HospitalInspections.org

Based on review of policies and procedures and staff interview, it was determined the hospital failed to:
(1) Comply with EMTALA regulations by not requiring formal In-service training to all intake staff.
(2) Define who a Qualified Medical Professional (QMP) is in facility Medical ByLaws and facility policy.
(3) Establish policy and procedures for EMTALA requirements.
These deficient practices could result in patient harm from staff not being adequately trained on emergency medical conditions and medical screening examinations, services being provided by unqualified personnel, and staff not being aware or trained on facility procedures regarding a patient having a medical emergency the hospital is not equipped to handle.

Findings Include:

(1) Failure to comply with EMTALA regulations by not requiring formal In-service training to all intake staff:

Hospital policy titled "Employee Orientation, Staff Development and Training" policy #HR-160 last revised 10/02/2023 did not address EMTALA training specifically in section "A. Orientation of Staff" or in section "B. Staff Development and Training".

Employee #1 provided a document titled "EMTALA Staff Training" and that it was reviewed with and signed by all staff.

Employee #16 ' s personnel record revealed no facility document titled "EMTALA Staff Training".

Employee #17 ' s personnel record revealed no facility document titled "EMTALA Staff Training".

Employee #18 ' s personnel record revealed no facility document titled "EMTALA Staff Training".

Employee #19 ' s personnel record revealed no facility document titled "EMTALA Staff Training".

Employee #20 ' s personnel record revealed no facility document titled "EMTALA Staff Training".

A request was made for Employees #16, 17, 18, 19 and 20 "EMTALA Staff Training" documentation and none was provided at the time of survey.

Employee #1 confirmed in an interview on June 12, 2025 that Employees #16, 17, 18, 19 and 20 did not have the "EMTALA Staff Training" present in their personnel records for review.

(2) Failure to define who a Qualified Medical Professional (QMP) is in facility Medical Bylaws and facility policy:

Hospital document titled "Bylaws Of The Medical Staff Of ChangePoint Psychiatric Hospital" did not define who a QMP is.

A request was made for facility policy and procedure regarding QMPs. None was provided at the time of survey.

Employee #2 confirmed in an interview on June 10, 2025 that a facility policy regarding QMPs was not available.

(3) Failure to establish policy and procedures for EMTALA requirements.

Hospital policy titled "Admission To Hospital" policy #CC-104 last reviewed 06/02/2025, revealed "...III. PROCEDURE: ...C. Emergency Medical Treatment and Labor Act (42 USC 1395dd)-EMTALA While EMTALA traditionally addresses the transfer of members for Emergency medical care between participating hospitals, there are some interpretative guidelines that also reference participating hospitals with "specialized capabilities"...To this end, ChangePoint Psychiatric Hospital considers EMTALA when the following provisions are met:...1. The member has not been admitted to the sending hospital;...2. The member is medically stable;...3. The member is psychiatrically unstable (currently defined as suicidal, homicidal, psychotic beyond baseline, or clinically indicated psychiatric care;...4. The sending hospital is unable to provide stabilizing psychiatric care ...5.The admitting Medical Officer at the Hospital agrees that the member meets Admission Criteria as established by the Program Description;...6. The Hospital has the resources and capacity to meet the needs of the member including physical environment, equipment, appropriate staff on-site or available;...7. The referring physician has documented that the medical risks of transfer are outweighed by the medical benefits of the transfer;...8. The member/guardian has agreed to the transfer after reviewing the risks and benefits of the proposed transfer and is willing to provide Informed Consent for Treatment at ChangePoint Psychiatric Hospital;...."

A request was made for an EMTALA policy regarding patients experiencing a medical emergency, initial treatment within the hospital ' s capabilities and capacity and the making of an appropriate referral to another hospital that is capable of providing necessary emergency services. None was provided at the time of survey.

Employee #1 and #2 both confirmed in interviews on June 9, 2025 through June 12, 2025 that the above policy provided was the only EMTALA policy for review at the time of survey.

Based on review of policies and procedures, medical records and staff interview, it was determined the hospital failed to ensure a medical screening exam (MSE) was completed for patients coming to the facility to determine whether or not an emergency medical condition exists. This deficient practice poses a potential risk to the health and safety of patients if life-threatening conditions are not recognized in a timely manner thus possibly delaying stabilizing treatment.

Findings include:

Hospital policy titled "Admission Process" policy #CC-104, last revised 04/04/2022 revealed "...III. PROCEDURE:...B. Crisis Assessment ...1. The clinician/staff member assessing the member in crisis completes a crisis assessment to determine if the member meets basic requirements for admission to a Psychiatric Specialty Hospital...."

A total of 20 Hospital medical records were randomly selected for review, ten (10) out of 20 patient medical records contained either incomplete or missing medical screening exams.

Patient #1 ' s medical record revealed the following:

Hospital document titled "30 Minute CSU Nursing Physician Examination" dated 3/28/2025 revealed it was incomplete. The time of which the assessment was completed was missing.

Patient #3 ' s medical record revealed the following:

Hospital document titled "30 Minute CSU Nursing Physician Examination" dated 5/1/2025 at 14:55 revealed it was incomplete. The vital signs section was left blank.

Patient #5 ' s medical record revealed the following:

Hospital document titled "30 Minute CSU Nursing Physician Examination" dated 5/14/2025 revealed it was incomplete. The vital signs were not completely filled out and the time of which the assessment was completed was missing.

Patient #13 ' s medical record revealed the following:

No hospital document titled "30 Minute CSU Nursing Physician Examination" was in Patient #13 ' s medical record.

Patient #14 ' s medical record revealed the following:

Hospital document titled "30 Minute CSU Nursing Physician Examination" dated 4/23/2025 revealed it was incomplete. The time of which the assessment was completed was missing.

Patient #16 ' s medical record revealed the following:

Hospital document titled "30 Minute CSU Nursing Physician Examination" dated 5/13/2025 at 06:10 revealed it was incomplete. The vital signs section was left blank.

Patient #17 ' s medical record revealed the following:

Hospital document titled "30 Minute CSU Nursing Physician Examination" dated 6/9/2025 revealed it was incomplete. The time of which the assessment was completed was missing.

Patient #18 ' s medical record revealed the following:

Hospital document titled "30 Minute CSU Nursing Physician Examination" dated 5/24/2025 at 09:32 revealed it was incomplete. The vital signs were not completely filled out.

Patient #19 ' s medical record revealed the following:

No hospital document titled "30 Minute CSU Nursing Physician Examination" was in Patient #19 ' s medical record.

Patient #20 ' s medical record revealed the following:

No hospital document titled "30 Minute CSU Nursing Physician Examination" was in Patient #20 ' s medical record.

Employee #2 confirmed during an interview on June 9, 2025 through June 10, 2025 that Patient #1, 3, 5, 14, 16, 17 and 18 had incomplete MSEs while Patients #13, 19 and 20 were missing an MSE all together.

Based on policies and procedures, medical records, and staff interviews, it was determined the Hospital delayed examination and treatment for Patients #1, 5, 14 and 17 who presented to the facility seeking medical and/or psychiatric treatment. Failure to provide timely medical examination and treatment poses a potential risk that a patient is denied necessary medical treatment.

Findings include:
Hospital policy titled "Admission Process" policy #CC-104, last revised 04/04/2022 revealed "...III. PROCEDURE:...B. Crisis Assessment ...1. The clinician/staff member assessing the member in crisis completes a crisis assessment to determine if the member meets basic requirements for admission to a Psychiatric Specialty Hospital...."
Patient #1 ' s medical record revealed the following:

Hospital document titled "30 Minute CSU Nursing Physician Examination" dated 3/28/2025 revealed the time of which the assessment was completed was missing.

Hospital document titled "Referral/Intake Log" revealed Patient #1 arrived at the hospital on 3/28/2025 at 19:15.

Patient #5 ' s medical record revealed the following:

Hospital document titled "30 Minute CSU Nursing Physician Examination" dated 5/14/2025 revealed the time of which the assessment was completed was missing.

Hospital document titled "Referral/Intake Log" revealed Patient #5 arrived at the hospital on 5/14/2025 at 17:55.

Patient #14 ' s medical record revealed the following:

Hospital document titled "30 Minute CSU Nursing Physician Examination" dated 4/23/2025 revealed the time of which the assessment was completed was missing.

Hospital document titled "Referral/Intake Log" revealed Patient #14 arrived at the hospital on 4/23/2025 at 19:00.

Patient #17 ' s medical record revealed the following:

Hospital document titled "30 Minute CSU Nursing Physician Examination" dated 6/9/2025 revealed the time of which the assessment was completed was missing.

Hospital document titled "Referral/Intake Log" revealed Patient #17 arrived at the hospital on 6/09/2025 at 11:10.

Employee #1 confirmed during an interview on June 9, 2025 that hospital document titled "30 Minute CSU Nursing Physician Examination" is the hospital ' s medical screening exam that is completed, dated, timed and signed within 30 minutes of patient arrival to the hospital by a registered nurse.

Based on policies and procedures, medical records and staff interview, it was determined the hospital failed to ensure patient transfers occurred pursuant to hospital policy. This deficient practice poses the potential risk that patients will receive inappropriate transfers and health needs will not be met as a result.

Findings include:

Hospital policy titled "Discharge/Refer/Transfer" policy #CC-117, last reviewed 10/07/2024 revealed "...e. Prior to transport medical staff (RN or Medical Officer) explains risk and benefit of a transport to the member or their representative based on their medical condition and chosen mode of transport ...g) Documentation in the member ' s record includes:...i) Consent for transfer by member or their representative, except in emergency ...ii) Acceptance of member by, and communication with, an individual at the receiving health care institution ...iii) Date and time of transfer to the receiving health care institution ...iv) Mode of transportation ...v) Type of professional assisting in the transfer if an order requires that a member be assisted during transfer ...."

A total of 20 Hospital medical records were randomly selected for review including patients who were transferred to another facility due to hospital lack of capability to treat a patient's emergency medical condition. Four (4) of four (4) transfers reviewed contained incomplete transfer documentation.

Review of Patient #2 ' s medical record revealed incomplete transfer documentation. Provider transferred Patient #2 to Summit Healthcare Emergency Room via EMS on May 8, 2025 at 16:30pm due to "severe hypoxemia". Patient consented to transfer. Documentation of communication with an individual at the receiving hospital was missing.

Review of Patient #7 ' s medical record revealed incomplete transfer documentation. Provider transferred Patient #7 to Summit Healthcare Emergency Room via EMS on April 13, 2025 at 13:48pm due to "alcohol withdrawal and intoxication". Patient consented to transfer. Documentation of communication with an individual at the receiving hospital was missing.

Review of Patient #8 ' s medical record revealed incomplete transfer documentation. Provider transferred Patient #8 to Summit Healthcare Emergency Room on May 19, 2025 for "medical clearance for her and baby". Documentation was missing time of transfer, mode of transfer, if the patient consented to transfer and communication with an individual at the receiving hospital.

Review of Patient #11 ' s medical record revealed incomplete transfer documentation. Provider transferred Patient #11 to Summit Healthcare Emergency Room via non-emergency EMS on May 31, 2025 at 14:30pm for medical clearance due to "acute alcohol intoxication". Patient consented to transfer. Documentation of communication with an individual at the receiving hospital was missing.

Employee #2 confirmed during an interview on June 9, 2025 through June 10, 2025 that all transfer documentation was incomplete for Patients #2, 7, 8 and 11.