Valley View Hospital Association

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 50313 Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements. FINDINGS 1. The facility failed to meet the following requirements under the EMTALA regulations: A-2406: Medical Screening Exam. (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. Based on interviews and document review, the facility failed to comply with the Emergency Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure a patient who presented to the facility with suicidal ideations received a medical screening exam. This failure was identified in one of three patients who presented to the facility with suicidal ideations. (Patient #7) A-2407: Necessary Stabilizing Treatment for Emergency Medical Conditions. (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either-- (i) Within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. Based on interviews and document review, the facility failed to comply with the Emergency Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure a patient who presented to the facility with suicidal ideations received stabilizing treatment. This failure was identified in one of three patients who presented to the facility with suicidal ideations. (Patient #7)”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 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: 50313 Based on interviews and document review, the facility failed to comply with the Emergency Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure a patient who presented to the facility with suicidal ideations received a medical screening exam. This failure was identified in one of three patients who presented to the facility with suicidal ideations. (Patient #7) Findings include: Facility policies: The EMTALA policy read, the scope of the policy applies to any individual that comes to the emergency department (as defined) and a request is made by the individual or on the individual’s behalf, or a prudent layperson observer would conclude from the individual’s appearance or behavior, a need for examination or treatment of any medical condition. Any individual who is not a hospital patient and is on hospital property (that is, the individual comes to the hospital but not to the dedicated emergency department), if either the individual requests examination or treatment for an emergency medical condition or if a prudent layperson observer would believe that the individual is suffering from an emergency medical condition. Emergency department means any department or facility of the hospital, regardless of whether it is located on or off the main hospital campus, that is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or at least one-third of its outpatient visits are for the treatment of emergency medical conditions per year. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. Medical screening exam means the process requiring determining, with reasonable clinical confidence, whether or not an emergency medical condition (EMC) exists.This is documented in the patient’s medical record.The facility will provide a medical screening examination and stability treatment or transfer to any individual identified in the scope above who either comes to the emergency department and requests such an examination or who is on hospital property who presents with or develops an emergency medical condition, and will not refuse to examine or treat individuals with an EMC. When a patient presents with or develops an emergency medical condition on hospital property that is not the emergency department, staff may transfer the patient to the hospital’s emergency department. The facility will provide necessary stabilizing treatment for emergency medical conditions and labor within our capability and capacity. The Urgent Care Standards of Care policy read, the following conditions will be redirected to be seen by the emergency department: Chest pain, stroke like symptoms, life or limb threatening injury or illness, pregnancy related issues, physical or sexual abuse, mental health consults or psychiatric emergencies, law enforcement medical clears, or any condition or complaint that exceed the resources available to urgent care (UC) providers. The advanced practice provider will seek expert consultation when necessary to ensure safe patient care. The Physician Operations, Suicidal Ideation and Behavioral Health for Outpatient Clinics and Ancillary Departments policy read, the purpose is to provide guidelines for identifying, assessing, and implementing safety precautions for patients with suicidal ideation (SI) and/or in need of a behavioral health crisis evaluation due to other behavioral health concerns. The scope includes patients expressing suicidal ideation in outpatient clinics, ancillary departments, and off-site ambulatory surgery. It is the responsibility of all staff who encounter patients, during the course of care, that expresses SI or present with behavioral health crisis. Patients who verbalize SI and/or present with a behavioral health crisis will have appropriate safety assessment and plan implemented. For staff in clinics/settings physically located at the facility working with patients that verbalize SI and/or a behavioral health crisis, an appropriate assessment and plan can be made by the crisis team or other behavioral health provider. Additional active suicidality/homicidal considerations: Do not leave the patient alone. Consider transport to the ED for crisis evaluation and intervention. If the actively suicidal patient refuses transfer for further evaluation and or elopes, notify the appropriate law enforcement agency. A. Document Review i. A review of Patient #7’s medical record revealed Patient #7 presented to the urgent care on 5/24/24 at 3:48 p.m. with a chief complaint of right sided oral and facial pain. The provider’s note revealed Patient #7 also complained of suicidal ideation. Patient #7 stated they did not have friends, felt isolated, and had minimal support at home. Patient #7 expressed they were depressed about their living situation and medical problems. Patient #7 was discharged from the urgent care with a referral for an outpatient mental health program. Patient #7 also received a prescription for Augmentin (an antibiotic that fights bacteria in the body) and 20 tablets of Percocet (an opioid pain medication). There was no evidence in the medical record of a medical screening examination for Patient #7’s suicidal ideations. This was in contrast to the EMTALA policy which read, an emergency medical condition included a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could have reasonably been expected to result in placing the health of the individual in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. Medical screening exam was the process requiring determining, with reasonable clinical confidence, whether or not an emergency EMC existed.This should have been documented in the patient’s medical record.The facility should have provided a medical screening examination and stability treatment or transfer to any individual who either came to the emergency department (ED) and requested such an examination, or who was on hospital property who presented with or developed an EMC, and would not refuse to examine or treat individuals with an EMC. When a patient presented with, or developed, an emergency medical condition on hospital property that was not the ED, staff should have transferred the patient to the hospital’s ED. This was also in contrast to the Physician Operations, Suicidal Ideation and Behavioral Health for Outpatient Clinics and Ancillary Departments policy which read, patients who verbalized SI and/or presented with a behavioral health crisis should have had an appropriate safety assessment and plan implemented. For staff in clinics/settings physically located at the facility working with patients that verbalized SI and/or a behavioral health crisis, an appropriate assessment and plan should have been made by the crisis team or other behavioral health provider. If the actively suicidal patient refused transfer for further evaluation and or eloped, staff should have notified the appropriate law enforcement agency. Additionally, this was in contrast to the Urgent Care Standards of Care policy which read, mental health consults or psychiatric emergencies, or any condition or complaint that exceed the resources available to urgent care providers would have been redirected to be seen in the ED. The advanced practice provider should have sought expert consultation when necessary to ensure safe patient care. An additional provider note filed on 5/24/24 at 9:44 p.m. revealed Patient #7 called the UC after discharge. Patient #7 expressed ongoing suicidal ideations and told the provider they were unable to reach the outpatient mental health program. Patient #7 expressed frustration that no one was helping them with their mental health concerns. The provider talked with Patient #7 about returning to the facility for a crisis evaluation and additional mental health resources in the ED. Patient #7 stated they would return to the facility the following day for an evaluation in the ED. B. Interviews i. An interview was conducted on 8/12/25 at 8:57 a.m. with the emergency department educator (Educator) #1. Educator #1 stated patients who entered the facility through the emergency department entrance had the option to be seen at the facility’s urgent care for an evaluation of their medical condition. Educator #1 stated registration staff were aware that certain chief complaints were not appropriate for the urgent care, and staff would have explained to patients at the registration desk that they must be evaluated in the emergency department. An additional interview was conducted on 8/13/25 at 12:51 p.m. with Educator #1. Educator #1 stated patients who were evaluated in the urgent care received a mental health and suicide risk screening during the intake process. This was in contrast to Patient #7’s medical record review which revealed no evidence of mental health and suicide risk screenings. Educator #1 stated data showed screenings identified patients who were at risk for suicide. Educator #1 stated staff would not know if a patient was at risk for suicide, or suffering from a mental health emergency, unless staff screened for this information, or if the patient self-reported the concern. After live record reviews for more recent urgent care patients, Educator #1 stated it was evident staff were not currently conducting a mental health and suicide risk screening during the intake process in the urgent care department. ii. An interview was conducted on 8/13/25 at 12:21 p.m. with registered nurse (RN) #2. RN #2 stated it was important to screen patients who presented to the facility for suicidal thoughts or behaviors. RN #2 stated if patient expressed suicidal thoughts or behaviors, staff should have taken specific precautions for the patient’s safety. RN #2 stated a patient with suicidal thoughts should have had their personal belonging screened for items which could have caused harm. Additionally, RN #2 stated patients with suicidal thoughts should have been monitored by staff and placed in a room that was free from items the patient could have used to harm themselves. RN #2 stated a patient with suicidal thoughts should never have been left alone by staff. RN #2 stated if a patient presented to the facility in the emergency department, or the urgent care, with suicidal ideations, staff should have notified an emergency department provider immediately. RN #2 stated providers would have ordered medical screening tests to rule out physical injuries, or ingestion of drugs or alcohol. RN #2 stated the emergency department provider would have ordered a mental health evaluation with a mental health professional to determine if the patient required in-patient treatment, a mental health hold, or if the patient was safe to be discharged home with a safety plan. RN #2 stated patients with suicidal ideation were at risk of harming themselves or others. iii. An interview was conducted on 8/13/25 at 12:20 p.m. with emergency department provider (Provider) #3. Provider #3 stated they had worked in both the emergency department and the urgent care area. Provider #3 stated nurses should have screened patients for mental health concerns and suicidal ideation during the urgent care intake process. This was in contrast to Patient #7’s medical record review which revealed staff did not screen Patient #7 for mental concerns or suicidal ideation during the urgent care intake process. Provider #3 stated if a patient presented to the facility with suicidal ideation, they should have been taken to a specific room in the emergency department that was safe for patients with mental health concerns or suicidal ideation. Provider #3 stated when a patient presented with a medical concern and expressed suicidal ideation they should have received a medical clearance examination that included blood work and other tests to screen for drugs, alcohol, or an ingestion that might have required contacting poison control. This was in contrast to Patient #7’s medical record review which revealed Patient #7 was not taken to a room in the emergency department that was safe for patients with suicidal ideation. Additionally, Patient #7 was not medically cleared or tested for drugs, alcohol, or potential ingestions. Provider #3 stated once a patient was medically cleared, the mental health team would have been contacted. Provider #3 stated the mental health team would have met with the suicidal patient either through telemedicine or in-person, and then worked with the provider and the patient to determine the course of treatment. Provider #3 stated patients who expressed suicidal ideation should have received a mental health consultation. Provider #3 stated if a patient elected to be seen in the urgent care, but expressed suicidal ideation, that patient should have been transferred to the emergency department for a mental health evaluation. Provider #3 stated it was concerning that a patient was seen in the urgent care for suicidal ideation and discharged home without being medically cleared or evaluated by the mental health team. Provider #3 stated the moment a patient in the urgent care expressed suicidal ideation they should have been transferred to the emergency department. iv. An interview was conducted on 8/13/25 at 11:57 a.m. with the admissions supervisor (Supervisor) #4. Supervisor #4 stated they oversaw the staff who registered patients in the emergency department and urgent care. Supervisor #4 stated if a patient presented to the facility with suicidal ideation or mental health concerns, they might have been able to be evaluated in the urgent care area. Supervisor #4 stated they were unsure and would have needed to ask urgent care staff if a suicidal patient could have been seen in the urgent care. Supervisor #4 explained that patients with behavioral health concerns were usually evaluated in the emergency department. This was in contrast to the Urgent Care Standards of Care policy which read, mental health consults or psychiatric emergencies, or any condition or complaint that exceeded the resources available to urgent care providers should have been redirected to be seen in the ED.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 50313 Based on interviews and document review, the facility failed to comply with the Emergency Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure a patient who presented to the facility with suicidal ideations received stabilizing treatment.This failure was identified in one of three patients who presented to the facility with suicidal ideations. (Patient #7) Findings include: Facility policies: The EMTALA policy read, the scope of the policy applies to any individual that comes to the emergency department (as defined) and a request is made by the individual or on the individual’s behalf, or a prudent layperson observer would conclude from the individual’s appearance or behavior, a need for examination or treatment of any medical condition. Any individual who is not a hospital patient and is on hospital property (that is, the individual comes to the hospital but not to the dedicated emergency department), if either the individual requests examination or treatment for an emergency medical condition or if a prudent layperson observer would believe that the individual is suffering from an emergency medical condition. Emergency department means any department or facility of the hospital, regardless of whether it is located on or off the main hospital campus, that is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or at least one-third of its outpatient visits are for the treatment of emergency medical conditions per year. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. The facility will provide a medical screening examination and stability treatment or transfer to any individual identified in the scope above who either comes to the emergency department and requests such an examination or who is on hospital property who presents with or develops an emergency medical condition, and will not refuse to examine or treat individuals with an emergency medical condition (EMC). When a patient presents with or develops an emergency medical condition on hospital property that is not the emergency department, staff may transfer the patient to the hospital’s emergency department. The facility will provide necessary stabilizing treatment for emergency medical conditions and labor within our capability and capacity. The Urgent Care Standards of Care policy read, the following conditions will be redirected to be seen by the emergency department: Chest pain, stroke like symptoms, life or limb threatening injury or illness, pregnancy related issues, physical or sexual abuse, mental health consults or psychiatric emergencies, law enforcement medical clears, or any condition or complaint that exceed the resources available to urgent care (UC) providers. The advanced practice provider will seek expert consultation when necessary to ensure safe patient care. The Physician Operations, Suicidal Ideation and Behavioral Health for Outpatient Clinics and Ancillary Departments policy read, the purpose is to provide guidelines for identifying, assessing, and implementing safety precautions for patients with suicidal ideation (SI) and/or in need of a behavioral health crisis evaluation due to other behavioral health concerns. The scope includes patients expressing suicidal ideation in outpatient clinics, ancillary departments, and off-site ambulatory surgery. It is the responsibility of all staff who encounter patients, during the course of care, that expresses SI or present with behavioral health crisis. Patients who verbalize SI and/or present with a behavioral health crisis will have appropriate safety assessment and plan implemented. For staff in clinics/settings physically located at the facility working with patients that verbalize SI and/or a behavioral health crisis, an appropriate assessment and plan can be made by the crisis team or other behavioral health provider. Additional active suicidality/homicidal considerations: Do not leave the patient alone. Consider transport to the ED for crisis evaluation and intervention. If the actively suicidal patient refuses transfer for further evaluation and or elopes, notify the appropriate law enforcement agency. 1. The facility failed to ensure a patient who presented to the facility with suicidal ideations received stabilizing treatment. A. Document Review i. A review of Patient #7’s medical record revealed Patient #7 presented to the urgent care on 5/24/24 at 3:48 p.m. with a chief complaint of right sided oral and facial pain. The provider’s note revealed Patient #7 also complained of suicidal ideation. Patient #7 stated they did not have friends, felt isolated, and had minimal support at home. Patient #7 expressed they were depressed about their living situation and medical problems. Patient #7 was discharged from the urgent care with a referral for an outpatient mental health program. Patient #7 also received a prescription for Augmentin (an antibiotic that fights bacteria in the body) and 20 tablets of Percocet (an opioid pain medication). This was in contrast to the EMTALA policy which read, an emergency medical condition included a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could have reasonably been expected to result in placing the health of the individual in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. The facility should have provided a medical screening examination and stability treatment or transfer to any individual who either came to the emergency department (ED) and requested such an examination, or who was on hospital property who presented with or developed an EMC, and would not refuse to examine or treat individuals with an EMC. When a patient presented with, or developed, an emergency medical condition on hospital property that was not the ED, staff should have transferred the patient to the hospital’s ED. The facility would provide necessary stabilizing treatment for emergency medical conditions within their capability and capacity. This was also in contrast to the Physician Operations, Suicidal Ideation and Behavioral Health for Outpatient Clinics and Ancillary Departments policy which read, patients who verbalized SI and/or presented with a behavioral health crisis should have had an appropriate safety assessment and plan implemented. For staff in clinics/settings physically located at the facility working with patients that verbalized SI and/or a behavioral health crisis, an appropriate assessment and plan should have been made by the crisis team or other behavioral health provider. Staff should not have left the patient alone. Transportation should have been considered to the ED for crisis evaluation and intervention. If the actively suicidal patient refused transfer for further evaluation and or eloped, staff should have notified the appropriate law enforcement agency. Additionally, this was in contrast to the Urgent Care Standards of Care policy which read, mental health consults or psychiatric emergencies, or any condition or complaint that exceed the resources available to urgent care providers would have been redirected to be seen in the ED. The advanced practice provider should have sought expert consultation when necessary to ensure safe patient care. An additional provider note filed on 5/24/24 at 9:44 p.m. revealed Patient #7 called the UC after discharge. Patient #7 expressed ongoing suicidal ideations and told the provider they were unable to reach the outpatient mental health program. Patient #7 expressed frustration that no one was helping them with their mental health concerns. The provider talked with Patient #7 about returning to the facility for a crisis evaluation and additional mental health resources in the ED. Patient #7 stated they would return to the facility the following day for an evaluation in the ED. B. Interviews i. An interview was conducted on 8/12/25 at 8:57 a.m. with the emergency department educator (Educator) #1. Educator #1 stated patients who entered the facility through the emergency department entrance had the option to be seen at the facility’s urgent care for an evaluation of their medical condition. Educator #1 stated the staff in the urgent care would have transferred patients with an emergency medical condition to the emergency department, if the patient elected to be seen in the urgent care. Educator #1 stated the patient should have received stabilizing treatment for their emergency medical condition. Educator #1 stated registration staff were aware that certain chief complaints were not appropriate for the urgent care, and staff would have explained to patients at the registration desk that they must be evaluated in the emergency department. ii. An interview was conducted on 8/13/25 at 12:21 p.m. with registered nurse (RN) #2. RN #2 stated it was important to screen patients who presented to the facility for suicidal thoughts or behaviors. RN #2 stated if patient expressed suicidal thoughts or behaviors, staff should have taken specific precautions for the patient’s safety. RN #2 stated a patient with suicidal thoughts should have had their personal belonging screened for items which could have caused harm. Additionally, RN #2 stated patients with suicidal thoughts should have been monitored by staff and placed in a room that was free from items the patient could have used to harm themselves. RN #2 stated a patient with suicidal thoughts should never have been left alone by staff. RN #2 stated if a patient presented to the facility in the emergency department, or the urgent care, with suicidal ideations, staff should have notified an emergency department provider immediately. RN #2 stated providers would have ordered medical screening tests to rule out physical injuries, or ingestion of drugs or alcohol. RN #2 stated the emergency department provider would have ordered a mental health evaluation with a mental health professional to determine if the patient required in-patient treatment, a mental health hold, or if the patient were safe to be discharged home with a safety plan. RN #2 stated patients who presented to the facility with suicidal ideations could have been discharged home with a safety plan if they had support at home from someone aware of, and participating, in the safety plan. RN #2 stated the risk of not providing treatment to a person with suicidal ideation was the patient using items to harm themselves, or to harm others. RN #2 stated a patient with suicidal ideation was not appropriate for the urgent care department because those rooms could not have been made safe from risks of harm, and there were not sufficient staff available to monitor a patient with suicidal ideation. This was in contrast to Patient #7’s medical record review which revealed Patient #7 expressed suicidal ideation in the urgent care department and was not transferred to the emergency department. Additionally, there was no evidence staff monitored Patient #7, screened Patient #7’s belongings, or ensured that Patient #7 was not left alone after Patient #7 expressed suicidal ideation. Finally, Patient #7 was discharged home without a safety plan after Patient #7 expressed they did not have support at home and felt isolated. iii. An interview was conducted on 8/13/25 at 12:20 p.m. with emergency department provider (Provider) #3. Provider #3 stated they had worked in both the emergency department and the urgent care area. Provider #3 stated nurses should have screened patients for mental health concerns and suicidal ideation during the urgent care intake process. This was in contrast to Patient #7’s medical record review which revealed staff did not screen Patient #7 for mental concerns or suicidal ideation during the urgent care intake process. Provider #3 stated if a patient presented to the facility with suicidal ideation, they should have been taken to a specific room in the emergency department that was safe for patients with mental health concerns or suicidal ideation. This was in contrast to Patient #7’s medical record review which revealed Patient #7 was not taken to a room in the emergency department that was safe for patients with suicidal ideation, instead they were discharged home. Provider #3 stated once a patient was medically cleared, the mental health team would have been contacted. Provider #3 stated the mental health team would have met with the suicidal patient either through telemedicine or in-person, and then worked with the provider and the patient to determine the course of treatment. Provider #3 stated a patient with suicidal ideation might be prescribed a medication to help with mood stabilization, or a safety plan for home. Provider #3 stated it was possible to discharge a patient with suicidal ideation home if safety plan was in place. Provider #3 stated safety plans required support from family or friends and a safe place for the patient to return to. Provider #3 stated patients who expressed suicidal ideation should have received a mental health consultation. Provider #3 stated if a patient elected to be seen in the urgent care, but expressed suicidal ideation, that patient should have been transferred to the emergency department for a mental health evaluation. This was in contrast to Patient #7’s medical record review which revealed Patient #7 did not receive a mental health consultation after expressing suicidal ideation. Additionally, Patient #7 was discharged home without a safety plan after expressing they had minimal support at home and felt isolated. Provider #3 stated it was concerning that a patient was seen in the urgent care for suicidal ideation and discharged home without being medically cleared or evaluated by the mental health team. Provider #3 stated the moment a patient in the urgent care expressed suicidal ideation they should have been transferred to the emergency department.”