HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interviews it was determined the facility failed to comply with 489.24 by failing to provide an appropriate medical screening examination (MSE) to rule out an emergency medical condition (EMC) (See tag; A-2406) and the facility failed to provide an appropriate transfer (See tag; A-2409).

Cross Reference:
489.24 (a) & 489.24 (c) Medical Screening Examination
§489.24 (e) Appropriate Transfer.

Based on review of facility documents, medical records (MR), and staff interviews it was determined that the facility failed to provide an appropriate medical screening examination to one (1) of twenty (20) patients, Patient #1. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A policy was reviewed titled "Care of the Suicidal Patient", reviewed 10/22. The policy has a section titled "Policy" which states "Weirton Medical Center is committed to providing a safe environment for patients, visitors, and employees. Early identification of patients at risk for suicide is a first step in providing care and intervention...5. When the patient presents to the Emergency Department it is the responsibility of the physician to evaluate the patient."

A policy was reviewed titled "Emergency Medical Treatment and Active Labor Act (EMTALA)", reviewed 8/24. The policy has a section titled "Policy" which states, in part, "Weirton Medical Center will treat all patients regardless of their ability or inability to pay. To this extent it is required that: ...all patients who come to a dedicated Emergency Department will have an emergency screening exam to determine if they are experiencing an emergency condition ..."

A medical record review was conducted for Patient #1. Patient #1 presented to the Emergency Department (ED) on 9/24/24 complaining of suicidal ideation, with no plan. An entry in the medical record titled "ED Note - Physician" completed by Staff #2 on 9/24/24 at 9:23 p.m. states, in part, "History of Present Illness: [Patient #1] comes to the emergency room complaining of not being on [his/her] right medications...Patient states [he/she] has suicidal thoughts but not actively suicidal at the same time. Patient said that [he/she] has attempted in the past taking too many pills..." The entry also contains a section titled "Medical Decision Making" which states, in part "...Patient cleared from a medical standpoint from the emergency room for psych management. Will continue to monitor Patient emergency room while setting up transfer."

A document without a title states in part, (Patient 1's name). Presenting problem SI [suicidal ideations] Diagnosis ...SI, depression. Treatment date: psych clear. Proposed discharge plan: to psych facility.

A document without a title states in part, (Patient 1's name). Clinical Diagnosis: Suicidal Ideations.

A review of a nursing note on 09/24/24 and electronically signed at 10:17 p.m. shows that five (5) inpatient facilities were contacted for transfer and the facility was still awaiting an inpatient psychiatric transfer at the time of discharge.

A review of ED discharge instructions included education materials on "Helping someone with suicide".

It should be noted there was no assessment for capacity, psychological evaluation or a suicide risk assessment in the medical record.

An interview was conducted with Staff #2 on 9/26/24 at 12:54 p.m. Staff #2 was asked about their interaction with Patient #1. Staff #2 stated in part. The Patient did not want to go to a facility that was a long distance from here. [His/Her] suicidal ideations were just wanting medications.

An interview was conducted with Staff #5 on 9/27/24 at 10:05a.m. Staff #5 was asked about triaging Patient #1. Staff #5 stated, "[He/She] was super nice. [He/She] said 'I've been feeling down, I need to get back on my meds.' [He/She] wanted to go to [another state] and said they were thinking about hurting [himself/herself] sometimes." Staff #5 was asked what actions were taken once triage was completed. Staff #5 stated, "[He/She] was placed in the psych room, nurse came and took all of [his/her] belongings and the doctor was told that the Patient was in the room."

Based on review of facility documents, medical records (MR), and staff interviews it was determined that the facility failed to provide an appropriate transfer to one (1) of twenty (20) patients, Patient #1. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A policy was reviewed titled "Emergency Medical Treatment and Active Labor Act (EMTALA)", reviewed 8/24. The policy has a section titled "Policy" which states, in part, "Weirton Medical Center will treat all patients regardless of their ability or inability to pay. To this extent it is required that: ...all patients who come to a dedicated Emergency Department will have an emergency screening exam to determine if they are experiencing an emergency condition; patients experiencing an emergency medical condition will be stabilized prior to transfer; and any transfers will occur only after the receiving hospital has agreed to accept the patient and the patient (or surrogate decision maker) has agreed to the transfer."

A medical record review was conducted for Patient #1. Patient #1 presented to the Emergency Department (ED) on 9/24/24 complaining of suicidal ideation, with no plan. An entry in the medical record titled "ED Note - Physician" completed by Staff #2 on 9/24/24 at 9:23 p.m. states, in part, "History of Present Illness: [Patient #1] comes to the emergency room complaining of not being on [his/her] right medications...Patient states [he/she] has suicidal thoughts but not actively suicidal at the same time. Patient said that [he/she] has attempted in the past taking too many pills..." This entry also contains a section titled "Medical Decision Making" which states, in part "...Patient main stable emergency room nontoxic in no acute distress not giving any trouble. Patient cleared from a medical standpoint from the emergency room for psych management. Will continue to monitor Patient emergency room while setting up transfer."

It should be noted that there is no documentation that the receiving facility was notified of the Patient, that report was given or the receiving facility was given the Patient's medical record.

An interview was conducted with Staff #2 on 9/26/24 at 12:54 p.m. Staff #2 was asked about their interaction with Patient #1. Staff #2 stated, "The Patient did not want to go to a facility that was a long distance from here. [His/Her] suicidal ideations were just wanting medications." Staff #2 was asked why a transfer was not completed for Patient #1. Staff #2 stated, "[He/She] called [his/her] [parent] and [parent] came to the Emergency Room. The Patient could have been transferred but [Patient #1] and [parent] were very pleased with the plan to follow up at another facility.

An interview was conducted with Staff #3 on 9/26/24 at 1:09p.m. Staff #8 was also present during this interview. Staff #3 was asked about their interaction with Patient #1. Staff #3 stated, "We started the process for transferring the patient to a psychiatric facility. We contacted several different facilities that evening," Staff #3 was asked why Patient #1 was not transferred to another facility. Staff #3 stated, "[His/Her] [parent] came to the emergency room. and [his/her] [parent] said they would take the Patient and get follow up care at another facility.