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Based on hospital A's (Crestwood Medical Center) policies and procedures, Emergency Department (ED) Central Logs, ED video footage, medical records (MR), and staff interviews, it was determined the hospital failed to ensure:



1. An appropriate medical screening examination (MSE) was provided within the capability of the hospital's emergency department to determine whether or not an emergency medical condition exists for all patients who presented to the ED.

2. Patients were reevaluated for the mental competency to make the decision to leave the hospital by a physician prior to the patient's leaving the ED.

3. A patient who presented to the ED with Suicidal Ideation was placed on an involuntary hold to transfer the patient for the completion of the MSE.

4. A description of the MSE and stabilizing treatment refused by the patient was documented, and the patient was informed of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment when he/she left without being seen (LWBS) was documented.


These deficient practices affected one of one patient reviewed via video footage, including Patient Identifier (PI) # 1, who presented to the ED for emergent care on 3/11/25, two of two psychiatric MRs reviewed, including PI # 15 and PI # 4, one of two MRs reviewed who LWBS, including PI # 17.

Findings Include:

Refer to A 2406, and A 2407, for findings.

Based on hospital policy, Emergency Department (ED) Central Logs, ED video footage, and interviews with staff, it was determined the hospital failed to ensure every patient who presented to the ED for emergent care was maintained on the central log on each individual who comes to the emergency department seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged.

This affected one of one patient reviewed via video footage, including Patient Identifier (PI) # 1, who presented to the ED for emergent care on 3/11/25 and had the potential to negatively affect all patients who presented to this hospital requesting emergency care.

Findings include:

Hospital Policy: Emergency Medical Treatment and Active Labor Act (EMTALA)

Policy Number: ED-PC-612

Revised: 7/14/22

Introduction: The purpose of this policy is to define the relevant terms and provide an overview of the EMTALA...

Definitions:

..."Central Log" means a log the hospital maintains of all individuals who present to the hospital seeking emergency medical assistance, and the disposition of such individuals...

1.0 General EMTALA Obligations; Central log

...1.2 Central Log

1.2.1 The hospital shall maintain a central log on each individual who comes to the ED seeking assistance. The purpose of the Central log is to track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition, and should include all patients presenting to the ED regardless of whether they actually received treatment... Patients should be entered into the central log/ED information system at the first point of contact...

1. Review of the ED Central Log dated 3/11/25 revealed a total of 13 patients were registered in the ED Central Log from 5:00 PM to 7:00 PM.

Review of the ED video surveillance dated 3/11/25 from 5:00 PM to 7:00 PM was conducted on 4/17/25 at 12:52 PM with Employee Identifier (EI) # 2, Quality and Regulatory Manager. The review of the video surveillance revealed PI # 1 entered the ED at 6:05 PM, approached the ED registration desk, spoke with the staff at the ED registration desk, then at 6:07 PM was observed to exit the ED. PI # 1 was identified via description of wearing a black shirt, shorts, and yellow crocks with her/his hair in braids.

Further review of the ED Central Log revealed no documentation of PI # 1 on the 3/11/25 from 5:00 PM to 7:00 PM.

Interviews were conducted on 4/18/25 with three hospital ED registrars and two hospital ED supervisors. Five of the five staff interviewed verbalized a patient should be entered into the ED central log upon presenting to the ED registration desk.

An interview was conducted on 4/18/25 at 9:01 AM with EI # 1, Chief Quality Officer, who confirmed there was no documentation of PI # 1 on the ED Central Log for 3/11/25.

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to maintain a Central Log on Patient #1 on 3/11/2025 who presented to hospital's ED seeking emergency medical assistance. Additionally, the hospital failed to ensure that the first point of contact entered Patient #1 into the Central Log ED information system as stated in the facility's Policy.

Based on review of the hospital policies and procedures, Medical Records (MR), Emergency Department (ED) central log, ED video surveillance and interviews with staff it was determined the hospital failed to:

1. Provide an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department to determine whether or not an emergency medical condition exists for all patients who presented to the ED.

2. Reevaluate patients for the mental competency to make the decision to leave the hospital by a physician prior to the patient leaving the ED.

3. Place a patient who presented to the ED with Suicidal Ideation on an involuntary hold to transfer the patient for the completion of the MSE.

This deficient practice affected one of one patient reviewed via video footage, including Patient Identifier (PI) #1, two of two psychiatric MRs reviewed, including PI # 15 and PI # 4, and had the potential to affect all patients served by the hospital ED.

Findings include:

Hospital Policy: Emergency Medical Treatment and Active Labor Act (EMTALA)
Policy Number: ED-PC-612
Revised: 7/14/22

Introduction: The purpose of this policy is to define the relevant terms and provide an overview of the EMTALA...

Definitions:

...Comes to the ED means an individual who: ...has presented at a hospital's dedicated ED and requests examination or treatment for a medical condition or has such a request made on his or her behalf...is on hospital property...and requests examination or treatment for what may be an emergency medical condition...

Emergency Medical Condition (EMC) means: A medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably be expected to result in:

...Serious impairment to bodily functions...

With respect to an individual with psychiatric symptoms: That acute psychiatric or acute substance abuse symptoms are manifested; or that the individual is expressing suicidal or homicidal thoughts or gestures and is determined to be a danger to self or others.

...MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exits...

2.0 MSE

2.2 Medical Screening

2.2.1 When an individual comes to the ED requesting medical treatment, an appropriate MSE, within the capabilities of the ED...shall be provided to determine whether an EMC exits...

2.2.3 MSE shall be performed by qualified medical personnel (QMP), who may be an ED Physician or other licensed practitioner... The ED physician or QMP on duty shall be responsible for the general care of all patients presenting themselves to the ED and remains with the ED physician until...the patient arrives at the receiving hospital following appropriate transfer.

....2.2.4 Note that the MSE is not an isolated event, but it is an on-going process.

Hospital Policy: Behavioral Health Assessments
Policy Number: ST-PC-955
Revised: 12/3/24

1.0 Purpose:

1.1 To establish guidelines for psychiatric treatment and if necessary involuntary hold of patients who present to Crestwood Medical Center.

2.0 Policy:

2.1 It is the policy of Crestwood Medical Center to provide a mechanism for the involuntary evaluation and treatment of any patient with signs and symptoms of mental illness or conditions which would potentially impair the patient's capacity to make medical treatment decisions, and/or signs and symptoms of mental illness such that he/she is likely to be of immediate danger to self or others...

3.0 Procedure:

3.1 Patient Self-Presents to ED...

3.1.1 ...A patient who self presents to the ED...when the patient is exhibiting signs and symptoms of mental illness or conditions which would potentially impair the patient's capacity to make medical treatment decisions, and/or signs and symptoms of mental illness such that he/she is likely to be of immediate danger to self or others, the examining physician or the patient's attending physician may hold the patient involuntarily using the Involuntary Patient Hold form...

3.1.3 The designated staff will contact the on-call Community Mental Health Officer (CMHO) for...county, who can be reached 24 hours per day...

3.1.3.3 The designated staff will present the patient case to the CMHO, who will give a verbal hold order authorizing the involuntary treatment of the patient, if warranted.

3.1.4 In the event that the on-call CMHO cannot be reached, or declines to become involved in the case, staff will implement the following procedure:

3.1.4.1 The examining physician, and a second physician will sign the Involuntary Patient Hold form...

3.1.5.1 This hold shall extend for a period of not more than the lesser of forty-eight (48) hours or the time reasonably necessary to evaluate and observe the patient sufficiently to establish whether or not there is a need to request an involuntary commitment from the Probate Court...

3.1.6 Patients admitted on an Involuntary Patient Hold should be transferred to a mental health facility...

1. Review of the ED Central Log dated 3/11/25 revealed a total of 13 patients were registered in the ED Central Log from 5:00 PM to 7:00 PM.

Review of the ED video surveillance dated 3/11/25 from 5:00 PM to 7:00 PM was conducted on 4/17/25 at 12:52 PM with Employee Identifier (EI) # 2, Quality and Regulatory Manager. The review of the video surveillance revealed Patient Identifier (PI) # 1 entered the ED at 6:05 PM, approached the ED registration desk, spoke with the staff at the ED registration desk, then at 6:07 PM was observed to exit the ED. PI # 1 was identified via description of wearing a black shirt, shorts, and yellow crocks with her/his hair in braids.

There was no evidence the facility offered or provided a MSE for PI # 1 who arrived on 3/11/25 at 6:05 PM.

An interview was conducted on 4/18/25 at 9:01 AM with EI # 1, Chief Quality Officer, who confirmed there was no documentation PI # 1 was offered or provided a MSE on 3/11/25. The facility failed to ensure that their policy and procedure was followed as evidenced by failing ensure that a medical screening examination was provided for patient #1 when she/he presented to the hospital's ED, and requested an examination, for a medical condition.

An interview was conducted on 4/18/25 at 10:58 AM with PI # 1 who verbalized he/she presented to the hospital ED due to being on menstrual cycle for a long time. PI # 1 verbalized the registrar said "...no one would be able to see me, there was no sense in coming because they would not do anything about it that I would just need to see my OB/GYN (Obstetrics and Gynecology)..."

2. PI # 15 presented to the hospital ED on 3/14/25 at 10:55 PM via ambulance with a chief complaint of being harassed by spirits for three years.

Review of the Nursing Assessment dated 3/15/25 at 1:00 AM revealed the patient was anxious and exhibiting bizarre behavior.

Review of the ED Physician Note dated 3/15/25 at 5:09 AM revealed the patient was experiencing delusions, paranoid behavior, and hallucinations of getting information from the President with a history of Schizophrenia.

Review of the Nursing note dated 3/15/25 at 5:48 AM revealed the hospital was attempting to transfer the patient to a psychiatric hospital.

Review of the Nursing note dated 3/15/25 at 8:33 AM revealed the patient verbalized he/she wanted to leave, the ED physician was made aware, and the patient left the ED.

Review of the ED Physician Disposition Summary dated 3/15/25 at 8:36 AM revealed the patient "eloped" with a diagnosis of Schizophrenia, Unspecified.

Review of the MR revealed no documentation the ED physician reexamined/reevaluated the patient's competency, in order to discharge the patient prior to transferring the patient for the completion of the MSE.

An interview was conducted on 4/18/25 at 7:49 AM with EI # 2 who confirmed there was no documentation the ED Physician reexamined/reevaluated the patient's competency to be discharged from the hospital ED prior to transferring the patient for the completion of the MSE.

An interview was conducted on 4/18/25 at 1:53 PM with EI # 3, ED Registered Nurse, who was discharge nurse for PI # 15. EI # 3 verbalized PI # 15 hears voices. EI # 3 verbalized the patient had gotten tired of waiting on a transfer, said he/she wanted to leave, and was discharged home.

An interview was conducted on 4/18/25 at 11:38 AM with EI # 4, ED Medical Director, who verbalized when a patient with a psychiatric complaint requests to leave the hospital the ED provider would need to determine if they have the capacity to leave or not.

3. PI # 4 presented to the hospital ED on 1/9/25 at 6:57 PM with a chief complaint of Suicidal Ideation (SI), history of Bipolar Disorder, use of cocaine four days ago, and feeling like things were after him/her.

Review of the ED Physician note dated 1/9/25 at 7:04 AM revealed the patient presented to the ED with SI, feeling like giving up, a history of Bipolar, cocaine use, seeing things, feeling like things are after him/her, decreased appetite and insomnia.

Review of the Triage Assessment dated 1/9/25 at 7:05 PM revealed the patient had anxious behavior and was tearful with a Suicide Risk Assessment level of high risk for suicide.

Review of the ED Physician note dated 1/10/25 at 3:21 AM revealed the patient was actively suicidal with a plan to run out in front of traffic and reported auditory and visual hallucinations.

Review of the ED Physician note dated 1/10/25 at 3:24 AM revealed the patient was medically clear and the hospital will begin seeking psychiatric placement for the patient.

Review of the ED nursing note dated 1/10/25 at 10:15 AM revealed the patient had been accepted for a transfer to a psychiatric unit.

Review of the No Harm Contract form dated 1/10/25 at 10:45 AM revealed the patient signed a no harm contract affirming he/she did not intend to harm self and agreed to consult the hospital before injuring self. Further review of the No Harm Contract revealed the form was witnessed by two ED nurses.

Review of the ED nursing discharge assessment note dated 1/10/25 at 11:13 AM revealed the patient left AMA (Against Medical Advice) with a signed safety plan in place. There was no documentation the ED physician was notified of the patient leaving AMA.

Review of the Disposition Summary dated 1/10/25 at 11:14 AM revealed the patient left AMA with a diagnosis of SI.

Review of the MR revealed no documentation the ED physician reexamined/reevaluated the patient's competency to make the decision to leave AMA.

An interview was conducted on 4/18/25 at 8:13 AM with EI # 2 who confirmed there was no documentation the ED physician was notified of the patient requesting to leave the ED, the patient was placed on an involuntary hold for the completion of the MSE, and no documentation the ED Physician reexamined/reevaluated the patient's competency to make the decision to leave the hospital AMA prior to the patient leaving the hospital ED AMA.

An interview was conducted on 4/18/25 at 9:23 AM with EI # 5, ED nurse for PI # 4. EI # 5 was unable to recall the patient but verbalized in order for a patient with a psychiatric complaint to leave the ED the ED Provider would need to reevaluate them to assess their harm to self or others. If they are assessed as a harm to self or others, then there is a two-provider form which has to be done and usually involves probate. EI # 5 verbalized the ED can call the behavioral health officer at the city police department.

The facility failed to ensure their policy and procedures were followed as evidenced by failing to re-examine/re-evaluate PI # 15 and PI # 4, both patients presented to the hospital's ED exhibiting signs and symptoms of mental illness (experiencing having visual hallucinations) potentially impaired their capacity to make medical treatment decisions, and or signs and symptoms of mental illness such they are likely to be of immediate danger to themselves and others. There was no documentation in the medical record to indicate PI # 15's and PI # 4's cases were presented to the on-call CHMO for review, or that the examining physician and a second ED physician signed the involuntary hold forms for these patients as stated in the facility's policy.

Based on review of the hospital policy, medical records (MR), and interviews with staff it was determined the hospital failed document a description of the Medical Screening Exam (MSE) and stabilizing treatment refused by the patient, and the patient was informed of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment when he/she left without being seen (LWBS).

This deficient practice affected one of two MRs reviewed who LWBS, including Patient Identifier (PI) # 17, and had the potential to affect all patients served by the hospital Emergency Department (ED).

Hospital Policy: Emergency Medical Treatment and Active Labor Act (EMTALA)
Policy Number: ED-PC-612
Revised: 7/14/22

Introduction: The purpose of this policy is to define the relevant terms and provide an overview of the EMTALA...

Definitions:

Emergency Medical Condition (EMC) means: A medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably be expected to result in:

...Serious impairment to bodily functions...

MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exits...

2.0 MSE

...2.1.3 If a patient informs the ED...staff that he/she is leaving the hospital prior to receiving an MSE, staff should endeavor to persuade the patient to stay until he/she can be screened...The ED physician or qualified medical personnel (QMP) should discuss the risks of leaving with the patients. If...the patient refuses to stay, ED staff should obtain the patient's signature, date and time, on an AMA (Against Medical Advice) form, indicating that they have been informed of the risks of leaving the ED prior to receiving an MSE or prior to receiving stabilizing treatment for an EMC... ED staff must document...the efforts undertaken to convince the patient to stay...

2.2 Medical Screening

...2.2.3 MSE shall be performed by QMP, who may be an ED Physician or other licensed practitioner... The ED physician or QMP on duty shall be responsible for the general care of all patients presenting themselves to the ED and remains with the ED physician until...the patient arrives at the receiving hospital following appropriate transfer.

...3.0 Stabilizing Treatment

3.1 If it is determined through an MSE that an EMC exists...ED personnel shall...provide such further medical examination and treatment as may be required to stabilize the medical condition...transfer the individual to another appropriate facility that can meet the patient's needs...

1. PI # 17 presented to the hospital ED on 3/16/25 at 7:14 PM via ambulance with a chief complaint of an overdose of Fentanyl and meth (Methamphetamine) earlier in the day and on 3/14/25.

Review of the Nursing Assessment dated 3/16/25 at 7:21 PM revealed the patient had agitated behavior, refused to wait for the physician, and requested to LWBS.

Review of the ED Outcome Nursing Note dated 3/16/25 at 7:27 PM revealed the patient left the ED.

Review of the MR revealed no documentation the ED physician or QMP was notified of the patient requesting to LWBS. Additionally, there was no documentation in the MR of a description of the MSE and stabilizing treatment refused by the patient, and the patient was informed of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment.

An interview was conducted on 4/18/25 at 11:06 AM with EI # 6, ED Triage nurse for PI # 17. EI # 6 verbalized she/he vaguely remembered the patient being uncooperative, not wanting to answer questions, and didn't seem pleased the ambulance brought him/her into the ED. EI # 6 verbalized if a patient requests to leave the ED without being seen she/he would tell the ED provider. EI # 6 verbalized it would be up to the provider if they want to go and talk to the patient before they leave. EI # 6 verbalized a general note would be documented of the notification of the ED provider and the explanation of the risks and benefits of staying for the MSE and/or stabilizing treatment to the patient or an AMA form would be used.

An interview was conducted on 4/18/25 at 8:12 AM with EI # 2, Quality and Regulatory Manager, who confirmed there was no documentation the ED physician or QMP was notified of the patient requesting to LWBS, of a description of the MSE and stabilizing treatment refused by the patient, and the patient was informed of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment.