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Based on review of Medical Staff Bylaws and Rules and Regulations, hospital EMTALA (Emergency Medical Treatment and Labor Act) policy and other policies and procedure, medical records, adult psychiatric unit staffing and bed census, and interview, it was determined Gadsden Regional Medical Center failed to:

1. Identify and approve individual(s) qualified to perform the medical screening examination (MSE) in the hospital medical staff bylaws or rules and regulations. This had the potential to affect all patients presenting to the emergency department (ED).

2. Provide an MSE appropriate to a patient's presenting signs and symptoms. This deficient practice affected Patient Identifier (PI) # 1 and had the potential to affect all psychiatric patients presenting to this hospital.

3. Provide stabilizing treatment within their capability and capacity for a patient with a psychiatric emergency medical condition. This deficient practice affected PI # 1 and had the potential to affect all psychiatric patients presenting to this hospital.

4. Provide an appropriate transfer that included signed certification by the physician that the medical benefits of treatment at another facility outweighed the risks of being transferred. This deficient practice affected PI # 3 and had the potential to affect all patients transferring from this hospital.

Refer to A2406, A2407 and A2409 for findings.

Based on review of the hospital's Rules and Regulations of the Medical Staff, Medical Staff Bylaws, medical record (MR) review, hospital policy and interview, it was determined the hospital failed to:

a. Identify the Qualified Medical Personnel (QMP) determined qualified to provide an appropriate Medical Screening Exam (MSE) in their Rules and Regulations of the Medical Staff and/or Medical Staff Bylaws.

b. Provide an MSE appropriate to a patient's presenting signs and symptoms.

This deficient practice affected Patient Identifier (PI) # 1 and had the potential to affect all patients presenting to the facility's Emergency Department (ED).

Findings include:

Hospital Policy: Emergency Medical Treatment and Labor Act (EMTALA)
Policy Version: Six
Revision Date: 7/14/2022

Definitions:

For the purpose of this EMTALA policy, the following terms are defined as follows:

MSE is the process...at which it can be determined whether or not an emergency medical condition (EMC) exists...Such screening must be performed by QMP (defined below)...

QMP refers to those individuals defined in the hospital's medical staff Bylaws or Rules and Regulations, and approved by the governing board to perform the initial MSE...

...II. Medical Screening Examination:

...B. Medical Screening

When an individual comes to the ED requesting medical treatment, an appropriate MSE, within the capabilities of the ED (including ancillary services routinely available to the ED), shall be provided to determine whether an EMC exists...

The MSE includes both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of an EMC...

MSE shall be performed by QMP, who may be an Emergency Department (ED) physician, or other licensed practitioner appointed and approved by the Hospital's Medical Staff and Board of Trustees...

1. A review of the hospital's Rules and Regulations of the Medical Staff, and Medical Staff Bylaws conducted on 11/13/24, revealed the individuals qualified to conduct the MSE were not identified.

An interview was conducted on 11/15/24 at 12:15 PM with Employee Identifier # 2, Chief Quality Officer, who confirmed the QMP approved to perform the MSE's in the ED were not identified in the hospital's Rules and Regulations of the Medical Staff nor the Medical Staff Bylaws.

2. PI # 1 presented to the facility ED via private vehicle from a group home for intellectually disabled on 10/29/24 at 3:48 PM for a psychiatric screening exam with a chief complaint of refusing to speak, caregiver reports delusional, reports "shutdown and aggressive."

Review of PI # 1's ED MR revealed the following:

Triage assessment was performed by Employee Identifier (EI) # 3, Registered Nurse (RN), on 10/29/24 at 3:53 PM, which included the Columbia-Suicide Severity Rating Scale (C-SSRS). EI # 3 documented PI # 1 refused to answer the questions and was classified as high risk for suicide. The RN also documented high suicide risk interventions which included physician notification, mental health face to face before leaving area, complete safe room checklist with placement in a dedicated ligature resistant room (refers to the design, and construction of a room to minimize the risk of self harm or suicide by removing cords, ropes, to eliminate hanging or strangulation), and initiating one to one continuous observation.

PI # 1 was on psychiatric medications including Quetiapine (medication primarily used to manage certain mental health conditions), Benztropine (medication used to improve movements side effects caused by antipsychotic medications), and Risperidone (medication used to treat symptoms of schizophrenia).

An initial MSE was performed by EI # 4, Certified RN Practitioner (CRNP), on 10/29/24 at 4:22 PM which included a history of present illness (HPI), review of systems (ROS), and physical examination (PE). EI # 4 documented PI # 1 presented with a psychiatric problem, had moderate intellectual disability (is difficulty in conceptual, social, and practical areas of living), and was brought to the ED with delusions, decreased talking and withdrawal. The CRNP also documented PI # 1 had been acting aggressive, making homicidal threats against the other residents, and they (group home) would like for PI # 1 to be evaluated and possibly have medications adjusted before return. EI # 4 further documented the duration of symptoms was constant, character of symptoms was homicidal threats with periods of agitation, that PI # 1 appeared to be shutting down and only mumbling answers to others and mumbling to himself/herself frequently.

EI # 4 documented PI # 1 was cooperative, alert and oriented to person, place, time and situation, with no focal neurological deficits observed. The impression and plan diagnosis were Homicidal Thoughts and Acute Psychosis.

EI # 4 further documented PI # 1 was not a candidate for the facility's psychiatric unit due to moderate intellectual disability, and an order was placed by the CRNP on 10/29/24 at 8:56 PM to transfer PI # 1 to an acute psychiatric facility for evaluation and treatment. The visit was certified as a medical emergency by EI # 4.

There was no documentation a psychiatrist had completed an assessment to determine the patient's IQ (intelligence quotient) and level of intellectual disability.

On 10/31/24 at 3:31 AM, EI # 5, ED physician, documented that a psychiatric consult was placed for medication reconciliation recommendations during PI # 1's ED hold, and otherwise they would proceed with transfer process as planned.

On 11/1/24 at 12:37 PM, EI # 6, Licensed Medical Social Worker (LMSW), documented a Transfer Center Behavioral Health (BH) Screening with information gathered from PI # 1, an unnamed health professional, and a caregiver from the group home where PI # 1 resided. PI # 1 had been brought to the ED for homicidal ideation and psychosis and had a history of intellectual disability with multiple personalities. His/her symptoms had worsened over the past few weeks and was brought to the ED due to psychosis and delusions with decreased talking and making homicidal threats. Symptoms/behaviors over the last 72 hours included withdrawing/shutting down, being delusional, and expressing homicidal ideation towards other residents. PI # 1 was mostly in his/her own mind, had not been himself/herself lately, and staff couldn't "snap him/her out of it." PI # 1 was responding to conversations in his/her mind, and had not been eating.

A mental status exam performed by EI # 6 as part of the BH screening documented PI # 1 had poor eye contact, guarded behavior, severely impaired insight, and was suicidal/homicidal due to making threats towards residents at the group home. Speech was soft with prolonged speech latency (a noticeable delay with response) and dysarthric (slurred). Mood was anxious, affect was flat. EI # 6 was unable to determine PI # 1's orientation or assess his/her thought process. Thought content was delusional with hallucinations and his/her condition was likely to deteriorate without treatment. PI # 1 was unable to reliably contract for safety.

EI # 7, ED physician, documented on 11/2/24 at 2:20 AM there was no available facility to place PI # 1 in at the time. EI # 7 also documented PI # 1's caregiver was willing to take him/her home and follow up with his/her primary care physician as needed.

PI # 1 was discharged back to the group home on 11/2/24 at 10:30 AM.

A review of the psychiatric on-call log revealed the facility had a psychiatrist that was on call 10/29/24 to 11/2/24.

There was no documentation a psychiatric consult was performed to complete the MSE, no documentation the patient's symptoms had resolved, and that he/she was no longer a threat to others, or that his/her psychosis had resolved.

An interview was conducted on 11/15/24 at 10:55 AM with the psychiatrist on call 10/29/24, EI # 11, who stated he/she received no information on PI # 1, nor a referral for admission.

The facility failed to ensure that thier own Policy and Procedure was followed as evidenced by failing to ensure that an appropriate MSE was provided for patient #1 on 10/29/2024, that was within the capabilities of the ED including ancillary services routinely available to the ED (A Psychiatrist was on- call on 10/29/24 and available). This patient had an identified emergency medical condition.

Based on medical record (MR) review, interviews and hospital policies and procedure, it was determined the facility failed to provide stabilizing treatment as required that was within their capability and capacity for a patient with a psychiatric emergency medical condition (EMC) that presented to the hospital's emergency department (ED).

This deficient practice affected Patient Identifier (PI) # 1, and had the potential to affect all patients seeking emergency psychiatric care at this hospital.

Findings include:

Hospital Policy: Emergency Medical Treatment and Labor Act (EMTALA)
Policy Version: Six
Revision Date: 7/14/2022

Definitions:

For the purpose of this EMTALA policy, the following terms are defined as follows:

...Capability refers to the hospital's physical space, equipment, supplies and services (e.g. trauma care, pediatrics.....or psychiatry), including ancillary services routinely available to the emergency department and emergency services available to inpatients. Capabilities of the staff of a facility means the level of care that the personnel of the hospital can provide within the training and scope of their professional licenses. This includes coverage available through (the) hospital's on-call physician roster. The hospital is responsible for treating the individual within the capabilities of the hospital as a whole...

Capacity refers to the ability of the hospital to accommodate the individual requesting examination or treatment...Capacity encompasses such things as numbers and availability of qualified staff, beds, and equipment...

Stabilized/Stabilization: ...To stabilize means, to provide such medical treatment necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely...

Stable for Discharge: A patient is stable for discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions...

...Stabilizing Treatment:

If it is determined through an MSE (medical screening exam) that an EMC exists...ED personnel staff shall: (1) provide such further medical examination and treatment as may be required to stabilize the medical condition...within the capabilities of the staff and facilities available at the hospital or (2) transfer the individual to another appropriate facility...

A. On-Call Physicians, On-Call List, and Simultaneous Call

...The hospital shall maintain a list and/or schedule of physicians by name, speciality and contact information, who are on call for duty after the MSE to provide treatment necessary to stabilize an individual with an EMC...

Hospital Policy: ED Emergency Services System
Policy Version: One
Revision Date: 9/30/2022

Statement of Purpose:

To provide an overview and guidelines for the functioning of the emergency care system.

...Disposition Phase of Care:

...2. Admission to Psychiatric Unit

a. The emergency physician must determine the need for admission in collaboration with the psychiatrist on call.

Hospital Policy: Admission Criteria
Division: Psychiatry
Policy Number: 02.001
Revised Date: 01/09/2023

Overview:

...Patients must require inpatient psychiatric hospitalization services at levels of intensity and frequency exceeding what may be rendered in an outpatient setting...There must be evidence of failure at, inability to benefit from, or unacceptable risk in an outpatient treatment setting...For all patients there must be a reasonable expectation of improvement in the patient's condition (or in certain cases a need for admission to establish a diagnosis - psychiatric diagnostic evaluation)...Patients admitted to the adult unit should be primarily independent in their activities of daily living.

Policy:

Admission to the Psychiatric Program is indicated for patients who have an appropriate DSM (Diagnostic and Statistical Manual of Mental Disorders) diagnosis...

Procedure:

1. Admission Criteria: Examples of inpatient admission criteria (Severity of Illness) include but are not limited to:

1.1. Threat to self, requiring 24-hour professional observation:
a. suicidal ideation or gesture within 72 hours prior to admission...

1.2. Threat to others requiring 24-hour professional observation:
...b. significant verbal threat to the safety of others within 72 hours prior to admission.

...7. A mental disorder causing major disability in social, interpersonal, occupational, and/or educational functioning that is leading to dangerous or life-threatening functioning, and that can only be addressed in an acute inpatient setting.

8. A mental disorder that causes an inability to maintain adequate nutrition...

9. Failure of outpatient psychiatric treatment...Reasons for failure...could include:
a. Increasing severity of psychiatric symptoms
...d. Due to the severity of psychiatric symptoms, the patient is unable to participate in an outpatient psychiatric treatment program.

Exclusion Criteria: Patients referred for admission with any of the exclusionary criteria below may be reviewed on a case by case basis by the designated program leaders.

...3.2 Patients with a substantiated diagnosis of intellectual disability (mental retardation or autism spectrum disorder) with no acute behavioral change or no known psychiatric disorder and no expectation for a positive response to treatment.

Hospital Policy: Inquiry and Pre-Admission Assessment
Division: Psychiatry
Policy Number: 02.101
Last Revised: 10/16/13

Policy:

...C. Pre-admission evaluation are completed by a clinically competent mental health professional.

D. The risk of the individual harming himself or herself or others, including staff is evaluated at the time of initial intake.

Procedure:
Request for Pre-admission Evaluation and Patient Choice

1. ...individuals referred for psychiatric inpatient treatment shall be pre-screened by a clinically competent staff member prior to the clinical review by a licensed physician who is solely responsible for the clinical decision to authorize the admission.

...7. The attending physician, or program director is always consulted and assessment information reviewed for him/her before disposition is made...

1. PI # 1 presented to the facility ED via private vehicle from a group home for intellectually disabled adults on 10/29/24 at 3:48 PM with a chief complaint of refusing to speak, caregiver reports delusional, normally calm and talkative, reports "shutdown and aggressive"; denies harm to himself.

A review of PI # 1's ED MR revealed PI # 1 was on psychiatric medications including Quetiapine, Benztropine, and Risperidone.

An initial MSE was performed by Employee Identifier (EI) # 4, Certified Registered Nurse Practitioner (CRNP), on 10/29/24 at 4:22 PM which included a history of present illness (HPI), review of systems (ROS), and physical examination (PE). EI # 4 documented in the HPI that PI # 1 presented with a psychiatric problem, had moderate intellectual disability, and was brought to the ED with delusions, decreased talking and withdrawal. The CRNP also documented PI # 1 had been acting aggressive, making homicidal threats against the other residents, and they (group home) would like for PI # 1 to be evaluated and possibly have medications adjusted before return. EI # 4 further documented that PI # 1 appeared to be shutting down and only mumbling answers to others and mumbling to himself/herself frequently. The impression and plan diagnosis were Homicidal Thoughts and Acute Psychosis.

EI # 4 further documented PI # 1 was not a candidate for the facility's psychiatric unit due to moderate intellectual disability, and an order was placed by the CRNP on 10/29/24 at 8:56 PM to transfer PI # 1 to an acute psychiatric facility for evaluation and treatment. The visit was certified as a medical emergency by EI # 4.

There was no documentation a psychiatrist had completed an assessment to determine PI # 1's IQ (intelligence quotient) level of intellectual disability.

In an interview with EI # 4 on 11/14/24 at 10:20 AM, EI # 4 stated PI # 1 was non-verbal, and the person with PI # 1 told him/her PI # 1 was a special needs person. EI # 4 stated he/she didn't see any documentation of PI # 1's intellectual ability. EI # 4 stated when asked that PI # 1 did not receive a psychiatric evaluation that night, that PI # 1 stayed several days in the ED, but he/she never saw PI # 1 again.

Continued review of PI # 1's MR revealed 11 facilities were contacted from 10/30/24 to 11/2/24 by the facility's Transfer Center in attempt to find psychiatric inpatient placement for PI # 1.

On 10/31/24 at 4:40 AM, EI # 5, ED physician, placed a psychiatric consult for medication reconciliation recommendations during PI # 1's ED hold while waiting for transfer.

There was no documentation the psychiatric consult was completed.

On 11/1/24 at 12:37 PM, EI # 6, Licensed Medical Social Worker (LMSW), documented a Transfer Center Behavioral Health (BH) Screening with information gathered from PI # 1, an unnamed health professional, and a caregiver from the group home where PI # 1 resided. EI # 6 documented PI # 1 was brought to the ED due to delusions, decreased talking, and making homicidal threats. PI # 1 was from a group home with a history of intellectual disability. His/her symptoms had been worsening over the past few weeks. PI # 1 had been brought to the ED for homicidal ideation and psychosis. Symptoms/behaviors over the last 72 hours included withdrawing/shutting down, being delusional, and expressing homicidal ideation towards other residents. EI # 6 also documented per group home staff, PI # 1 had multiple personalities, and there had been an increase/worsening of symptoms. PI # 1 was mostly in his/her own mind, had not been himself/herself lately, and staff couldn't "snap him/her out of it." PI # 1 was responding to conversations in his/her mind, and had not been eating.

A mental status exam performed by EI # 6 as part of the BH screening documented PI # 1 had poor eye contact, guarded behavior, severely impaired insight, and was suicidal/homicidal due to making threats towards residents at the group home. Speech was soft with prolonged speech latency (a noticeable delay with response) and dysarthric (slurred). Mood was anxious, affect was flat. EI # 6 was unable to determine PI # 1's orientation or assess his/her thought process. Thought content was delusional with hallucinations.

EI # 6 further documented PI # 1's condition was likely to further deteriorate without treatment, and PI # 1 was unable to reliably contract for safety. EI # 8, ED physician, was consulted who authorized voluntary IP (inpatient) psychiatric treatment for safety and stabilization.

Further review of PI # 1's MR revealed there was no documentation a psychiatrist completed an assessment.

On 11/2/24 at 2:20 AM EI # 7, ED physician, documented PI # 1 had been very calm, stable and not exhibited any aggression or agitation during his/her ED stay and there was no available facility to place PI # 1 in at the time. EI # 7 also documented PI # 1's caregiver was willing to take him/her home and to follow up with his/her primary care physician as needed. PI # 1 was discharged back to the group home on 11/2/24 at 10:30 AM with a discharge diagnosis of Acute Psychosis and Homicidal Thoughts.

Review of the discharge instructions revealed there were no new prescriptions or change to treatment. Phone numbers were given for the National Suicide Prevention Lifeline and National Poison Control Center.

A review of the bed census for the adult psychiatric unit 10/29/24 to 11/2/24 was conducted with EI # 1, Chief Nursing Officer, and EI # 10, Director of Psychiatric Services on 11/15/24. At 4 PM on 10/29/24, the adult psychiatric unit had five open beds. 10/30/24 at 4 AM, all beds were full. EI # 1 and EI # 10 stated the five open beds from 4 PM 10/29/24 were filled with psychiatric patients already holding in the ED for admission.

Continued review of the adult psychiatric bed census revealed the following:

10/29/24 11:36 PM - facility went on psychiatric diversion due to no open beds in the psychiatric unit. The ED psychiatric extension was full with eight patients, one being PI # 1.
10/30/24 4:00 AM - no open beds.
10/30/24 4:00 PM - one bed was open, the ED was holding two psychiatric patients.
10/31/24 4:00 AM - no open beds
10/31/24 4:00 PM - four open beds
11/1/24 4:00 AM - two open beds
11/1/24 4:00 PM - three open beds
11/2/24 4:00 AM - one open bed

Review of staffing for the adult psychiatric unit 10/29/24 to 11/2/24 revealed there was adequate staffing all shifts per the schedule and staffing matrix provided by EI # 10.

An interview was conducted on 11/14/24 at 11:05 AM with EI # 9, Medical Director of the Psychiatric Unit. EI # 9 stated mild to moderate disability would normally be acceptable for admission, and it was determined by their ability to manage activities of daily living, to communicate, and documentation of any IQ testing.

There was no documentation a case-by-case review or assessment of PI # 1's intellectual ability was conducted by a designated psychiatric qualified medical professional per policy.

An interview was conducted on 11/15/24 at 10:55 AM with the psychiatrist on call 10/29/24, EI # 11, who stated he/she received no information on PI # 1, nor a referral for admission.

The facility failed to provide stabilizing treatment as required that was within their capability and capacity and admit PI # 1 for inpatient psychiatric evaluation and treatment for his/her identified EMC.

Based on medical record (MR) review, hospital policy and interview, it was determined the hospital failed to provide an appropriate transfer that included signed certification by the physician that the medical benefits of treatment at another facility outweighed the risks of being transferred.

This deficient practice affected Patient Identifier (PI) # 3, one of four transfer MR's reviewed, and had the potential to affect all patients transferring from this hospital.

Findings include:

Hospital Policy: Emergency Medical Treatment and Labor Act (EMTALA)
Policy Version: Six
Revision Date: 7/14/2022

...IV. Transfer of Individuals

A. Transfer Requirement:

If a patient is determined to have an emergency medical condition (EMC) following a medical screening exam (MSE) and...(b) the treating physician determines that the hospital has exhausted its capabilities to stabilize the patient's EMC, and that the benefits of an appropriate transfer outweigh the risks of such transfer, the hospital shall take reasonable steps to initiate an appropriate transfer, described below.

...A licensed physician evaluates the individual and signs a certification, which must include a summary of the risks and benefits specific to that patient, that based upon information available at the time of the transfer, the medical benefits reasonably expected from appropriate medical treatment at another medical facility outweigh the risk to the individual of effecting the transfer...

1. PI # 3, age seven, presented to the hospital via emergency medical service (EMS) on 5/12/24 at 8:57 PM with a chief complaint per EMS of temperature 103.9 degrees Fahrenheit and a heart rate of 149.

Review of PI # 3's MR revealed PI # 3 received a MSE by a physician at 9:13 PM who determined PI # 3 would benefit from transfer to a children's hospital due to tachycardia, otitis media, therapy failure due to antibiotic resistance and hyperthyroidism.

Further review of PI # 3's MR revealed the benefits and risks of transfer were identified, but there was no signed certification by the transferring physician that the benefits of transfer outweighed the risks of transfer.

An interview was conducted on 11/15/24 at 1:05 PM with Employee Identifier # 1, Chief Nursing Officer, who confirmed the transferring physician did not sign the certification that the benefits of transfer outweighed the risks.