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Based on document review and interviews, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to provide an appropriate medical screening examination to determine if an emergency medical condition existed, as required. (A-2406)

The immediate jeopardy (IJ) was identified on 10/9/2024, due to the hospital's failure to ensure patients presenting to the hospital's emergency department received a medical screening exam to determine if an emergency medical condition existed. The IJ was announced on 10/9/2024 at 5:00 PM during a meeting with the Chief Executive Officer, Chief Nursing Officer, and Vice President of Clinical Operations. The IJ was not removed by the survey exit date of 10/9/2024.

Based on document review and interview, it was determined that for 7 of 20 clinical records (Pt. #1, Pt. #2, Pt. #6, Pt. #7, Pt, #14, Pt, #18, and Pt. #19) reviewed for patients seeking emergency medical services, the Hospital failed to conduct an appropriate medical screening examination, including a complete triage assessment and an examination by a licensed medical practitioner or physician in consultation with the psychiatrist, to determine whether or not an emergency medical condition existed, as required.

Findings include:

1. The Hospital's Medical Staff Bylaws (dated 11/14/2018), were reviewed, and included the definition of a Qualified Medical Personnel (QMP), "Qualified Medical Personnel means a licensed registered, advanced practice nurse (APN) or licensed physician whose scope of responsibilities are approved by the hospitals governing board. In respect to a psychiatric assessment/evaluation, Licensed Clinical Social Workers ("LCSW"), Licensed Marriage and Family Therapists ("LMFT"), and Licensed Mental Clinicians ("LMHC"), Master's prepared individual in a Human Services Field/Psychology or Bachelor's prepared individual in Human Services Field in consultation with a Masters prepared staff are also identified as QMP... Persons q ualified to perform medical screening in consultation with the psychiatrist include physicians, RN [Registered Nurse]Practitioner, Physician Assistants, Nursing Supervisors, and RNs, excluding medical emergencies in which the physician is notified ASAP..."

2. The hospital's policy titled, "Triage System" (dated 12/2023), was reviewed and required, "Persons presenting with either a stated or observed emergency will be triaged according to the determined level of emergency situation ...The clinician determines the priority, psychiatrically. The RN assesses the medical priority and acts accordingly: Priority 1-Life threatening medical emergency ...Initiate medical emergency procedures and notify a physician on site, if no one is present, the on-call physician. Initiate transfer to a licensed medical facility capable of treating the specific emergency. Following are some examples of Priority 1 situations: ... Actively suicidal ... homicidal ...Acutely psychotic ... Priority 2- Requires the notification of an on-site or on-call physician. i. Examples of Priority 2 situations include: ... 3. Mild withdrawal symptoms ..."

3. The hospital's policy titled, "Standby Emergency Medical Screening" (revised 12/2023) was reviewed and required, " ... 2. The Nursing Supervisor will conduct an emergency medical and mental health screening ...4. The Nursing Supervisor will contact the physician on-call regarding the initial screening and confer with the on-call physician regarding the patient's disposition ...5. If warranted based on the medical and mental health screening, a 911 call will be placed to transport to a local hospital emergency department ... Emergency Requirements: Provide an appropriate medical screening examination within the capability of the hospital ... to determine if a medical condition exists.. The examination must be conducted by an individual(s) who is determined qualified by the hospital bylaws or rules and regulations and how meets the requirements ..."

4. Pt #1 presented to the Intake/A & R (Assessment & Referral) department, as a walk-in (with parents), on 5/29/2024 at 7:28 PM. Pt #1 was not admitted to or transferred from the Hospital. Pt #1 left the hospital at 8:15 PM.
-A Consent to Assessment was signed and dated by Pt #1's parents, on 5/29/2024 at 7:00 PM. The form included, "Assessments are completed by licensed clinicians or a master's level clinician under the supervision of a licensed person. The clinician will consult with a physician and determine the most appropriate level of care for you. This could include inpatient, partial hospitalization, intensive outpatient, or referrals to other qualified providers. If it is determined that [Hospital] is unable to meet your needs, you will be provided referrals and resources to alternative treatment providers."

-The Triage Form-Assessment Needs (dated 5/29/2024) was completed by Pt #1's parents. However, the section on the form (includes vital signs and triage priority), that is required to be completed by the A & R staff, was not completed. The triage assessment lacked documentation of Pt #1's vital signs.

-Pt #1's Intake Assessment (dated 5/29/2024 at 7:40 PM), documented by the Intake Specialist (E #4 - Licensed Social Worker), included, " ...Presenting Problem: Pt is a 12 y/o [year old] ...presenting as a walk-in. Pt is autistic and [Pt #1's] trigger for meltdown is when [Pt #1's] electronic device is taken. [Pt #1's] electronic device was taken by [Pt #1's] teacher and [Pt #1] grabbed them by the neck, threatening to kill them and hit on the head with closed fist. [Pt #1] report social withdrawal and hopelessness sometimes ... [Pt #1] was recommended inpatient; however, parents refused to consent and took pt home against medical advice ...Level of Determination: Acute Inpatient Psychiatric ... [box checked] Symptoms/behaviors indicative of need of 24hr observation and assessment of the patient's condition (circle all that apply): Homicidal Ideations ..." The Intake Assessment form includes a section that would indicate if a physician was consulted. Pt #1's form had a psychiatrist's name (MD #2), documented as "consulted". However, there was no time documented when MD #2 was consulted or documentation that the information in the intake assessment was reviewed by MD #2 or that MD #2 determined the appropriate level of care needed for Pt #1.
Pt #1's clinical record did not include any documentation from a psychiatrist or medical physician indicating discussion with parents regarding leaving against medical advice. The clinical record lacked documentation of a medical screening examination by a physician or mid-level provider. The Intake Director (E #16) confirmed these findings.

The A &R Intake log (dated 5/29/2024) indicated Pt #1's disposition as "Info-only". The documented time of departure on the log was at 8:15 PM (47 minutes after arrival time). The log included a note by E #4 which included, "Pt was assessed and recommended inpatient due to threats to kill [Pt #1's] teacher. Pt mother and father refused treatment to be MOT [medical observation transfer] to [contracted transfer acute care hospital], DCFS will be called to report ..."

Pt #1 was not evaluated by a physician or in consultation with the psychiatrist.

5. Pt #2's record was reviewed and indicated that Pt #2 presented to the Intake/A & R department, as a walk-in (with parents), on 3/7/2024 at 9:16 AM. Pt #2 was not admitted and left from the A & R department at 10:00 AM. Pt #2 was referred to an outpatient psychiatric program.

-The Triage Form-Assessment Needs (dated 3/7/2024) was completed by Pt #2's parents. However, the section on the form (includes vital signs and triage priority), that is required to be completed by the A & R staff, was not completed. The triage assessment lacked documentation of Pt #2's vital signs.

-Pt #2's Intake Assessment (dated 3/7/2024 at 9:16 AM) completed by A & R Clinician (E #31 - Licensed Social Worker), included, "Summary of Clinical Information: Pt is a 12 y.o [year old] turning 13 next week presenting as a walk-in with severe anxiety, school refusal and depression..[Pt #2] states that [Pt #2] is sad and overwhelmed ...[Pt #2] denies SI/HI [suicidal/homicidal ideation]. [Pt #2] referred to PHP/IOP [outpatient psychiatric program]."

Pt #2 was not evaluated by a physician or in consultation with the psychiatrist.

6. Pt #6's record was reviewed and indicated that Pt #6 presented to the Intake/A & R department, as a walk-in (with parents), on 5/14/2024 at 2:42 PM. Pt #6 was not admitted and left the Hospital at 3:15 PM. Pt #6 was referred to an outpatient psychiatric program.

-Pt #6's Triage Form-Assessment Needs (dated 5/14/2024) was initiated by A & R staff. However, the form lacked a signature of whom completed the assessment.

-Pt #6's Intake Assessment (dated 5/14/2024 at 2:42 PM) completed by E #1 (Chief Nursing Officer) and E #16 (LCPC - licensed clinical professional counselor), included, "Summary of Clinical Information: [Pt #6] meets criteria for outpatient services. [Pt #6] is given referrals. [Pt #6] is not presenting with criteria for inpatient admission. [Pt #6] could benefit from learning coping skills...Provisional Discharge Plan: Follow up with psychiatry, therapy."

Pt #6 was not evaluated by a physician or in consultation with the psychiatrist.

7. Pt. #7's record was reviewed and indicated that Pt #7 presented to the hospital's Intake/A&R Department as a walk-in on 10/06/24 at 8:51 PM. The clinical record included the following:

-Triage Form-Assessment Needs form completed by E #32 (licensed social worker) , dated 10/06/24, the section titled, "A&R Staff to Complete" including vital signs and Chief Complaint of Depression, was completed by a Licensed Social Worker. The patient was discharged to home and referred to outpatient services.

Pt #7 was not evaluated by a physician or in consultation with the psychiatrist.

8. Pt. #14's record was reviewed and indicated that Pt #14 presented to the hospital's Intake/A&R Department as a walk-in on 08/06/24 at 6:36 PM. The clinical record did not include the Triage Form-Assessment Needs, however, the clinical record contained the following:

-Transfer Form (hospital to hospital only) dated 08/07/24 at 8:13 PM (completed by a clinician- masters in psychology, unlicensed/E #30) " ... (name of Pt. #14) Clinical Information/Presenting Problem: Needs medical clearance; Preliminary Psych Diagnosis: Psychosis ... Reasons for Transfer: Medical Emergency/evaluation needed: low heart rate at 42 on initial assessment. Excessive psych history ... history of ending up in ICU (intensive care unit) 2 years ago for severe detox symptoms. Blood Pressure-126/64 (normal range 90/60 - 140/90); Pulse 42 (normal range 60-80) ... Does the patient have an emergency medical condition: [yes box checked] ... Patient Consent to Transfer ..."

Pt #14 was not evaluated by a physician prior to transfer to hospital where they have a transfer agreement.

9. Pt. #18's record was reviewed and indicated that Pt #18 presented to the hospital's Intake/A&R Department as a walk-in on 10/02/24 at 7:18 PM. The clinical record included the following:

-A Consent to Assessment, dated 10/02/24 at 7:18 PM, signed by (Pt. #18) and legal guardian.

-Triage Form-Assessment Needs, completed by Pt #18's parent indicated that (Pt. #18) has a history of depression, anxiety, and bipolar disorder, with previous hospitalization 05/2022. However, the section on the form (that includes vital signs and triage priority), that is required to be completed by the A & R staff, was blank/not completed. The triage assessment lacked documentation from a Registered Nurse, Nursing Supervisor, or Mental Health technician that would assess Pt #1's vital signs and chief complaint. The clinical record did not include documentation indicating that a clinician or nurse had further discussions with (Pt. #18) or a disposition.

-The A&R Intake log indicated disposition as "Info only ... left and will come back tomorrow. (Pt. #18) denies SI (suicidal ideation) and psychosis."

Pt #18 had no assessment completed on presentation and was not evaluated by a physician or in consultation with the psychiatrist.

10. Pt. #19's record was reviewed and indicated that Pt #19 presented to the hospital's Intake/A&R Department on 10/01/24 at 2:06 PM. The clinical record included the following:

-A Consent to Assessment, dated 10/01/24 at 2:06 PM, signed by (Pt. #19).

-Triage Form-Assessment Needs, completed by Pt. #19, indicated that Drug use (heroin) in last 24 hours ... Medical history: Seizure with Detox ... Withdrawal symptoms from substance abuse ... started 09/30/24 ... nausea, sweating, shaky ... Section to be completed by A&R Staff was completed by Chief Nursing Officer (E#1) and included only vital signs at 2:57 PM and Clinical Opiate Withdrawal Scale (COWS) total score 13 (13-24 indicates moderate withdrawal)."

-Assessment and Referral Progress Notes by clinician (E #33 - Social Worker intern), dated 10/03/24 (2 days later), included, "(Pt. #19) was a walk-in on 10/01/24, seeking detox for heroin ... (E #1) performed a COWS ASSESSMENT ... met criteria for admission. (Pt. #19) decided only wanted to be admitted ... if given methadone ... was given the name of an addiction counselor and left ..." The clinical lacked documentation that a physician was notified of (Pt. #19) meeting criteria due to active moderate withdrawal and refusal for admission.

Pt #19 was not evaluated by a physician or in consultation with the psychiatrist.

11. On 10/2/2024 at 10:45 AM and on 10/8/2024 at 1:05 PM, interviews were conducted with the Chief Medical Officer/Psychiatrist (MD #1). MD #1 stated that MD #1 is consulted by the A &R staff for "sticky cases", if the staff is unsure of dispositions and if they are handling the patient appropriately according to the Mental Health Code. MD #1 stated that for patients that present to the hospital, the nursing supervisor would be the person to perform the initial medical evaluation. MD #1 stated that if there are questions or medical concerns, the staff can contact the medical physician or APN on-call for advice. MD #1 stated that the hospital has a 24-hour on call schedule. MD #1 stated that MD #1 is not sure how staff, including physicians receive training on EMTALA (Emergency Medical Treatment and Labor Act).

12. On 10/3/2024 at 9:05 AM, a phone interview was conducted with the A & R Intake Specialist/Social Worker (E #4). E #4 stated that E #4 was the Intake Specialist when Pt #1 presented to the A &R department. E #4 stated that Pt #1 was with Pt #1's (parent) when Pt #1 presented. E #4 stated that Pt #1's (parent) stated that Pt #1 choked Pt #1's teacher at school and stated that Pt #1 would kill the teacher. E #4 stated that since this is considered homicidal ideation, then E #4 wanted Pt #1 admitted as inpatient. E #4 stated that Pt #1 was not transferred to another hospital, and Pt #1 left with the (parent). E #4 stated that Pt #1 was not seen by a doctor, and that the "medical advice" was given by E #4. E #4 stated that Pt #1 was not assessed by a RN.

13. An interview was conducted with an Advanced Nurse Practitioner (APN/E #28) on 10/08/24 at 12:41 PM. E #28 stated that when patients walk-in to the intake department for an assessment, the patients are not evaluated by the APN. The patients are assessed by the clinicians in the intake department, if the patient has medical concern the Nurse Supervisor will call the on-call practitioner for advice to determine if the the patient should be transferred to the emergency department at different hospital. E #28 was not aware of the EMTALA policy and was not sure if E #28 received training about EMTALA.

14. An interview was conducted with the Clinician (E #29 - Counselor) on 10/08/24 at 12:45 PM. E #29 stated that E #29 is a Clinician in the intake department and conducts assessments for patients that are transferred from other hospitals or walk-in for an evaluation. The psychological assessments are conducted by E #29 or other clinicians, the medical part of the assessment and vital signs are conducted by a nurse or the nurse supervisor. E #29 was asked about E #29's knowledge of the EMTALA requirements. E #29 stated that EMTALA requires that staff consult with the nurse supervisor and the physician on call if a patient requires to be transferred.

15. On 10/9/2024 at 10:03 AM, an interview was conducted with a Psychiatrist (MD #2). MD #2 stated that all patients that present to this Hospital should be assessed due to EMTALA. MD #2 stated that if MD #2 is on-call, then MD #2 would be called by a nursing supervisor with a brief history. MD #2 stated that if MD #2 agrees with the nurse assessment, then the patient would be admitted and sent to the unit. MD #2 stated that if a pediatric patient (under 13) presents and is suicidal or homicidal, then the patient would have to be sent to another hospital via ambulance (for safety reasons). MD #2 stated that if the patient's parents refuse transfer, then the CMO (MD #1) should be notified as this could get complicated. MD #2 stated that MD #2 was not called or made aware of the case involving Pt #1 (although MD #2's name is documented). MD #2 stated that (after reviewing Pt #1's clinical record), Pt #1's school must have wanted the patient to come here to the hospital. MD #2 stated that this situation could have been potentially dangerous, if the patient was not sent out to an appropriate facility.