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Based on review of medical records, Emergency Medical Services, Prehospital Patient Care Report, Complete Version 3.5, policy and procedures, Medical Staff Rules and Regulations and interviews with staff, it was determined that the facility failed to ensure that an appropriate Medical Screening Examination (MSE) was provided within the capability of the hospital's emergency department to include available ancillary services (psychiatrist services) to determine whether or not an emergency medical condition existed, for one patient (P) (P#1) of 20 sampled patients. P#1 presented to the facility's ED on 10/30/24 at 9:48 p.m. via ambulance due to altered mental status (AMS) (a change in mental function or level of consciousness). P#1 was discharged to home on 10/31/24 at 3:52 a.m. P#1 was readmitted to the facility's ED on 11/2/24 at 4:39 p.m. on an involuntary hold from an outside facility.

Findings included:

Cross refer to A-2406 as it relates to the facility's failure to provide an appropriate medical screening exam within the capability of the hospital's emergency department.

Based on review of medical records, Emergency Medical Services, Prehospital Patient Care Report, Complete Version 3.5, policy and procedures, Medical Staff Rules and Regulations and interviews with staff, it was determined that the facility failed to ensure that an appropriate Medical Screening Examination (MSE) was provided within the capability of the hospital's emergency department to include available ancillary services (psychiatrist services) to determine whether or not an emergency medical condition existed, for one patient (P) (P#1) of 20 sampled patients. P#1 presented to the facility's ED on 10/30/24 at 9:48 p.m. via ambulance due to altered mental status (AMS) (a change in mental function or level of consciousness). P#1 was discharged to home on 10/31/24 at 3:52 a.m. P#1 was readmitted to the facility's ED on 11/2/24 at 4:39 p.m. on an involuntary hold from an outside facility.

Findings included:


The Emergency Service Report, Prehospital Patient Care Report Complete Version 3.5 for patient #1 dated 10/30/2024 was reviewed. The report revealed the Chief Complaint as "Altered Mental Status." Further review revealed in part, "Patient is a 28 Years old Male complaining of altered mental status for 10 minutes. Pt. found wondering around parking lot by PD (Police Department). Patient is not verbally responsive. Patient follows commands after multiple requests. Patient is minimally cooperative with vital signs and assessment prior to loading in ambulance ...Patient has a known history of delta 8(a psychoactive substance found in Cannabis sativa plant) use per PD. Patient going to Memorial ED (Emergency Department) for eval (Evaluation) ...Vitals were assessed as 10:30 2024 9:12 PM GCS (Glascow coma scale-tool used to assess level of consciousness)- 11 (drowsy or obtunded) ... Alert ...Pulse 125 (normal heart rate 60-100) ...10/30/2024 9:18 PM ...Alert ...Pulse: 131 ...BP (Blood Pressure -normal 120/80) ...Medications administered:.. Normal Saline Dose: Keep vein open ...IV (intravenous) site: (L) Left Hand ...Other Symptoms: Excessive sweating ...Behavior, strange and inexplicable ...Report called into ED ...Disposition: Patient Treated and Transported."


A review of P#1's medical record revealed that P#1 presented to the facility's ED on 10/30/24 at 9:48 p.m. via ambulance due to altered mental status (AMS) (a change in mental function or level of consciousness), (Pt (patient) ...after Police called EMS for AMS/Anxiety. Hx (History) substance abuse. Pt. following commands but nonverbal in triage. BGL (Blood glucose level) 215 (normal 60-100). Pt. Tachycardiac (fast heart rate) on arrival). Continued review of P#1's medical record revealed that P#1 was triaged on 10/30/24 at 9:50 p.m. and assigned an acuity level of two (Emergent). The patient's ED triage vital signs at 9:52 PM were listed as BP 179/107, Heart rater of 120 beats per minute.

P#1 was ordered a chest x-ray, computed tomography (CT) (imaging to create detailed pictures) scan of the head, and electrocardiogram (a test that measure the electrical activity of the heart), laboratory blood work, urine analysis, and a urine drug screen panel. A review of an "ED Provider Note" dated 10/30/24 at 10:17 p.m. (Physical Examination) by ED Medical Doctor (MD) BB revealed that P#1: Cardiovascular: Tachycardiac; Neurological: Mental Status: He is alert; Comments: Patient was, not talking but looks around and moves all extremities; Psychiatric: with a mood and affect as normal. Further review revealed, "Medical Decision Making: This patient presents with altered mental status. Differential diagnosis includes electrolyte abnormality, accidental drug overdose, stroke, intracerebral hemorrhage, urinary tract infection encephalopathy, pneumonia, or other infection. The patient will be monitored closely throughout the emergency department stay. Their disposition will depend on their work-up results and frequent re-evaluations ... Course. Pt. much improved ...ED consult: none. ED Reevaluation: None. Clinical Impression: Diagnoses: Altered mental status, unspecified altered mental status type Tetrahydrocannabinol (THC) use disorder, mild abuse ...Disposition: Discharge Stable" There was no documentation in the MR by the ED provider to indicate the patient started speaking, and there was no reassessment of the patient's mentation. The MSE was not appropriate as evidenced by failing to ensure a psychiatric evaluation (ancillary services) was provided that was within the capability of the hospital's ED to determine whether or not an emergency medical condition existed. The medical record dated November 2, 2024, revealed that Patient #1 returned to the hospital's ED for a "Psychiatric Evaluation" Further review of the medical record revealed the patient's Mom called for psychiatric care because the patient has been roaming around different cities and states due to paranoia.

P#1 tested positive for urine tetrahydro cannabinoid (THC-chemical compound, responsible for altered state of perception). Continued review of P#1's medical record revealed that on 10/31/24 at 12:29 a.m., Registered Nurse (RN) AA conducted a suicide risk screening and noted that P#1 had no risk identified. On 10/31/24 at 12:29 a.m., RN AA noted that P#1 was alert and oriented to person, place, time, and situation and was ambulatory.

Continued review of P#1's medical record revealed that on 10/31/24 at 3:10 a.m. had a heart rate of 98 beats per minute, respirations of 16 breaths per minute (normal was 12 to 20), blood pressure of 154/91, and oxygen saturation of 99% on room air P#1 was discharged on 10/31/24 at 3:52 a.m. to home, ambulatory, with discharge instructions. The patient was discharged to self-care there was no documentation in the medical record to indicate that any family member was contacted.

A review of the facility's "Rules and Regulations ", last revised 3/25/22, revealed, 1.1, 6, Medical Screening Examination:
a. Any individual who comes to the Medical Center Emergency Department requesting examination or treatment shall be provided with an appropriate medical screening examination (MSE). The purpose of the MSE is to determine if the individual is experiencing an emergency condition.

A review of the facility's policy titled, "EMTALA - Medical Screening Examination and Stabilization ", policy #11175306, last revised 05/2022, revealed that the purpose of the policy was to establish guidelines for providing appropriate medical screening examinations (MSE) and any necessary stabilizing treatment or an appropriate transfer of the individual.
Continued review revealed, Procedure:
1. When an MSE is required, a hospital must provide an appropriate MSE within the capability of the hospital ' s emergency department, including ancillary services routinely available to the ED, to determine whether an EMC exists. An MSE is required when:
a. The individual comes to an ED of a hospital and a request is made by the individual or on the individual ' s behalf for examination or treatment for a medical condition, including where:
i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition.

A review of the facility's policy titled, "Discharge Planning: Role of Healthcare Team ", policy #16508093, last revised 12/2023, revealed that the purpose of the policy was to provide a systematic process of collaboration among the healthcare team and patient/family in planning for the patient ' s discharge.
Continued review revealed, Procedure:
A. Assess and identify high risk discharge indicators
1. Admitting Patient Care Nurse will assess and identify high risk discharge indicators upon admission and make a referral to the appropriate discipline.

During a telephone interview on 11/14/24 at 8:01 a.m., Medical Doctor (MD) BB. MD BB recalled that P#1 presented with a complaint of altered mental status (AMS). MD BB said that for patients who present with this complaint, he would order a urine drug screen, blood work, and any pertinent imaging to help determine the cause of the alteration. MD BB recalled that P#1 tested positive for cannabis and in his experience, this sometimes causes patients to be momentarily altered. MD BB recalled that the plan was to observe P#1 for a while and then determine the best course of action for P#1. MD BB recalled that P#1 was always alert just refused to verbally communicate. MD BB recalled that after some time P#1 did speak and was alert and oriented. MD BB said that if patients do not pose an immediate threat to themselves or others and are medically cleared, then the plan is to monitor them and then discharge them as appropriate. MD BB said that nursing staff help with providing resources to patients who are discharging from the ED and require it. MD BB said that this can range from shelters to obtaining rides.
MD BB recalled that P#1 did not present as a psychiatric patient when MD BB provided care for him on 10/30/24. MD BB recalled that P#1 presented as a more drug-related AMS patient and after P#1 began to speak and demonstrated being oriented then MD BB felt comfortable in discharging him.

During a telephone interview on 11/13/24 at 3:41 p.m., Medical Director MM said that she has been the Medical Director of the emergency department (ED) for almost nine months. Medical Director MM said that the biggest decision point to see if a patient is stabilized and ready for discharge from the ED is when the physician is deciding on whether the patient must be on a 1013 hold or not. Medical Director MM said that for many psychiatric patients, if there is not a medical concern but more of a psychiatric concern, then the physician must determine whether that patient requires further treatment, inpatient versus outpatient. Medical Director MM said that if a patient can be safely discharged from a medical standpoint and is alert, oriented, with a reasonable mood and affect then physicians may discharge these individuals and provide them with follow up resources as appropriate. Medical Director MM said that if the patient requires further examination and treatment or would benefit from seeing a psychiatrist then these patients should be placed on a 1013 hold for further examination and placement.