St Francis Hospital- Emory Healthcare

“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: 52769 Based on review of medical records, Medical Staff Bylaws, policy and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate ongoing medical screening examination for one (P) (P#1) of 20 patients reviewed when P#1 was discharged without receiving the behavioral health screening as ordered by the provider. Findings include: Cross refer to A-2406 as it relates to the facility’s failure to provide an appropriate medical screening exam.”

“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: 52769 Based on review of police report, medical records, Medical Staff Bylaws, policy and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate and ongoing medical screening examination including behavioral health services to determine whether an emergency medical condition existed for one (P) (P#1) of 20 patients reviewed when P#1 was discharged without receiving the behavioral health screening ordered by PA DD. Specifically, P#1 was discharged without receiving the behavioral health screening as ordered by the emergency room provider. Findings include: A review of a police department report dated 10/26/25 revealed that at approximately 10:25 p.m., the police officer responded to a call regarding a suicide attempt. The police officer located P#1 at a bridge (no time documented) and collaborated with the emergency medical services to transport the patient to facility A. A review of the 10/26/25 ambulance trip report, revealed that P#1 was picked up on 10/26/25 and assessed at 10:08 p.m. (Central Standard Time). P#1’s chief complaint was suicidal ideation. Further review documented that P#1 was transported to facility A. A review of the facility’s (Facility A) Emergency Department Log revealed that Patient #1 presented to the Emergency Department (ED) via ambulance and was registered as a patient on 10/26/25 at 11:25 p.m. A review of the ‘ED Note Physician’ by Physician Assistant (PA) DD dated 10/26/25 at 11:27 p.m. revealed that P#1 stated she was tired of life and wanted to talk to a counselor. The note further documented that P#1 denied suicidal and homicidal ideations, visual and auditory hallucinations and was not on any medication. The note documented that P#1 had a history of suicidal ideations and had been hospitalized in the facility’s off-site mental health center in the past. A review of facility A’s ED note by (Clinical Coordinator) CC II on 10/26/25 at 11:27 p.m. revealed that P#1 1 stated that she wanted to speak to a counselor but denied suicidal and homicidal ideation. CC II documented P#1 as a level two acuity (needed to be seen urgently). A review of the PA DD’s orders on 10/26/25 at 11:32 p.m. revealed that he ordered a consultation with a Behavioral Health Intake Coordinator for P#1, and close observation. Continued review of the record revealed that P#1 was discharged from Facility A on 10/27/25 at 1:41 a.m. with a diagnosis of depression with instructions to follow up with a primary care provider in two to four days. A review of the ‘Behavioral Health Forms’ dated 10/27/25 at 1:02 a.m. revealed that P#1 left before an assessment could be performed. A review of P#1’s ED record from Facility A failed to reveal a behavioral health assessment. A review of P#1’s medical record from Facility B revealed that she arrived to the ED on 10/27/25 at 3:56 p.m. with a complaint of ‘suicidal’. A review of facility B’s Behavioral Health Assessment note on 10/27/25 at 8:52 p.m. revealed that P#1 was assessed using telehealth (remote healthcare services). P#1 was assessed and endorsed suicidal ideation. Continued review revealed that P#1 was determined to be a high suicide risk per the C-SSRS. P#1 was discharged from Facility B via transport to Facility C on 10/27/25 at 10:27 a.m. A review of a behavioral health facility (C) revealed that P#1 was admitted on 10/28/25 at 4:22 p.m. with major depressive disorder documented by the medical doctor (MD). A review of facility C’s discharge noted on 11/6/25 at 11:59 a.m. documented by the registered nurse (RN) that P#1 was discharged per physician’s orders and left on 11/6/25 at 11:40 a.m. A review of the facility’s Medical Staff By-laws revealed in article II that the purpose of the medical staff was to provide a mechanism that ensured all patients admitted to or treated in any of the facilities or services of the facility received a uniform level of appropriate quality care, treatment and services commensurate with community resources during the length of stay with the organization. Review of “Appendix “B”-Rules and Regulations,” revealed that rules and regulations were adopted in connection with the Medical Staff Bylaws and made apart thereof. Article V 1. Any individual who is presented to the Emergency Department (ED) should have been provided with a medical screening exam (MSE) to determine whether the individual experienced an emergency medical condition (EMC). An EMC was defined as active labor or as a condition that manifested such symptoms that the absence of immediate medical attention was likely to cause serious dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual or unborn child. A review of the facility policy titled, “EMTALA - Medical Screening and Treatment of Emergency Medical Conditions”, number LL.026, effective 11/16/23 revealed that any individual who came to the facility or premises and requested examination or treatment was provided an appropriate medical screening examination performed by a physician or qualified medical personnel to determine whether an emergency medical condition existed. An emergency medical condition was a medical condition that manifested 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 condition could reasonably be 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 medical screening examination (MSE) was the process required to reach with reasonable clinical confidence, the point at which can be determined whether an emergency medical condition existed, or a woman was in labor. Such screening must be done within the facility’s capability and available personnel, including on-call physicians. The MSE must be performed by a physician or other qualified medical personnel. The medical screening examination was an ongoing process, and the medical records must reflect continued monitoring based on the patient’s needs and must continue until the patient was either stabilized or appropriately transferred. During an interview with Clinical Coordinator (CC) AA on 12/8/25 at 10:50 a.m. in the Behavioral Health Unit (BHU) annex, she revealed that patients are taken to the BHU annex to wait for placement to a mental health facility. CC AA reported that patients who had suicidal ideations as recent as one week ago, would not be discharged home. A phone interview was conducted with physician’s assistant (PA) DD on 12/9/25 at 9:34 a.m. PA DD revealed that he worked in the emergency room (ER) at night. PA DD further revealed that he evaluated patients who came in for mental health concerns and decided whether they should be 1013 (mental health involuntary hold on individuals who are a danger to themselves or others). PA DD reported that he initiated a standing order set for patients who presented with mental health issues which included a psychiatric evaluation. PA DD further reported that once the order was initiated, the patient should have had a psychiatric evaluation prior to discharge. PA DD stated that he did not take a patient’s trip reports from emergency medical services (EMS) but talked to the charge nurse to see why the patient presented to the ED. PA DD acknowledged that if a patient came in after a suicide attempt, he would not discharge them to go home. A phone interview was conducted with Therapeutic Care Provider (TCP) EE on 12/9/25 at 1:10 p.m. TCP EE reported that she worked the night shift in the ER and at the facility’s behavioral health center off site. TCP EE further reported that she conducted behavioral health intake assessments on patients when they first presented in the ED. TCP EE further reported that if she assessed a patient who presented with suicidal ideations, she would have them admitted to the facility. A phone interview was conducted with Clinical Coordinator (CC) II on 12/9/25 at 9:43 p.m. CC II stated that her duties included triaging patients in the ED and getting them to where they need to go. CC II further reported that any patient who presented to the ED with suicidal ideation automatically received an acuity level two and should have had a behavioral health consultation. CC II further stated that any patient that came in with a suicidal ideation was automatically put on a 1013 and evaluated by a psychiatrist. CC II stated that patients who presented with suicidal ideations automatically had orders for blood and urine tests, and a consultation for behavioral health.”

“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: 49398 Based on review of policy and procedures, incident logs, medical records, and interviews with staff it was determined that the facility failed to ensure that two (P#1 and P#3) of twenty sampled patients were informed of the risks and benefits of leaving the facility against medical advice (AMA). Cross refer to A-2407 as it relates to the facility’s failure to ensure that patients leaving AMA are informed of the risks and benefits of doing so for all patients leaving AMA per the facility’s policy.”

“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: 49398 Based on a review of policy and procedures, an incident log, medical records, and staff interviews it was determined that the facility failed to ensure the risks and benefits of leaving AMA were explained and documented for four (P#1, P#3, P#6, P#14) of twenty sampled patients. P#1, P#3, P#6, and P#14’s medical records failed to include documentation that the risks and benefits of leaving AMA were explained to the patient or patient’s representative. Findings Included: A review of the facility’s policy titled “Against Medical Advice, Elopement, and Left Without Treatment (All)”, policy number 12259691, last approved 10/22, revealed that when a patient decided to leave any department of the hospital without the physician’s consent or knowledge, hospital staff should attempt to provide for the care, welfare, safety, and security of the patient without infringing on the patient’s rights. Definitions: “Left Without Treatment (LWOT): All persons who presented at a patient access area but left before being seen by a doctor. “Emergency Room- Patients who leave before treatment was complete: A patient classification that encompasses those individuals leaving the emergency department (ED) after the medical screening exam (MSE) but before the provider documented the treatment was complete. “Against Medical Advice (AMA): All patients who had been seen by a doctor in a patient care area left the hospital against medical advice. Procedure- AMA 1. Verbalize understanding of the risk related to refusing treatment. AMA Recommended Actions: The Registered Nurse (RN) would: 1. Notify the attending as soon as possible. 2. Notify the Unit Director and/or House Supervisor. 3. Provide the patient and/or legal guardian with information on the risk of leaving the hospital AMA and the benefits of staying. Make the patient aware of his/her condition and the danger he/she is assuming. Instruct the patient/legal guardian that the hospital and physician were no longer legally responsible once he/she left. 4. If possible, obtain the patient’s signature on the AMA form and attach the form to the medical record (MR). If a patient refuses to sign the form and leaves the hospital, the date, time, and patient’s refusal to sign the form should be documented in the patient’s MR and on the AMA. 5. Complete a hospital Occurrence Report. 6. Document in nurses’ notes the reason the patient the patient/legal guardian gives for leaving and the instructions they were given. The condition of the patient/legal guardian should be noted and his/her objective mental and physical status. Post-Elopement actions of the non-behavioral health and/or patient not at risk of harming themselves or others: The RN should- 1. Search the hospital property: Note- If staff contacts the patient, they should attempt to encourage the patient to stay and receive treatment. 2. Notify the attending physician as soon as possible. 3. Notify co-workers and security for assistance. 4. Notify the Unit Director and/or House Supervisor. 5. Notify the patient’s authorized contact to ensure the patient is safe. 6. Document that the patient eloped in the patient’s medical chart and what subsequent actions were taken, including who was notified. 7. Complete hospital Occurrence Report. 8. Once the search for the patient has been completed and they have not been located on the campus, the patient would then be discharged in the electronic MR. If the patient did not meet the criteria for AMA, notify the Police Department immediately and verbally notify the Director of Risk Management. LWOT: 1. The patient was classified as LWOT if the patient meets the following criteria: a. Has not been evaluated by a provider. b. Document in the record that the patient LWOT, including the time it was discovered. c. If the reason for the LWOT was known or could be obtained, indicate this on the Emergency record triage record. d. If staff were aware of the patient leaving the ED prior to an MSE, discuss the risks and benefits and attempt to get the patient to stay at the hospital and document in the MR. A review of the facility’s policy titled “Occurrence Reports”, policy number 13176973, last approved 3/2023, revealed that an occurrence was a hospital-related event not consistent with the usual or desired operation of the hospital or the care of the patient. The responsibility was for all staff. The Safety Incident Management (SIM) also known as RL Solutions, was an electronic occurrence reporting system and was accessible through the hospital intranet. Occurrence Reports were as follows: “ Anything that occurred to a patient or visitor that was unexpected and caused harm or had the potential to cause harm. “ Anything consistent with routine patient care “ Anything clinical or any process you identified as something to avoid in the future. “ Good Catch events Reportable events included AMA and elopements. Submitting Occurrence Reports: 1. SIM reports could be submitted. 2. Reports should include the event date, patient information, and a detailed summary of the event. Enough information should be provided for the event to be investigated including patient information, specific department/location of the event, and potential witnesses to the event. 3. Only factual information should be reported. 4. Risk Management should be contacted immediately for all occurrences associated with injury, and for any Sentinel Event. A review of the facility’s incident log dated 1/1/24 through 4/9/24 failed to reveal that an incident was completed on P#1, P#3, P#6, and P#14, after all were documented as leaving the ED AMA. A review of P#1’s ED medical record revealed that P#1 walked into the ED on 3/7/24 at 10:03 p.m. with a chief complaint of left-sided chest pain and lightheadedness. Continued review revealed that a medical examination screening (MSE) was conducted with patient (P) #1 on 3/7/24 at 11:24 p.m. P#1 had a history of congested heart failure (weakened heart condition, coronary artery disease (narrowing or blockage of the coronary arteries), and hypertension (pressure in your blood vessels is too high). A review of “Orders”, dated 3/7/24, revealed that P#1 was ordered an electrocardiogram (EKG) 12 lead (heart’s electrical activity recorded from electrodes on the body surface) at 10:07 p.m., 10:51 p.m., and 11:51 p.m. In addition, at 11:52 p.m. orders were placed for a chest x-ray and blood work. The results of the blood work were posted to P#1’s medical record on 3/8/24 at 5:22 a.m. A review of “Admit-Discharge-Transfer Form”, dated 3/8/24 at 1:57 a.m., revealed that P#1 told registration they were leaving at 1:36 a.m. Further review revealed that P#1’s ED disposition was documented as left against medical advice (AMA). In addition, the AMA form was not provided, reviewed, or signed by P#1. P#1 was discharged at 1:57 a.m. A medical record review of P#3 revealed that P#3 presented to the facility’s ED on 3/6/24 at 4:28 p.m. with a complaint of chest pain, severe heavy bleeding, and passing clots. An MSE was completed at 5:27 p.m. Continued review revealed that the “Admit-Discharge-Transfer Form” was completed at 7:54 p.m. by Registered Nurse (RN) EE. The following was documented: ED disposition- Left AMA ED Reason for leaving- Unknown. Refusal of Treatment Form- Form not read; patient left. ED Risk of Leaving AMA- No Further review of the medical record revealed that P#3’s discharge disposition was changed to AMA on 3/6/24 at 8:54 p.m. Continued review failed to reveal an AMA form or physician notification. A review of the medical record for P#6 revealed that P#6 arrived at the facility’s ED on 3/1/24 at 10:10 p.m. with a complaint of back pain. Continued review revealed that P#6 had a disposition of left AMA on 3/2/24 at 4:39 a.m. The medical record failed to reveal an AMA form. Continued review failed to reveal documentation that risks and benefits of leaving AMA was discussed with P#6. A review of P#14’s medical record revealed that P#14 arrived at the facility’s ED on 1/3/24 at 8:27 p.m. from an urgent care center for further treatment. Continued review revealed that P#14 had a disposition set as left prior to triage on 1/3/24 at 9:09 p.m. The MR did not reveal documentation of any listed times P#14 was called by the triage nurse. During an interview on 3/10/24 at 12:50 p.m. with Director of Patient Safety (DPS) II in a conference room, DPS II stated that these surveyors would not be able to find occurrence reports for any patients that left the facility’s ED AMA in the incident log because she looked. She added that the only unit that would file an occurrence report for patients who leave AMA would be a unit that cares for patients who have been admitted and the patient leaves AMA. A follow-up interview was conducted on 4/10/24 at 1:00 p.m. with Director of Emergency Services (DES) FF in the boardroom. DES FF stated she had been in the position for two years. DES FF explained that if a patient left after an MSE was completed, the disposition would be left AMA. She explained that if a patient wanted to leave the ED prior to discharge, she expected staff to try and figure out why the patient wanted to leave. She also expected staff to contact the charge nurse and the patient’s provider. The expectation was that the provider would speak to the patient at the bedside about the risks and benefits of leaving. DES FF said that the charge nurse was responsible for ensuring that the AMA form was signed and that the risks and benefits specific to the patient were listed. She explained that the nurse and provider should sign the AMA form. DES FF said an occurrence report was not filed for patients who left AMA. She explained that she was unaware that facility policy required that occurrence reports be filed for patients who left AMA. She said that the charge nurse was responsible for changing the depositions for discharge, including AMA, elopement, and leaving without treatment (LWOT). DES FF explained that if a patient left before being triaged or receiving an MSE, the disposition would be LWOT. DES FF said that she expected staff to try to call out for a patient thrice, fifteen minutes apart, before changing a patient’s disposition to LWOT. Staff should be documenting these actions in the patient’s medical record. DES FF also explained that elopement dispositions were for behavioral health patients who had left prior to discharge. She said that if a patient had a 1013 (legal document to hold a patient involuntarily for mental health treatment) and left the ED, local law enforcement would be notified. If a behavioral health patient did not have a 1013 and left the ED prior to discharge, staff would be expected to call the patient or legal guardian to check on the patient. In addition, she said that a copy of a 1013 should always be in the patient’s medical record. She explained that documents (i.e., AMA, 1013) were not scanned into the medical records in the ED. The documents were scanned in the medical records by the facility’s Health Information Management (HMI) department. DES FF explained that she sent out a monthly update flyer about four weeks ago to educate staff about AMAs. Prior to the education, the patient’s nurse was responsible for entering the discharge dispositions into the medical record. She also explained that staff were unable to view if the provider had started the MSE in the medical record. The MSE was not available in the MR until the provider signed off, usually 24 hours. During an interview on 4/10/24 at 1:32 p.m. in the conference room, Registration Clerk (RC) GG said that she has been employed at the facility for seven years. RC GG said that when patients walk into the ED, they are greeted by an RC who performs a mini registration that includes taking the patient’s name, inquiring if the patient was seeking treatment and what was their reasoning for seeking treatment. RC GG said that if the patient reports shortness of breath (SOB), chest pain, bleeding, or anything that may require performing an electrocardiogram (EKG) (a test to record the electrical signals of the heart) then they call for a triage nurse to immediately see the patient. RC GG said that all other patients are logged in and waiting for a triage nurse to call the patient for triage. RC GG said that for anything that may require clinical care or if the patient is in visual distress, the RC must alert the triage nurse via a walkie-talkie. RC GG said that the RCs have a discharge desk, and once patients are discharged, they visit the desk to discuss payment. RC GG said that if a patient decides to leave prior to being seen by a provider, the RC requests the patient to come to the registration desk to inform them and the RC will attempt to get the triage nurse to assess the patient. RC GG said that sometimes patients leave the waiting room, and they simply walk out prior to being seen by a provider and the RC should notify the Charge nurse. RC GG said that registration does not occur in the back, so the RC does not play a part in patients who leave against medical advice (AMA) unless the patient stops by the front registration desk or the discharge desk. RC GG said that if the patient comes to either desk, they will inform the Charge nurse and the provider so that they may talk with the patient. An interview was conducted with Nurse Practitioner (NP CC) on 4/10/24 at 3:05 p.m. in the conference room. NP CC stated that he recalled P#2 because she presented to the ED from another facility stating that she had sepsis and needed a bolus (a single, large dose of medicine). P#2 was seen in the ED’s Rapid Care Unit (RCU). NP CC recalled reviewing P#2’s lab work from a previous visit. NP CC spoke with the patient and advised her that he did not see any indication of sepsis. NP CC stated that he left to review the previous chart and write new orders and when he returned, he was advised by the nurse that P#2 had walked out and left. NP CC stated that he does not list patients as AMA until he can speak with them first and explain the risks and benefits of leaving AMA. NP CC added that if a patient leaves before he can speak with them, he would document them as LWOT or elopement. NP CC said he would never document a patient diagnosis as elopement or document a discharge disposition as AMA in the same ED visit. He further added that it was his expectation of staff to notify him when a patient says they want to leave without treatment so he can speak with the patient prior to discharge. NP CC stated that patients who want to leave without treatment are asked to sign an AMA form which is additionally signed by the provider prior to discharge.”