registered nurses. Additionally, they will confer with a psychiatrist to determine an appropriate recommendation.

The facility failed to provide Patient #13 with a sufficient medical screening exam to rule out if an emergency medical/psychiatric condition existed within their capability and capacity prior to transfer. The facility had the appropriate medical equipment (blood pressure cuff/machine) to monitor and evaluate the patient's elevated blood pressure, available 24 hour RN coverage, and on-call coverage for both psychiatrist and medical physician coverage per the facility's on-call scheduled dated 04/28/17. The patient also had his prescription blood pressure medication available if needed per documentation from Hospital B.





























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