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Based on record reviews, policy reviews and staff interviews the hospital inappropriately discharged 1 (Patient 9) of 20 sampled patients prior to providing within the hospital's capabilities, a Medical Screening Examination (MSE) sufficient to determine whether a Psychiatric Emergency Medical Condition (EMC) existed, in accordance with the facility EMTALA policies. The failure to follow the hospital's policy and procedures for performing a MSE to determine a Psychiatric Emergency Medical Condition has the potential to cause harm or death due to a delay in treatment. The total sample of 20 records, was taken from the central logs of patients presenting to the Emergency Department for a MSE from 6/1/21-11/30/21.

Findings are:

See also A 2406.

A. Review of the facility "Medical Staff Rules and Regulations" last revised 12/02/20 states under "2.2 EMERGENCY TREATMENT AND ACTIVE LABOR ACT (EMTALA):
1- An appropriate medical screening examination to determine if the patient has an emergency medical condition. Physician assistants and nurse practitioners may perform a medical screening examination if they have been approved to do so by their department. In addition, a psychiatric screening examination to determine whether a patient has an emergency psychiatric condition may be performed by psychologists, psychiatrists, psychiatric social workers, psychiatric clinical nurses (registered nurses), licensed marriage and family therapists, and licensed professional counselors. Registered nurses in the Labor & Delivery Unit may do the medical screening examination on a pregnant patient for the limited purpose of determining whether the patient is in labor. If the medical screening examination is performed by a non-physician and knows initially that the medical screening examination for the presenting complaint is outside his or her scope of practice, the practitioner must be contacted and be available to see the patient within 30 minutes.
2- For treatment which is necessary to stabilize the patient's emergency medical condition, including treatment for an unborn child, there shall be a list of practitioners, including specialists and subspecialists, who are on call to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. the on call practitioner shall be available for contact and respond within 30 minutes to provide further examination and treatment.
3- If necessary, an appropriate transfer to another medical facility.
4- Neither the screening nor any necessary treatment may be delayed in order to inquire about the person's insurance status or how they are going to pay.

B. A review of a form that the facility identified as an "On Call Specialty List" dated 9/7/21. This form listed:
1) Department -Psychiatrics; Name-PSY D; on call time-8:00-8:00; Number- phone number; Special call Instructions- Name of Psychological Services group
2) Department-Psychiatrics-ED Use; Name- the name of facility case manager; on call time- 8:00- 17:00 (5:00 PM); Number-CM extension; Special call Instructions-facility Case Manager M-F 8:00-17:00
3) Department-Psychiatrics- [Psychiatric Unit at Hospital B-3.5 miles away]; on call time-8:00-8:00; Number-Hospital phone number.

C. In an interview on 12/8/21 at 2:30 PM with the ED Medical Director, clarification was requested about the form the facility identified as an "On Call Specialty List" dated 9/7/21. The ED Medical Director if all the listings of the different specialties were "On Call" and available if the ED Physicians phoned them and requested them to come to the hospital and see the patient? The ED Medical Director responded, "No, this form is more of a reference for telephone numbers our staff can reach out. They are not all on call and available. We started that list when we were just opening our ED more as a resource, it really is not an On Call list. We do have a Cardiologist and General Surgeon that will come if called. Asked the ED Medical Director to explain the 3 reference related to Psychiatric resources. The ED Medical Director stated, "those are just references, the 2nd one the case manager is an employee here and if she is here will assist us with psychiatric community resources, the other two are just resources but are not On Call." The ED Medical Director stated, "We will separate those to make it clearer, we will make a resource/reference telephone number list and a separate "On Call" list of physicians/practitioners that would be on call to come in if needed." We do not have Psychiatric Services here at this Hospital.

D. Review of Patient 5's 9/7/21-9/8/21 ED medical record showed at 10:40 PM the ED Dr examined Patient 5. The ED Dr documented Patient 5 had "complaints of suicidal ideation and drinking alcohol for the last 2 days up to 2 gal (gallons) of vodka, comes in very intoxicated with nausea and vomiting. Patient states no plan as far as suicidal ideation." Further documentation showed Patient 5 had a history of Bipolar 1 disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), depression, and PTSD. Further documentation showed Patient 5 was intoxicated but can move extremities without any difficulty equal bilateral and suicidal ideation with severe intoxication.

Further documentation from the ED Dr documented IV fluids, oxygen, lab work, chest x-ray, EKG (electrocardiogram-tracing of heart), stabilized blood sugar and blood pressure and food was provided. Patient 5's blood alcohol came back at 0.170 (0.16-0.19% is very drunk-strong state of depression, nausea, disorientation, dizziness, increased motor impairment, blurred vision and judgement and perception severely impaired). "Patient initially indicated suicidal ideation but no plan. After Kearney Police Department assessed the patient for the possibility of an EPC (Emergency Protective Custody-a status which the patient is identified a threat to himself or others) recommendations were not indicated. Patient was discharged from the emergency room for self committal to [Psychiatric Unit at Hospital B] on own accord." Pt states he wants to check himself in to [Psychiatric Unit at Hospital B] tonight for evaluation and treatment. Pt given discharge instructions and verbalizes understanding. Cab voucher given to patient, states he plans to go directly to [Psychiatric Unit at Hospital B] on his own accord."

E. In an interview on 12/8/21 at 3:58 PM, the ED nurse recalled on 9/7/21 Patient 5 came by EMS, intoxicated. We did labs, fluids, had Kearney Police Department come and evaluate him for suicidal ideation. They recommended to him to seek treatment and he was cleared. He was discharged home but then the patient told me he wanted to go to the [Psychiatric Unit at Hospital B] and commit himself. I remember we gave him a cab voucher, "he said he wanted to go to [Psychiatric Unit at Hospital B]. He had no suicidal thoughts with me and he was cleared to go home on discharge. He was alert & oriented. I thought he was free to do what he wanted when he left due to he was discharged."

Based on record reviews, policy reviews and staff interviews the hospital inappropriately discharged 1 (Patient 5) out of 20 sampled patients, prior to providing within the hospital's capabilities, a Medical Screening Examination (MSE) sufficient to determine whether a Psychiatric Emergency Medical Condition (EMC) existed. The total sample of 20 records, was taken from the central logs of patients presenting to the Emergency Department for a MSE from 6/1/21 - 11/30/21. This failure has the potential for all patients presenting to the Emergency Department (ED) to be discharged prior to receiving a MSE which could result in harm or death due to delay in treatment. According to facility provided information the ED sees an average of 870 patients per month.

Findings are:

A. Review of Patient 5's 9/7/21-9/8/21 ED medical record showed at 10:40 PM the ED Dr examined Patient 5. The ED Dr documented Patient 5 had "complaints of suicidal ideation and drinking alcohol for the last 2 days up to 2 gal (gallons) of vodka, comes in very intoxicated with nausea and vomiting. Patient states no plan as far as suicidal ideation." Further documentation showed Patient 5 had a history of Bipolar 1 disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), depression, and PTSD. Further documentation showed Patient 5 was intoxicated but can move extremities without any difficulty equal bilateral and suicidal ideation within severe intoxication.

Further documentation from the ED Dr documented IV fluids, oxygen, lab work, chest x-ray, EKG (electrocardiogram-tracing of heart), stabilized blood sugar and blood pressure and food was provided. Patient 5's blood alcohol came back at 0.170 (0.16-0.19% is very drunk-strong state of depression, nausea, disorientation, dizziness, increased motor impairment, blurred vision and judgement and perception severely impaired). "Patient initially indicated suicidal ideation but no plan. After Kearney Police Department assessed the patient for the possibility of an EPC recommendations were not indicated. Patient was discharged from the emergency room for self committal to the [Psychiatric Unit at Hospital B] on his own accord."

B. Review of EMS (Emergency Medical Service-Ambulance) documentation titled "Prehospital Care Report" on 9/7/21 at 9:59 PM shows Emergency Medical Technicians (EMT) - Paramedics were dispatched to a Patient 5's apartment. Further documentation showed that Patient 5 was lying on the floor with limited responsiveness. Patient 5 told the paramedics that he drank 2.5 L (liters) of vodka starting earlier in the day for "personal reasons" (En route Patient 5 stated that he was trying to harm himself by drinking to much). The paramedics documented the patient quickly stood up and walked to the stretcher and arrived at the hospital (Patient 5 requested to go to this hospital) at 10:30 PM and care was transferred to the emergency department (ED) nursing staff.

C. Review of Patient 5's 9/7/21-9/8/21 ED medical record showed the patient arrived by ambulance at 10:30 PM. At 10:32 PM the ED nurse documented that Patient 5 was intoxicated, he reported drinking 2.5 L of vodka in the last 2 days. Further documentation showed Patient 5 had a history of alcohol abuse, depression, and PTSD (post traumatic stress disorder). The depression screening identified the patient had "occasional passing suicidal thoughts." Further documentation from the ED nurse showed that Patient 5 was examined by the ED Dr at 10:40 PM and ordered intravenous (IV) fluids, lab, X-Rays and monitoring for Patient 5 until time of discharge on 9/8/21 at 3:30 AM.

The ED nurse further documented on 9/8/21 at 3:30 AM upon discharge "Pt discharged home per pedis (walking) in good condition. Pt states he wants to check himself in to the [Psychiatric Unit at Hospital B] tonight for evaluation and treatment. Pt given discharge instructions and verbalizes understanding. Cab voucher given to patient, states he plans to go directly to the [Psychiatric Unit at Hospital B]on his own accord."

D. In an interview on 12/8/21 at 3:58 PM, the ED nurse recalled on 9/7/21 Patient 5 came by EMS, intoxicated. We did labs, gave fluid and had the Kearney Police Department come and evaluate him for the need of an EPC (Emergency Protective Custody-a status which the patient is identified a threat to himself or others) due to his suicidal ideation. They recommended to him to seek treatment and he was cleared. He was discharged home but then the patient told me he wanted to go commit himself at the [Psychiatric Unit at Hospital B]. I remember we gave him a cab voucher, "he said he wanted to go to the [Psychiatric Unit at Hospital B]. He had no suicidal thoughts with me and he was cleared to go home on discharge. He was alert & oriented." When inquiring why [Psychiatric Unit at Hospital B] was not notified that Patient 5 would be presenting for assessment of his suicidal ideation, the ED nurse replied " I thought he was free to do what he wanted when he left due to he was discharged."

E. In an interview on 12/8/21 at 2:00 PM, ED Dr recalled on 9/7/21 Patient 5 came to the ED with intoxication and suicidal ideation but with no plan. He further recalled getting the patient medically stable, we gave him IV's, checked lab, and other things. His alcohol was less than 2 and he was medically stable. "I called the Kearney Police Department to see if he would be recommended for an EPC due to his suicidal ideation, they interviewed him and said he did not meet the criteria." "This gentlemen has made this an "event" every now and then (has had similar visits to this ED). We gave him a voucher for the cab for where ever he wanted to go because he was discharged." I remember him being very lucid. "I do not think he had a Psychiatric Emergency Medical Condition and he was medically stable."

The surveyor read the ED Dr the 9/8.21 3:30 AM note from the ED RN on discharge documented, "Pt discharged home per pedis (walking) in good condition. Pt states he wants to check himself in to the [Psychiatric Unit at Hospital B] tonight for evaluation and treatment. Pt given discharge instructions and verbalizes understanding. Cab voucher given to patient, states he plans to go directly to the [Psychiatric Unit at Hospital B] on his own accord." The ED Dr commented "I wish I and (the ED RN) would have communicated better about that."

F. In an interview on 12/8/21 at 2:30 PM with the ED Medical Director, clarification was asked about the use of the Kearney Police Department for evaluating the patients. The ED Medical Director indicated that, "yes we do frequently call the Police Department to see if the patient meets the criteria for an EPC. We probably do depend on their recommendations too heavily, we will be looking at that process."

G. Review of Patient 5's 9/8/21 [Psychiatric Unit at Hospital B] ED psychiatric intake showed he arrived on 9/8/21 at 3:54 AM . At 3:54 AM The Psychiatric ED nurse performed the "Psychiatric Immediate Care Clinic Evaluation"(a psychiatric tool to assess the current mental status of a patient and reports the findings to the Psychiatrist). The Psychiatric ED nurse documented that Patient 5 presented with the complaint that "I relapsed and am having suicidal thoughts." Further documentation showed that Patient 5 indicated he relapsed with alcohol approximately 4 days ago and the symptoms have been getting worse and now are severe. Patient 5 told the Psychiatric ED nurse that "he had the recent relapse and increased thoughts of suicide with a plan to hang himself." He has a history of depression, anxiety and substance abuse. Further documentation showed the suicide risk assessment was completed with "The Columbia Suicide Severity Rating Scale." The Columbia Suicide Severity Rating Scale identified the patient responded "yes to the questions; a current suicide ideation, plan, intent, and access to means; and has had previous suicidal ideation, plan, intent, and attempt; indicating the patient is at High Risk of suicide.

Further documentation from the Psychiatric RN showed that Patient 5 was tearful with poor eye contact, disheveled (unkept & messy appearing), anxious, depressed, and having racing thought process. "Patient 5 is wanting help. The (Psychiatrist) is called at 4:15 AM. (The Psychiatrist) accepts the patient into the Inpatient Unit for Mental Health Services."

H. In an interview on 12/9/21 at 2:45 PM, the Psychiatrist at [Psychiatric Unit at Hospital B] that performed the Psychiatric History and Physical on 9/8/21 at 10:57 AM, recalled that Patient 5 arrived to their facility in a cab from Kearney Regional Medical Center. "On arrival he stated he was suicidal, he did not have a plan, but could not contract for safety. Therefore he met the criteria for an inpatient admission. He was treated for PTSD, depression, bipolar, which he had previous diagnosis of, but said he had not been taking his medication." "I believe he had a Psychiatric Emergency Medical Condition related to his mental health upon arrival here on that night."