Ozark Health

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 37145 Based on clinical record review, policy review, and interview the facility failed to ensure an appropriate medical screening exam was provided and not delayed for one (# 1) of one patient with suicide attempt received by ambulance to the Emergency Department (ED). This failed practice had the likelihood to affect all suicidal psychiatric patients coming to the ED. Findings follow: A. Review of the facility Policy “EMTALA GUIDELINES”, revised May 2, 2019, showed: “All patients presenting to (Referring hospital) for a non-scheduled visit and seeking care must be accepted and evaluated regardless of the patient’s ability to pay. All patients shall receive a medical screening exam that includes providing all necessary testing and services within the capability of the hospital to reach a diagnosis. Federal Law requires that all necessary definitive treatment be given to the patient and only maintenance care can be referred to a physician’s office or clinic. Emergency Medical Conditions under EMTALA Law constitute any condition that is a danger to the patient or unborn fetus or could result in a risk of dysfunction or impairment to the smallest body part or organ if the patient is not treated in the near future. B. Review of the facility policy “EMERGENCY TREATMENT OF MINORS” revised, September 22, 2021, showed, “All attempts will be made to contact the parents or guardian of a non-emancipated minor prior to treatment. If unable to obtain permission from parent or guardian, the Child Protective Agency or the local law enforcement agency will be contacted to assume responsibility. In the event of a life-threatening condition, treatment will not be delayed, the Emergency Department physician will sign for treatment. If phone consent is obtained from parent(s) or legal guardian; two nurses must verify the phone consent and document in nursing documentation. When phone consent has been obtained for treatment of the minor, arrangements should be made to discharge the minor.” C. Review of the facility policy “PSYCHIATRIC PATIENTS” revised, April 2019 showed, “When there are two psychiatric patients admitted to the Emergency Department, this ER (Emergency Room) will be considered at psych(psychiatric) capacity. Emergency Department staff will notify EMS dispatch that this Emergency Department is at psych capacity and cannot accept any known patients needing psychiatric evaluation.” D. Review of the facility policy “TRIAGE” effective, May 2016 showed, “Category of Level 2 acuity: Life/Limb loss is eminent unless intervention is taken and considered unstable. The treatment and assessment should occur between 5-15 minutes.” E. Review of the prehospital care report by Emergency Medical Services (EMS) dated 04/13/24 showed, “unit notified at 11:54 AM, and dispatched Emergent with complaint reported to dispatch of a 14-year-old female with suicidal ideations. Officer was reported to be on scene. EMS arrived at scene at 12:16 PM. Patient was found in back seat of local deputy’s patrol car and said she wanted to go for some help. She walked with the deputy to the ambulance, entered the back and lay on the cot. Her primary complaint was suicidal for five (5) days. After EMS evaluation transport required nonemergent transport to a hospital capable of providing adequate care for the chief complaint. EMS transported patient to the (Referring Facility), the closest most appropriate facility capable of providing care for the patient. F. Review of the EMS Response Times and Mileage dated 03/14/24 showed, “unit dispatched at 11:55 AM, at scene at 12:16 PM, Departed scene at 12:27 PM, and arrived at destination (Referring facility) at 12:45 PM. EMS was back in service at 2:05 PM.” G. Review of the Transfer of Patient Care form dated 04/13/24 showed, the ED Director signed the transfer of patient care form on 04/13/24 at 2:03 PM. H. Review of the Referring ED Physician Chart showed, “Time to room, assessment, triage, and Physician notification were completed on 04/13/24 at 2:06 PM. I. Review of the Physician chart dated 03/14/24 at 2:06 PM showed, “Provider treatment notes, Ambulance arrived without report and (named EMS staff) escorted patient into ER (Emergency Room) MD (Medical Doctor) saw patient on arrival and had EMS and patient go to room 2(Psychiatric room). (Named EMS staff) advised all vitals stable, MD verified patient not in distress.” J. Review of the Triage Assessment dated 04/13/2024 at 2:06 PM showed Patient was moved from room 1 with initial vitals at presentation blood pressure (BP 111/68, heart rate (HR) 96, respiratory Rate (RR) 20, Temperature (temp) 98.0 Fahrenheit (F). There was no evidence vital signs were ever repeated. There was no evidence of cardiac monitoring or IV (intravenous fluids) given to the patient in the ED record. At transfer, the record showed, IV status not applicable. K. Review of the Nursing Chart showed, “Note: date 04/13/24 at 2:55 PM, Patient arrived with EMS and seen by MD (Medical Doctor) upon arrival. EMS told this nurse, grandfather signed for patient to be transported. This nurse in the room with patient as blood being drawn and EKG (electrocardiogram) completed. Patient # 1 told this nurse she had a plan to run away and run into oncoming traffic because she feels worthless because her family is always yelling and cussing at her about dumb things and was mad because she told her grandparents she wanted to live in OK (Oklahoma) with her other grandparents. Patient then told this nurse she tried to OD (overdose) this morning by taking three (3) of her Effexor pills when she woke up around 7:00 AM.” Review of Treatment Notes dated 04/13/24 at 3:05 PM showed, “ED Medical Director notified of patient statement to this nurse about possible OD. At 3:23 PM Called poison control. Patient takes Effexor ER 75 mg. Patient told this nurse she took three pills this morning. Poison control said there is a delayed possible cardiac and seizure effect and patient needs to be observed/admitted for 11-18 hours. At 3:38 PM, Medical Director called Arkansas Children’s hospital for transfer at 3:34 PM, patient accepted by Physician at Arkansas Children’s hospital, will be going to ED. At 4:48 PM, EMS called for urgent transfer, at 5:57 PM EMS arrived for transfer of patient to Arkansas Children’s hospital.” L. Review of patient # 1’s clinical record was completed with the ED Manager on 05/02/24 at 8:40 AM. The ED Manager verified patient # 1 arrived at ED at 12:45 PM and time to room, assessment, triage, and Physician notification were completed on 04/13/24 at 2:06 PM. M. On 05/02/24 at 9:39 AM the Medical Director was asked to review patient # 1’s ED record with Surveyor and was asked: 1.What time did this patient arrive in the ED? He said the EMS arrived around 12:45 PM, and walked the patient into the ER, they had not called report in to us. The ER was burning up that day. We were full and the 2 nurses were with some critical patients. I saw patient # 1 come in with EMS and met them at the desk. I did a quick assessment, took a report from EMS, and told them to go to room 2 (a psychiatric room) with the patient. The 2 EMS personnel remained in attendance with Patient #1 until care assumed by ED nurse at 2:06 PM. The Mental Health Screening showed the patient room was assessed for safety, Social Services referral submitted, and Columbia Suicide Severity Scale addressed. The scale was not provided in the ED record. 2.What time does the record show that patient # 1 was placed in a room, triaged, and you were notified? It says 2:06 PM, but there was no delay in assessment or treatment, there was a delay in registration. Patient # 1’s Medical Screening exam started at 12:45 PM when EMS walked her through the doors. I saw her, asked her some questions, made sure she was stable and had EMS take her to exam room 2, EMS remained with patient until nursing staff assumed care.””