Effingham Health System

“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: 42305 Based on review of facility policies, medical records, Medical Staff Bylaws reviews, law enforcement reports, and interviews, it was determined that the facility failed to provide an appropriate Medical Screening Examination (MSE) that included ancillary services and psychiatric consultations for two (Patient #1 and Patient #22) of 22 (P#1 P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18, P#19, and P#20, P#21, P#22) patients who presented to the hospital’s ED. Patient #1 and Patient #22 were brought to the ED by law enforcement due to attempts and/or threats to harm self and/or others. Patient #1 and Patient #22 endorsed homicidal ideations vocalized a desire to harm family members during their emergency department admission. The facility failed to provide comprehensive psychiatric medical screening examinations, which were within the capability of the hospital’s emergency department, prior to both patients being taken from the ED into police custody after assaulting staff. As this resulted in inappropriate medical screening examinations for Patient #1 and Patient #22. Cross-reference to Tag C-2406 .”

“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: 42305 Based on review of the facility’s Medical Staff Bylaws, review of Policies and Procedures, medical records review, Family Violence Reports review and interviews it was determined the facility failed to ensure that an appropriate Medical Screening Examination (MSE) was provided within the capability of hospital’s ED (Emergency Department) including the ancillary services of laboratory and diagnostic studies and Psychiatric consultation/ Evaluation routinely available to the ED in order to determine whether or not an emergency medical condition existed for 2 (two) of 22 (twenty-two) patients reviewed who came to the ED seeking mental health evaluations. Both patients (Patient #1 and Patient #22) voiced homicidal ideations and subsequently displayed aggressive behaviors prior to and immediately after discharge from the hospital’s ED. As this resulted in an inappropriate Medical Screening Examinations for Patient #1 and Patient #22. Findings Include: Review of the facility policy titled, “Emergency Medical Treatment and Labor Act) (EMTALA)” reviewed 1/31/26, revealed in part, “Policy Statement: I shall be the policy of Effingham Health System (EHS) to ensure that all individuals who came to ...(“Hospital”) the hospital for a possible emergency medical condition ... “are entitled to, and will receive, the appropriate care as outlined in the Emergency Medical Treatment and Labor ACT ... Definitions: ... Capability: The level of care that Hospital personnel can provide within the training and scope of their professional licenses. This includes coverage available through the Hospital’s roster. Capability Is measured by the physical space, equipment, supplies and specialized services that the hospital provides (e. g .... psychiatry ...) ... Emergency Medical Condition(EMC): A medical condition manifesting itself by acute symptoms of sufficient severity including ( ...Psychiatric disturbances, and or substance abuse) such that an ordinary prudent layperson could reasonably expect the absence of immediate medical attention could reasonably expected to result in either: Placing the health of the individual ...in serious jeopardy; or Serious impairment to ...mental functions; or ...other serious medical or medical consequences, including without limitation, posing a threat of harm to self and others ...Psychiatric Emergencies: An individual expressing suicidal or homicidal thoughts or gestures. . .that may indicate an intent to harm in any way oneself or another and determined dangerous to self and others ...Procedure: B. APPROPRIATE MEDICAL SCREENING AND STABILIZATION: ... The adequacy of a MSE depends on the presenting signs and symptoms elicited in the patient history, A MSE is a process and involve multiple stress and reassessment over time to include diagnostic evaluation and/or consultation with specialty physicians as needed.” The facility’s Medical Staff Bylaws reviewed approved by: The Medical Executive Committee on August 20, 2024, the Hospital Authority on August 27, 2024, was reviewed. The section titled “F. Psychiatry Staff” stated in part, “The Psychiatry Staff would consist exclusively of practitioners who were under contract to provide psychiatry services to patients utilizing the Hospital.” Review of Articles XII, Rules and Regulations the section titled “Consultations 7.1” revealed that quality medical care included the proper and timely use of consultation. The attending physician was primarily responsible for requesting a consultation from a qualified consultant when indicated. The facility’s Policy titled Management 1013 or 2013 Patients, Department: Patient Care, Section: Security, Review Date: 02/16/2026 was reviewed. The Policy revealed in part, “When a physician documents that a patient is 1013.., all patient rights are waived, and the hospital is responsible for the safety and well-being of the patient ... Definitions: 1013- A mentally ill patient that presents a substantial risk or imminent harm to self or others as manifested by recent overt acts or recent expressed threats of violence which presents probability of physical injury to self or others ...Procedures:...if the patient does become physically aggressive a “Code Grey” (hospital emergency code is activated to signal a combative , aggressive or violent person ) will be initiated.” The “Family Violence Report dated “November 28, 2025, at approximately 0012 (12:02 AM) was reviewed. The section of the report titled “Officer Supplementals” provided by the sheriff’s office revealed in part, “I responded to the incident location in reference to the incident location in reference to 911 ...hangup. While en route, a Computer -Assisted Dispatch (CAD) alert rang ...The alert from the CAD was “male, combative, autistic” (autistic -condition characterized by persistent differences in social communications, interactions and behavior). Further review revealed that the officer observed P#1 forcefully push a female family member against the wall. Another family member (a male) attempted to release P#1’s grasp, but P#1 attempted multiple times to headbutt the male family member. The officer also observed P#1 attempt to spit in the female family member’s face twice as the officer was grabbing P#1 to detain him. Patient #1 hands were bound and placed in handcuffs. The male family member informed the officer of a prior episode where P#1 tried to stab the female family member with a butcher knife. The female family member suggested that P#1 be transported to the hospital for a mental evaluation. Further review revealed, Patient #1 was transported to Effingham Health System ED for a mental evaluation. The female family member followed the LEO via privately owned car to the hospital. Continued review revealed in part, “Upon arrival, Patient #1 was released to ER (Emergency Room) staff’s custody; under the care of (ED Physician) MD CC. I briefed MD CC on the entire incident leading up to his arrival ...The Officer asked MD CC if he needed me to stay around but he said to ask Patient # 1’s female family member. Patient #1’s female family member asked Patient #1, and he said yes. ...I stayed until I was informed by the ER Nurse, (RN BB), MD CC-said he was not signing a 10-13 (in Georgia an emergency involuntary mental health commitment (civil hold) initiated when a person poses a imminent danger to themselves or others Law enforcement is allowed to transport the individual to facility for an evaluation) against Patient #1 as Patient #1 was to be released to his female family member’s custody upon discharge ...” The officer stayed in the ED at the request of P#1. Further review of this report revealed in part, “P#1 flipped his middle finger to his female family member, then non-verbally threatened his female family member by changing the middle finger to a finger gun while making comments (inaudible).” The officer informed RN BB about the new behavior and non-verbal threats. RN BB went to speak to P#1. RN BB told the officer that P#1 “admitted to her that he was homicidal against his female family member. RN BB informed MD CC of what the officer had observed as well as her own observations, but MD CC had told her they would only monitor P#1 for about an hour then still release him to his female family member’s custody. RN BB said MD CC cleared me to leave the hospital as Pt#1 was in their custody.” The Medical Record for Patient #1 was reviewed. The section of the medical record titled “Encounter Information” revealed that P#1 arrived at the ED on 11/28/25 at 1:13 a.m. for a psychiatric evaluation. Review of “ED Triage” by the Registered Nurse (RN AA) documented on 11/28/25 at 1:17 a.m. revealed that P#1 came in with the Sheriff Count Officer for a psychiatric evaluation. “Pt. (Patient) reports that he got angry. Pt. at this time denies SI (Suicidal Ideation- thoughts of ending one’s life) or HI (Homicidal Ideation-thinking about or planning to kill another person).” Patient #1’s acuity (a triaged based classification system measuring the severity of a patient’s illness, or Injury) was listed as “2 -EMERGENT” (High Risk Situation). A suicide screening was completed, and the patient’s level was “Low Risk.” Review of the “ED Provider Note” documentation by the Medical Doctor (MD CC) on 11/28/25 at 4:20 a.m. revealed that P#1 was seen at 1:18 a.m. P#1 had a history of autism and developmental delay. He came to the ED after apparently getting agitated in front of the police, who he called to his own house. P#1 apparently spit at a family member and became aggressive. The patient’s “Problem List / Past Medical History Ongoing” was listed as Autism, Seizures and Tobacco use. The Physical Examination revealed in part, Psychiatric: Patient clearly with autistic features ...” P#1 was assessed by MD CC to have agitation and autism. Medication orders were obtained, the patient was given Lorazepam (Ativan-medication used for anxiety disorder and seizure management). Further review revealed that Patient #1 was discharged to self and ambulatory on 11/28/25 at 2:59 a.m. Review of the complete ED medical record failed to reveal any ancillary studies such as laboratory testing, neurological testing, or any other diagnostic studies were performed. There was no documentation as to why further testing was not indicated. Additionally, the medical record failed to reveal a comprehensive psychiatric consultation/evaluation was performed to evaluate the patient’s high risk of harming others; as law enforcement reported to the ED staff he observed Patient #1’s violence and aggression toward his family members. Patient #1 also became aggressive/violent towards an ED staff member status/post discharge. The (Name) County Sherriff Family Report dated 11/28/25 was reviewed. The victim in this report was listed as RNBB. The section of the report titled “Narrative” reveled in part, “ ...at 0234 hrs. [2:24 AM], I responded to Effingham Health in reference to a disorderly individual (Patient #1) who had struck a hospital nurse. Upon my arrival, I began speaking to the nurse/victim (RN BB) who said the offender (Patient #1) had been discharged from the hospital ER doctor’s care and was to be sent home with his female family member. The Nurse/Victim said while walking the offender (Patient #1) outside, the Offender (Patient #1) turned to her with an aggressive stance, called her a racial slur, then proceeded to slap her hands away from her body. ...I placed the offender (Patient #1) under arrest and transported him to the ... County Jail ...” During a telephone interview with the complainant on 2/2/26 at 2:40 p.m., the complainant stated that Patient #1 called the police because he was agitated and thought he was going to hurt someone. The police took Patient #1 to the ED. Patient #1 was discharged, and while the family member went to get the car, Patient #1 struck a nurse. The police were called, and Patient #1 was taken to jail. The complainant said that the family wanted Patient #1 to have psychiatric care, The complainant also stated that she had expressed her concern with MD CC, but MD CC had informed her that Patient #1’s issues were not psychiatric but behavioral. An interview took place with the ED Nurse Manager (RN II) on 2/3/26 at 11:13 a.m. during a tour of the ED. RN II said psychiatric consultations were available from a contracted group through telehealth monitors, primarily for patients who were on involuntary holds seeking placement at a behavioral health facility. An interview took place with RN BB on 2/3/26 at 1:54 p.m. RN BB said Patient #1 came to the ED with a family member and officer. Allegedly, Patient #1 was acting out at home. MD CC did an assessment and believed it was more behavioral. A telephone interview took place with the ED Medical Director (MD FF) on 2/3/26 at 2:17 p.m. MD FF said psychiatric screening examinations were part of the core competencies of ED physicians. Physicians would perform full assessments with ancillary data. A telephone interview took place with the ED physician (MD CC) on 2/3/25 at 5:05 p.m. MD CC said if anybody was having thoughts of harming themselves or others, they would get the same physical examination as anyone else. Appropriate psychiatric questions would be asked to get an idea of mental status. Usually, a relative or friend would be there to provide additional information. The Medical Record for Patient #22 was reviewed. The section of the medical record titled “Encounter Information” revealed that Patient #22 arrived at the ED on 12/10/25 at 1:30 p.m. for Suicidal Ideations (thoughts). The “ED Triage” by Registered Nurse (RN JJ) documented on 12/10/25 at 1:35 p.m. revealed that Patient #22 arrived with the sheriff’s office stating that he wanted to kill himself and other people. Patient #22’s acuity level was listed as “2 (Emergent)”. Review also revealed that Patient #22 had a history of bipolar disorder (a mental health condition that causes extreme high and low mood swings) and schizophrenia (a serious mental disorder that affects how a person thinks, feels, and acts making it difficult to distinguish reality from imagination). Patient #22 had an active diagnosis listed as “Aggressive Behavior.” Review of the Suicide Screening revealed that Patient #22 answered yes to questions concerning thoughts about killing himself and previous attempts to end his life in the past month. Review of the “ED Provider Note” by the Doctor of Osteopathy (DO KK) on 12/10/25 at 2:51 p.m. revealed that Patient #22 was seen at 1:32 p.m. Patient #22 had a history of schizophrenia and was brought in stating that he was suicidal and homicidal. A Review of Systems was completed. A psychiatric evaluation by DO KK stated that P#22 did not appear to be hallucinating or responding to internal stimuli. A 1013 was enacted for a psychiatric consultation given the patient’s history. The “Form 1013 Certificate Authorizing Transport to Emergency Receiving Facility & Report ... (Mental Health)” dated 12/10/2025 at 1:59 p.m. was reviewed. The form stated in part, “At the time of my evaluation, the conditions checked below were present: (Checked) This individual appears to be mentally ill. My opinion is based on the following observations: Pt. states he wants to kill himself and other people. This Individual: (Checked) Has committed /expressed recent overt acts/threats towards others. (Checked) Has committed /expressed recent acts/threaten ...violence to self.” Unfortunately, during the patient’s time in the ED, he assaulted one of the staff members who had elected to press charges. The “1013 Form” was rescinded and Patient #22 was discharged from the ED at 2:20 p.m., into police custody. Review of the “Orders” dated 12/10/2025 at 2:03 p.m. included a consultation with case management, laboratory testing was canceled, and the 1013 was rescinded because Patient #22 was discharged to Law Enforcement custody. Review of the complete medical record failed to reveal a comprehensive psychiatric consultation /evaluation was performed to evaluate patient’s risk to harm himself and/or others. Further review revealed no homicidal assessment was conducted, even though the patient stated he was having homicidal ideations. There was no documentation in the medical record to indicate that Code Grey was called when Patient #22 became aggressive with an ED staff member as stated in the facility’s policy. An interview took place with the ED Nurse Manager (RN II) on 2/3/26 at 11:33 a.m. in the Conference Room. RN II said a 1013 was a mandatory hold for a patient to be evaluated for safety of either the patient or others. RN II said it was up to the provider to evaluate a patient to see if it was a behavioral issue or a true psychosis event requiring stabilization. Psychiatric video consultations were an option. Usually, every 1013 patient would get a psychiatric evaluation. An interview took place with the RN JJ on 2/4/26 at 9:33 a.m. in the Conference Room. RN JJ said. Patient #22 came in saying he had suicidal thoughts without a plan. A telephone interview took place with DO KK on 2/4/26 at 12:08 p.m. DO KK said after speaking to Patient #22 and getting his mom’s input, it was determined that Patient #22 was not actually suicidal. There were no signs of being suicidal or psychotic. The plan was to rescind the 1013. At that time Patient #22 assaulted a security guard. An interview took place with the Security Team Supervisor (SS LL) in the Conference Room on 2/4/26 at 1:17 p.m. SS LL said Patient #22 came with police officers and walked himself to Room 12, which was the psychiatric room. Patient #22 said he did not want SS LL sitting near the doorway. SS LL told Patient #22 that she was required to sit there. Patient #22 told SS LL he was going to hurt her if she did not move. When SS LL went to move out of Patient #22’s way, he came behind her and pushed her. Patient #22 was on 1013 and was not mentally stable He looked agitated and was mad at his family. He stated that he was going to “F up” his mama and his sister. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that Patient #1 and Patient #22, both psychiatric patients expressing suicidal and homicidal ideations, thoughts and gestures, and indicated an intent to harm in any way oneself or others received an appropriate medical screening examination.”