So Crescent Beh Hlth Sys - Anchor Hospital Campus

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 40979 Based on medical record review, video surveillance review, facility documents, staff interviews, and review of facility policy, it was determined that the facility leadership failed to protect patients from all forms of abuse when two patients (P) (P#1 & P#3) of five (P#2, P#4, & P#5) sample patients were abused by one patient (P#2). Findings include: A review of P#1’s medical record revealed that she was admitted to the facility on 3/13/25 with major depressive disorder (mental disorder characterized by a persistent low mood, loss of interest or pleasure in activities). Review of nurse note dated 3/13/25 at 6:25 p.m. revealed P#1 was sent to ER (emergency room) after being attacked by peer. The peer punched P#1 in the head and nose for unknown reasons; nurse manager was on the unit when the incident occurred. Review of nurse note dated 3/13/25 at 9:00 p.m. revealed spoke to ER charge nurse for acceptance, full report given. P#1 was accompanied by a staff member at her side. Patient was calm and cooperative upon her transfer. No distress upon her transfer. A review of video surveillance dated 3/13/25 at 6:13 p.m. revealed the following: 00:12 females standing and sitting at the end of the hallway 00:38 RN DD walks out of P#1’s room with linen in her hand 00:58 RN DD unlocks door to linen closet 01:41 P#2 runs into P#1’s room swinging her arms 01:43 MHA CC runs behind P#2 01:48 all staff heading to P#1’s room Review of P#2 incident report #25-67272 revealed the following: A. Date of Incident: 03/12/2025 Time: 9:45 p.m. B. Incident Type: aggression patient towards patient. Comments: “At 9:45 p.m. patient get agitated because the other patient sreamed [sic] in another room, patient still on 1:1 (one on one) got out of her room and physically and agresively [sic] punched the other patient in her face multiple times. Other patient face noted with redness and sting of blood on her nose, but no active blleding [sic] noted on her nose.” Review of P#1 incident report #25-68212 dated 3/13/25 revealed the following: A. Date of Incident: 03/13/2025 Time: 6:25 p.m. B. Incident Type: aggression by another patient. I. Treatment or Intervention Given: Emergency Room. Comments: “ Patient was sent to the ER (emergency room) after being attacked by her peer. Her peer punched her in the head and nose ....” Review of P#2 incident report #25-68242 dated 3/13/25 revealed the following: A. Date of Incident: 03/13/2025 Time: 6:25 p.m. B. Incident Type: aggression patient towards patient. H. Injury. Self-inflicted. Comments: “Patient attacked her peer for unknown reasons. She punched her in the head forehead area and nose. Code 1 was called. Staff separated her from her peer. Patient’s left index finger was slightly swollen. First aid applied. Good range of motion. Internist formed-X-ray orders received and placed. All other appropriated notifications made.” Review of P#1 incident report #25-71711 dated 3/17/25 revealed the following: A. Date of Incident: 03/13/2025 Time: 6:28 p.m. B. Incident Type: Change in Condition. D. Type of Injury: Bruise. H. Injury caused by other patient. N. Physician Response. Treatment required. Comments. “Pt presented with c/o (complaints of) headache after being hit by another patient. No obvious injury beyond slight pinkness to face region. No lacerations or cuts. Patient remained Alert Ox3, verbalizing needs, ambulating without difficulty. Took water without difficult. However anxious. Addendum 3/18/25 8:51 a.m. : Pt.was discharged from (the acute care hospital) back254 home with mother. Dr at (acute care hospital) consulted with treating inpatient DR on discharge plan. No injuries identified from ED visit.” An interview was conducted with Registered Nurse (RN) BB on 3/24/25 at 4:15 p.m. in the administration conference room. RN BB stated that she recalled P#1 and P#2 and the incident that took place on the adolescent unit earlier this month. RN BB stated that she did not witness the altercation; however, she completed the paperwork to transfer P#1 to the hospital after the altercation with P#2. She continued to explain that she was given detailed information from RN DD who witnessed the assault. RN BB continued to explain that RN DD told her that there was a verbal exchange between P#1 and P#2 in the dayroom a few minutes earlier and according to RN DD, she wanted to removed P#1 from the situation and escorted her to her room. RN BB recalled that RN DD stated that P#2 followed her (RN DD) and P#1 to P#1’s room and attacked P#1 for no reason. RN BB stated that as soon as she heard the altercation she ran out of the back room to see what was going on and immediately got P#1 out of the room to keep her safe and away from P#2. RN BB stated that she immediately assessed P#1 and advised the nurse manager that she needed to go to the hospital. She continued to explain that she notified P#1’s mom of the assault. An interview was conducted with Assistant Director of Nursing (ADON) AA on 3/25/25 at 11:00 a.m. in the administration conference room. ADON stated that she did recall the incident that involved P#1 and P#2 on 3/13/25 on the adolescent unit. She continued to explain that on the day of the incident, she was on the unit making her rounds and noticed P#1 in the dayroom area conversing with her peers. P#2 was on a one-to-one, was also in the dayroom area. ADON continued to explain that P#2 was on one-to-one due to her history of seizures, not because of her aggression. She continued to say that P#2 had several aggression incidents while at the facility and it had been difficult to regulate this patient. She continued to explain that she was notified of the altercation soon after it occurred and advised RN BB to contact P#1’s guardian as well as the physician regarding the assault. ADON continued to explain that she was advised that P#1’s physician requested that she (P#1) be sent to the hospital to be assessed. ADON stated that the charge nurse on duty was responsible for making nursing assignments based on the acuity. An interview was conducted with Registered Nurse (RN) DD on 3/25/25 at 3:00 p.m. in the administration conference room. RN DD stated that she did recall P#1 and the incident that occurred between P#1 and P#2 earlier this month. She continued to explain that on the day of incident she was working on the adolescent unit when she noticed all the girls in the dayroom talking among themselves. She continued to explain that she noticed P#2 verbally teasing P#1 and due to the verbal teasing she decided to move P#1 to her room away from P#2. RN DD stated that she continued to keep her eye on P#2 because she had a history of physically attacking and assaulting patients and staff. She continued to explain once she moved P#1 to her personal room, she walked out to get fresh linen to make her bed. She continued to explain that she instructed P#1 to stay in her room until she returned because she could see P#2 was still in the dayroom and she was concerned for P#1’s safety. RN DD stated that by the time she walked into the linen room, she could hear a commotion coming from P#1’s room and she ran down the hallway along with other staff to break up the fight. RN DD stated when she entered P#1’s room she witnessed P#2 hitting P#1 on her head. She continued to explain that MHA CC was already in P#1’s room attempting to break up the fight and eventually removed P#2 from P#1’s room. RN DD stated that she immediately assessed P#1 and gave report to ADON. She continued to explain that she gave an account of what happened to RN BB who was making contact with P#1’s guardian and the physician. RN DD stated that the physician ordered to have P#1 go to ED for further assessment. An interview was conducted with Mental Health Assistant (MHA) CC on 3/25/25 at 3:35 p.m. in the administration conference room. MHA CC stated that she did recall the incident that occurred between P#1 and P#2 on the adolescent unit. She continued to explain that she was next to P#2 all day on the day of the incident. MHA CC stated that P#2 required a staff member to remain with her at all times because of her spontaneous, erratic behavior. She continued to explain that before the incident she could recall sitting next to P#2 in the dayroom and P#1 had just arrived to the unit earlier in the day. MHA CC stated that P#2 was verbally teasing P#1 for no apparent reason. MHA CC stated that RN DD seemingly noticed something too because she removed P#1 from the dayroom and escorted P#1 to her personal room on the unit. She continued to explain that at one point all the girls were in the dayroom area standing up talking among themselves and as she stood next to P#2, P#2, unprovoked, took off running into P#1’s room hitting P#1. MHA CC stated as soon as P#2 started to run towards P#1 she started running after her, but P#2 made it, into P#1’s room in enough time to hit her a few times in the head. MHA CC stated that this is the reason P#2 is required to have one-to-one precautions because she has a history of reacting violently without warning and without reason. A review of the facility’s “Patients’ Right and Responsibilities” policy, Policy number RI.005, last reviewed 10/2022 revealed II. List of Rights. A. Without limitation patients shall be entitled to: Care in a safe and sanitary setting. Be free from neglect, exploitation; verbal, mental, physical, sexual abuse, and all forms of abuse, harassment and corporal punishment.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 49318 Based on review of policy and procedures, facility documents and staff interviews, it was determined that the facility failed to ensure that the medical record included documentation of the chain of custody of patient belongings when documentation supporting personal belongings and valuables removed from a patient upon admission, during hospitalization, and returned to patient upon discharge from facility for one patient (P) (P#1) of four records reviewed. Findings Include: A review of facility’s policy titled “Patients Belongings and Valuables Protocol,”, Policy No.: RL041, last revised 09/24, revealed that is the policy of the facility to provide safe storage of valuable patient possessions during in-patient treatment. All patients admitted to the facility will undergo a safety search. A patient’s belongings that have been brought into the hospital and that do not accompany the patient onto the assigned unit will be stored in the Patient Belongings Closet (PBC). For security purposes, belongings that are considered valuables will be stored in a safe within the Patient Belongings Closet. Storage of patient belongings and valuables and access to the Patient Belongings Closet will be done according to the following guidelines: Process for Belongings at Admission: 1. For patients who are brought into the facility via Emergency Services, they will undergo a safety search and have belongings and valuables removed, bagged belongings labeled and placed in a cubicle within the ARS Department. The safety searches will be conducted by two employees, one as the primary search conductor and the second to review and double check the process. 2. During this safety search time, the patient will be allowed to get phone numbers from their phone. 3. The patient will be given a document outlining the belongings process for them to sign during the admissions process. If the patient arrives with no belongings, this form will be used to document this and the patient will sign it. This form will be placed in the medical record. 4. After the patient is admitted, the belongings bag will be tagged with patient label and placed in the Patient Belongings Closet. Wallets, jewelry, electronic devices, credits cards, money, purses and any other valuables should be placed in the vault in the Patient Belongings Closet. 5. If the patient arrives wearing regular clothes, the patient will be allowed to go to the unit wearing those clothes (if they are appropriate) after the safety search is completed. 6. If the patient arrives wearing scrubs, the patient will be given new scrubs while in ARS 7. Appropriate belongings will be approved by ARS staff. Upon receiving the appropriate belongings that will accompany them to the unit and the list belongings/valuables that are stored, the patient will sign off on the list. One copy will be placed in the medical record, the second copy will be in the belongings binder housed in the ARS Dept. In the event the patient cannot sign, 2 staff will sign. 8. Once the patient has been processed through ARS, they will be accompanied by staff to the appropriate unit. They will receive their approved belongings on the unit after the scheduled belongings search has been completed Upon receiving their belongings, the patient will sign off on the list of belongings they received and the list of belongings/valuables that are stored. Process for Patient at Discharge: 1. On date of discharge Milieu Manager or designee will move patient’s belongings to the discharge closet to minimize delays at discharge. 2. The discharging MHA or nurse will retrieve the patient’s belongings, have the patient verify items that have been received, and then have the patient sign off that all belongings have been returned. The signed belongings sheet at discharge will be placed in the medical record. 3. Patient Advocate and Milieu Manager should be notified of any discrepancies in patient belongings. A review of the facility’s policy titled “Patient Rights and Responsibilities,” Policy: RL005, last revised 10/22, revealed that it was the policy of the facility to respect all patients without regard to race, religious creed, color, ancestry, national origin, sex, disability, marital status, familial status, or sexual orientation. The facility supported and protected the fundamental human, civil, constitutional, and statutory rights of the individual patient and recognized and respected the personal dignity of the patient at all times. Rights are restricted only in accordance with applicable law and regulation. Approximately two days prior to planned discharge, the Social Worker will give the patient another copy of “An Important Message from Medicare” to read and sign as a part of the discharge process. The second notice will be given no more than 2 days prior to discharge and no less than 4 hours prior to discharge. In the event a Social Worker is unavailable to provide the second notice, a nurse will give a copy of the form to the patient. If patients disagreed with the discharge decision, it was their right to appeal the discharge decision. If the patient exercised his right to contact the local Quality Improvement Organization (QIO) reviewer, staff would immediately contact the physician to rescind the discharge order until the QIO reviewer makes a determination to uphold the treatment team’s discharge decision or suspend the discharge. Patients had the right to be informed about treatment expectations, progress, and outcomes. It was the policy of the facility to fully disclose to the patient and family/significant other as desired, outcomes of care including errors, adverse occurrences, and outcomes that differ significantly from expectations. The attending physician would keep the patient and family/significant other as desired, informed of treatment expectations, progress, and outcomes of care during the course of hospitalization. The physician/designee would promptly inform the patient and family/significant other as desired when an error, adverse occurrence, or outcome of care that differs significantly from expectations occurs. The facilities provided written notice to all patients at the beginning of an inpatient stay or outpatient visit that there is no Doctor of Medicine or osteopathy present in the hospital 24 hours per day, seven days per week in order to assist the patient in making an informed decision about his/her care. The notice must explain how the hospital meets the medical needs of patients who develop an emergency medical condition at a time when no physician is present in the hospital. A review of Daily Progress Note dated 8/25/24 at 12:00 p.m. revealed that P#1 ambulated in wheelchair, denied SI/HI (Suicidal Ideations/Homicidal Ideations- to describe the thoughts of wanting to harm oneself or others), vital signs normal, cooperative and compliant with taking medications. Further review of Daily Progress Notes dated 8/26/24 P#1 denied SI/HI, less agitation and ready to go home. A review of Progress Record dated 8/27/24 at 2:00 p.m. revealed P#1was discharged to home. P#1 was given discharge instructions concerning medication compliance, suicide prevention, and compliance with aftercare appointments. P#1 verbalized understanding and belongings were returned. An interview was conducted with the Director of Risk Management (DOR) AA on 11/4/24 at 1:30 pm in the Intake room. DOR AA stated that she remembers P#1 and stated on admission patient was admitted to the Geriatric Unit and patient was very timid. DOR AA also stated that she was very surprised to see that the patient had been moved to the second most acute care unit due to agitation and threatening to harm others with his prosthetic leg. DOR AA stated that the prosthetic leg was electronic, and it was paired to the patient’s phone. DOR AA further stated that she does remember P1 had an altercation with a female patient. DOR AA stated that the incident happened at the nurse’s station and stated that she spoke with both patients. P1 was later discharged, and the female patient was moved to another unit. DOR stated that P#1 kept asking for his prosthesis and he was told that they were charging it for him. DOR AA stated that she saw the patient prior to discharge but did not see him leave with his prosthetic leg. DOR AA stated that Milieu Manager (MM) EE walked him to his vehicle, and he had his Prosthetic leg on. An interview was conducted with Mental Health Aid (MHA) CC on 11/ 5 24 at 10:45 a.m. in the intake room. MHA CC stated that she did remember P#1. MHA CC stated that she had two encounters with the patient. MHA CC also stated that in one encounter the patient was very aggressive due to another patient antagonizing him and threw water on him. MHA CC stated that if a patient had any personal belongings removed from them while on the unit the nurse would be notified, and the belongings would be put behind the nurse’s station and logged on the belongings and valuable form. MHA CC stated that she does remember the patient leaving with his prosthetic leg because he had a FILA shoe on the prosthetic foot. An interview was conducted with the Director of Clinical Services (DCS) DD on 11/5/24 at 12:00 p.m. in the intake room. DCS DD stated that she does remember P1 due to the high quality of his prosthetic leg. DCS DD stated that during a flash (group huddle with employees where discussions are held) meeting, It was discussed that P1 was threatening to remove his leg and hit people with it. The prosthetic leg was removed and taken from P1 and he was given a wheelchair. DCS DD stated that the leg was stored on the unit in a storage area. DCS DD stated that she remembers the leg stored on the unit because it needed to be charged so it would be ready for patient upon discharge. DCS DD stated that Milieu Manager (MM) EE walked P1 to his vehicle upon discharge and the patient was wearing his leg. An interview with MM EE was conducted on 11/5/24 at 12:50 p.m. in the intake room. MM EE stated that she remembers P1 being verbally aggressive and having a physical altercation with a female patient on the unit and he threatened to harm others with his prosthetic leg. MM EE stated that when P1 Prosthetic leg was removed it was placed in the belongings closet that is locked and only the supervisor on duty has the key. MM EE stated that once the leg was taken from P1 he was given a wheelchair, and the prosthetic leg should have been logged on his Belongings/Valuables Form in his chart. MM EE stated that upon discharge with all his belongings, P1 had his prosthetic leg on and she walked him to the minivan that he was driving parked on the left side of the facility. An interview was conducted with MHA GG on 11/5/24 at 2:00 p.m. in the intake room. MHA GG stated that she did remember P1 and he was very easily agitated due to not having his leg and verbally aggressive. MHA GG stated that P1 had his prosthetic leg taken because he was threatening to harm others. MHA GG stated that P1 kept reiterating that he needed his leg charged so it would be ready when he was discharged. MHA GG stated that P1 Prosthetic leg was locked in the valuables closet and only supervisors had the keys to that room. MHA GG also stated that anything taken from a patient on admission or while on the unit should be listed on the Belongings/Valuable Form in the patient’s chart. An interview was conducted with Medical Assistant/Social Worker (MASW) HH on 11/5/24 at 3:00 p.m. in the intake room. MASW HH did remember P! and stated that she remembered his leg being taken from him because he was trying to use it as a weapon. MASW HH stated that P1 was given a wheelchair, and he was still showing signs of aggression. MASW HH stated that the Prosthetic leg was at the Nurses station, and it was being charged. MASW HH further stated that P1 would not have left without his leg because he drove himself to the facility. A telephone interview was conducted with Patient Advocate (PA) LL on 11/8/24 at 11:45 a.m. PA LL stated that he received a message that P#1 wanted to speak with him and when he had his first encounter with P#1 it was very short. PA LL stated that prior to him getting to the unit something took place between P#1 and a new male staff member that had P#1 extremely upset so nothing was established on that visit. PA LL stated that he spoke with P#1 the next day and he was calmer and seemed to need someone to talk to. PA LL stated that P1 did not complain about anything he just seemed to be really depressed about not being able to take care of himself and he appeared to just need someone to talk to. PA LL stated that on 9/19/24 at 2:00 p.m. he received a call from P#1’s Case Manager (CM) stating that P#1 had called her and stated that he was not given his prosthetic leg back when he was discharged from the facility on 8/27/24. PA LL stated that he spoke with nursing staff and MM EE, and everyone stated that P#1 was given his leg back on discharge. PA LL also spoke with DCS DD, and she stated that she made sure his phone was fully charged so it could be used to synchronize with P#1’s prosthetic leg upon discharge. PA LL stated that after he spoke with several different staff members, he called P#1’s CM and left her a voicemail of his findings and CM never returned or responded to his phone call.”

“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: 42060 Based on a review of the facility’s Emergency Medical Treatment and Labor Act (EMTALA) log, medical records, video recording, policy and procedures, and interviews, it was determined that the facility failed to include one (P#1) of 21 sampled patient on the facility’s EMTALA log. In addition the facility failed to ensure that a medical screening examination (MSE) was provided for three (P#1, P#7, P#17) of 21 sampled patients. Findings: Cross refer to A-2405 as it relates to the facility’s failure to maintain a central log for P#1 who came accompanied by a trained mental health worker and law enforcement with a signed 1013 on 3/20/24. Cross refer to A-2406, as it relates to the facility’s failure to ensure that three (P#1, P#7, P#17) received an appropriate Medical Screening Examination (MSE).”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 42060 Based on a review of the facility’s Emergency Medical Treatment and Labor Act (EMTALA) log, medical records, video recording, policy and procedures, and interviews, it was determined that the facility failed to include one (P#1) of 21 sampled patient on the facility’s EMTALA log when P#1 arrived at the facility accompanied by a trained mental health worker and law enforcement with a signed 1013 (involuntary hold paperwork) on 3/20/24. Findings were: A review of the facility’s EMTALA log for 3/20/24 failed to reveal an entry for P#1. A review of police incident details revealed that P#1 was transported from a Community Mental Health Center (CMHC) on 1013 to the facility. Transport was initiated on 3/20/24 at 4:51 p.m. A review of video recordings of the facility lobby took place on 4/1/24 at 3:10 p.m. with the facility’s Director of Performance Improvement and Risk Management. The following was observed: Recording of 3/20/24 at 6:26 p.m. three people observed walking into the lobby; they were identified as the county police officer, Co-responder AA, and Patient #1. Co-responder AA had some papers with her; went to the check-in window, spoke with receptionist (EE), and appeared to sign the sign in sheet. P #1 and Co-responder AA sat in the lobby. At 6:33 p.m., Intake Counselor JJ was seen in the lobby talking with Co-responder AA; then walked to the back. At 6:35 p.m. Intake RN GG came out to the lobby, looked at the papers and spoke with Co-responder AA. The officer went outside. P #1 and Co-responder AA remained seated in the lobby. At 6:38 p.m. RN GG walked out of view of the camera. At 6:51 p.m., the officer came back into the lobby. Co-responder AA walked to the check-in window. At 7:17 p.m. the Officer, Co responder AA, and P #1 exited the lobby. At 7:18 p.m. an outside camera view showed their vehicle driving off. Review of the facility’s policy #: PC.007, revised 10/2022, titled “Assessment and Referral Services-EMTALA” revealed it was the policy of the facility to assess, stabilize and/or appropriately transfer individuals who come to the facility with an emergency medical condition (EMC). Further review of the policy revealed: 7. all persons presenting as walk-ins and or transfers. All persons presenting to the facility’s Admissions department will be entered into the EMTALA log. A phone interview with Co-Responder AA took place on 4/01/24 at 12:05 p.m. Co-Responder AA stated that she worked with the County Police Department as a Team Lead Co-Responder. Co-Responder AA explained that her role was as trained personnel in mental health crisis. Co-Responder AA signed P #1 onto the sign in sheet once they arrived at the facility. During an interview with the facility’s Director of Intake and Admissions (Director) (CC) on 4/1/24 at 12:57 p.m. in a private office, Director CC stated that he had been at the facility since 2016. Director CC explained the 1013 protocol at the facility. Director CC said once a patient with a 1013 arrived, the person at the front desk first notified the Intake Nurse that there was a 1013 that just arrived. Director CC said the 1013 patient bypassed the normal process that involved some waiting in the lobby, and they took the 1013 patient straight to the Intake area in the back where they completed all the paperwork, including putting the patient on the EMTALA log. During an interview with Front Desk Receptionist (Receptionist) EE on 4/1/24 at 4:40 p.m. in a private office, Receptionist EE recalled P#1 and the evening he arrived with the two escorts. Receptionist EE said she did the routine health questionnaire (Covid questions) for the patient and notified intake staff that a 1013 patient had just arrived. Receptionist EE recalled that the intake nurse (RN GG) came out and spoke with Co-responder AA. Intake Counselor (JJ) then came out and spoke with Co-responder AA. Receptionist EE said Intake Counselor JJ told her that they (the facility) had not received paperwork for P#1. Receptionist EE said she saw the officer, Co-responder AA and P #1 walk out of the lobby. Receptionist EE said she received training on EMTALA and explained that all patients who came to the facility and asked for treatment were provided an assessment. She explained her job was to have all patients sign in and call intake anytime a patient came to the lobby. Receptionist EE said she did not know the details around P #1 or why the nurse did not want to see him.”

“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: 42060 Based on a review of the facility’s Emergency Medical Treatment and Labor Act (EMTALA) log, medical records, video recording, policy and procedures, and interviews, it was determined that the facility failed to ensure that an appropriate medical screening examination was provided to individuals presenting to the hospital for emergency services for three (P#1, P#7, P#17) of 21 sampled patients. Specifically, P#1, P#7 and P#17 arrived at the facility for emergency psychiatric services and the facility failed to provide a screening assessment. Findings were: A review of the facility’s EMTALA log for 3/20/24 failed to reveal an entry for P#1. A review of police incident details revealed that P#1 was transported from a Community Mental Health Center (CMHC) on 1013 (involuntary commitment order) to the facility. Transport was initiated on 3/20/24 at 4:51 p.m. A review of video recordings of the facility lobby took place on 4/1/24 at 3:10 p.m. with the facility’s Director of Performance Improvement and Risk Management. The following was observed: Recording of 3/20/24 at 6:26 p.m. three people observed walking into the lobby; they were identified as the county police officer, Co-responder AA, and Patient #1. Co-responder AA had some papers with her; went to the check-in window, spoke with receptionist (EE), and appeared to sign the sign in sheet. P #1 and Co-responder AA sat in the lobby. At 6:33 p.m., Intake Counselor JJ was seen in the lobby talking with Co-responder AA; then walked to the back. At 6:35 p.m. Intake RN GG came out to the lobby, looked at the papers and spoke with Co-responder AA. The officer went outside. P #1 and Co-responder AA remained seated in the lobby. At 6:38 p.m. RN GG walked out of view of the camera. At 6:51 p.m. the officer came back into the lobby. Co-responder AA walked to the check-in window. At 7:17 p.m. the Officer, Co responder AA, and P #1 exited the lobby. At 7:18 p.m. an outside camera view showed their vehicle driving off. The facility failed to produce any further documentation of P#1’s visit. Review of P#1’s medical record obtained from the Community Mental Health Center (CMHC) revealed P#1 was a 17-year-old male with a history of Bipolar disorder with Psychotic Features (mental state associated with episodes of mood swings ranging from depressive lows to manic highs characterized by the presence of either delusions or hallucinations or both); Schizophrenia (a mental disorder that affects a person’s ability to think, feel, and behave clearly), ADHD (attention deficit hyperactivity disorder), ODD (oppositional defiant disorder: a disorder marked by defiant and disobedient behavior to authority figures) who presented to the local CMHC on 3/20/24 at 3:30 p.m. for a follow-up and medication management appointment. Record notes indicated P #1’s last visit had been over a month prior and P#1 was arrested for family battery during an altercation with his father. P #1 was taking the following medications at the time of the CMHC visit: Invega Sustenna 234 mg IM (injection) every month for psychosis Metformin 500 mg for metabolic syndrome prevention (an increase in blood glucose) Cogentin 1 mg twice a day for prevention of uncontrolled muscle movements. Vistaril 25 mg at noon and 50mg twice a day for anxiety Hydroxyzine Pamoate 50 mg for anxiety Continued review of P #1’s CMHC medical record revealed that the family reported that P#1’s behavior had not improved, and he continued to display aggressive behavior towards family and paranoia (a mental disorder characterized by extreme fear and distrust of others). During a standard interview with the CMHC provider (MD II), P #1 appeared to be engaged compared to his last office visit, P #1 denied hallucinations but appeared to be responding to internal stimuli (voices). MD II notes stated that P #1 became agitated in the CMHC office when his father asked him why he was so paranoid. P #1 accused his dad of coming to his room and planting devices. According to MD II, things got out of control; both P #1 and his father were difficult to redirect. P #1 was adamant that he would not agree to commit voluntarily to an inpatient facility for treatment. MD II made the decision to place P #1 on a 1013 (involuntary hold) hold due to acute psychosis, poor insight, threats toward parents, and a need for higher level of care. Review of the facility’s policy #: PC.007, revised 10/2022, titled “Assessment and Referral Services-EMTALA” revealed it was the policy of the facility to assess, stabilize and/or appropriately transfer individuals who come to the facility with an emergency medical condition (EMC). The policy stated that Qualified Medical Professionals (QMP’s) will provide an appropriate Medical Screening Examination for any individual who comes to the facility and requests an examination to determine whether the person had an emergency medical condition. The policy further revealed that an individual who is determined to have an EMC would be stabilized within the fullest capability of the facility, or transferred pursuant to this facility’s policy and procedure to another facility which can appropriately meet the person’s needs. PROCEDURE: 1. Definitions For purposes of this Policy, the following definitions shall apply: 1.1. “Comes to...” The facility “ means, with respect to an individual requesting examination or treatment that the individual is on the hospital property. For purposes of this section, “property” means the entire hospital campus. 1.2. “Emergency Medical Condition”, 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: 1.2.1. 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. 1.2.2. Serious impairment to bodily functions; or 1.2.3. Serious dysfunction of any bodily organ or part 1.3. “Qualified Medical Professional” are defined by job description as the Intake Director, Intake Counselors, Nurse Managers, Nursing Supervisors, Registered Nurses, and Physicians. Intake staff is trained to perform pulse and blood pressure assessments, complete the medical and psychiatric screening form, and determine the existence of an emergent medical condition related to psychiatric/substance abuse issues. Nurses and Physicians are trained to determine the existence of an emergency medical condition related to psychiatric/substance abuse or medical issues. Changes in any of the above items as related to provisions of clinical services, including additional categories of facility clinical employees shall be reviewed and approved before implementation. 2. Screening Examination An appropriate screening examination should be provided to the individual by Qualified Medical Professional (QMP) for determination as to whether or not an emergency medical condition exists. The screening examination shall not be delayed in order to inquire as to whether or not the individual has sufficient financial resources to pay for treatment, including the availability of insurance coverage. Continued review of the policy revealed that: 6. The facility must accept the transfer of someone from another hospital ED where: 6.1. The person has an emergency psychiatric condition. 6.2. The transferring facility cannot fully stabilize or treat the emergency psychiatric condition. 6.3. The facility has the specialized capability to stabilize and treat the emergency psychiatric condition, and 6.4. The facility has the capacity (i.e. beds, equipment, and staff) to treat the person. It must make the decision about accepting the transfer without regard to the patient’s ability to pay and thus should not request, obtain, or consider financial information until after the decision to accept the patient is made. 7. All persons presenting as walk-ins and or transfers. All persons presenting to the facility will be entered into the EMTALA Log. Review of policy No.: PC.008, title “Patient Comprehensive Triage & Assessment”, last reviewed 1/2017 revealed that all patients admitted to the facility were assessed/triaged and evaluated. Results of assessments are reviewed and integrated by the multidisciplinary treatment team to prioritize identified problems within the Master Treatment Plan. Procedures: 1.0 Triage/Assessment Patients are generally seen in the order that they arrive and triaged/assessed for any emergent situations. Patients are requested to complete their initial paperwork including the assessment information sheet and demographic sheets prior to being escorted from the lobby area to an assessment room. Patients’ clinical presentation and mental status are periodically reassessed during the initial triage/assessment. Assessment staff gives the patient an estimate of the amount of time and assessment process may take and offers food, beverage, etc. 2.0 Assessment and Referral Assessment is the process of determining the treatment needs of a patient and coordinating referral within the facility’s Health System or alternate provider. An inquiry call form is completed by the Assessment Coordinator and/or nursing personnel on each inquiry. The disposition of the individual is documented on the TRIMS and/or referral sheet and maintained in a confidential file in the Assessment Office or in storage. Basic medical information is obtained to ascertain the physical health of the individual to determine if any exclusionary medical conditions exist prior to admission. A phone interview with Co-Responder AA took place on 4/01/24 at 12:05 p.m. Co-Responder AA stated that she worked with the County Police Department as a Team Lead Co-Responder. Co-Responder AA explained that her role was as trained personnel in mental health crisis. Co-Responder AA said the County police employed trained mental health staff who escorted police officers responding to calls that involved patients with mental health issues. Co-Responder AA recalled that she accompanied a police officer on 3/20/24 responding to CMHC that involved P#1. Co-Responder AA said that the clinic physician had placed P#1 on a 1013 and requested that he (P#1) be transported to the facility. Co-Responder AA recalled that when they arrived at the CMHC, the 1013 form was complete and P #1 got in the police vehicle without incident. Co-Responder AA said she and the police officer transported P #1 to the facility. Co-Responder AA signed P #1 into the patient log once they arrived at the facility. Registered Nurse (RN) GG came to meet them in the lobby and after reviewing the 1013 form, RN GG told her that they (the facility) would not accept the patient (P #1) and a second staff member came out and confirmed that they did not accept P #1. Co-Responder AA said P #1 was calm and collected the entire time and she decided to take him home after she communicated with P #1’s parent. Co-responder AA confirmed that the Officer that escorted her and P #1 to the facility was off the week of the survey investigation. During an interview with the facility’s Medical Director (MD) BB on 4/1/24 at 12:30 p.m. in a private office, MD BB explained that he was the Medical Director of the facility and had oversight of admissions as well. MD BB stated that when a patient arrived as a 1013, the facility’s established protocol was to send the patient directly to the admission area for an assessment. MD BB said patients on a 1013 still had an assessment but there was no need for the patient to go through the normal intake process because a qualified professional already declared the patient 1013. MD BB explained the facility admitted all 1013 patients and there were no exceptions. MD BB said if the facility had no beds available, they (the facility) were to find the patient a place to stay at the facility while they were working with other facilities to find him/her a bed somewhere else. MD BB said the facility sometimes accepted patients even when they did not have a bed; and they sometimes moved patients to different units in an attempt to accommodate a patient in crisis. MD BB stated, “you do what you have to do when 1013 arrived”. MD BB said the first step was always to take the patient in and contact the families later for medication consent but keeping the patient here for his/her safety was the very first step whether it was a minor. MD BB said all staff, at least in the Intake Department, were aware of this practice. MD BB said if anyone turned down a 1013 patient, that would constitute a violation of their policy and that should never happen because staff received training on patients presenting in the lobby for treatment. During an interview with the facility’s Director of Intake and Admissions (Director) (CC) on 4/1/24 at 12:57 p.m. in a private office, Director CC stated that he had been at the facility since 2016. Director CC explained the 1013 protocol at the facility. Director CC said once a patient with a 1013 arrived, the person at the front desk first notified the Intake Nurse that there was a 1013 that just arrived. Director CC said the 1013 patient bypassed the normal process that involved some waiting in the lobby, and they took the 1013 patient straight to the Intake area in the back where they completed all the paperwork, including putting the patient on the EMTALA log. Director CC said once the patient was in the back, the Intake Counselor did the assessment, called the doctor to give report on the patient and give the doctor the result of the assessment. Director CC explained that the doctor was the only person who could decide to admit the patient, even a patient on a 1013. Director CC explained that once a patient was declared a 1013 at another facility, the patient had no choice but to be admitted. He said even in the case of a minor, they still admitted the patient and contacted family/guardian’s once they got the patient on the unit for safety. Director CC said only the doctor had the authority to change the patient’s status from 1013 to voluntary. Director CC said that a 1013 patient must be admitted, even if there was no bed available; he said they could always accommodate the patient on a couch somewhere, get him (the patient) stable while they looked for placement somewhere else. Director CC said they did that in the past. Director CC said that all staff recently completed an EMTALA refresher, and they talked about once a patient crossed the gate, he was on their property and such patient became their patient. Director CC further stated that he was certain they had a bed available when P #1 came in on 3/20/24. A phone interview with the CMHC Program Manager (Manager) (DD) took place on 4/1/24 at 3:00 p.m. Manager DD said she was a Licensed Clinical Social Worker (LCSW) at the CMHC where P #1 came for a routine follow up visit on 3/20/24. Manager DD recalled that during the visit on 3/20/24, P #1 decompensated while arguing with his parents. Manager DD said P #1 became loud, angry, and could not be verbally redirected. Manager DD said P #1 was making threats and the provider (MD II) decided to put P #1 on a 1013. Manager DD said at the CMHC, when a patient has a 1013, the CMHC called the local police for transport to the receiving facility. Manager DD recalled calling the facility on 3/20/24 around 4:14 p.m. seeking placement for P#1. She recalled speaking to RN GG. Manager DD recalled that she gave RN GG the 1013 status of P#1 as well as the current assessment. Manager DD said RN GG told her to bring P #1 to the facility. Manager DD said Doctor II completed the 1013 form for P#1 and she called the police department for transportation. Manager DD said one officer and Co-responder AA came to pick up the patient. Manager DD said P #1 got into the police vehicle without a problem. Manager DD said later that night he received communication that the facility did not accept the patient. During an interview with Front Desk Receptionist (Receptionist) EE on 4/1/24 at 4:40 p.m. in a private office, Receptionist EE recalled P#1 and the evening he arrived with the two escorts. Receptionist EE said she did the routine health questionnaire (Covid questions) for the patient and notified intake staff that a 1013 patient had just arrived. Receptionist EE recalled that the intake nurse (RN GG) came out and spoke with Co-responder AA. Intake Counselor (JJ) then came out and spoke with Co-responder AA. Receptionist EE said Intake Counselor JJ told her that they (the facility) had not received paperwork for P#1. Receptionist EE said she saw the officer, Co-responder AA and P #1 walk out of the lobby. Receptionist EE said she received training on EMTALA and explained that all patients who came to the facility and asked for treatment were provided an assessment. She explained her job was to have all patients sign in and call intake anytime a patient came to the lobby. Receptionist EE said she did not know the details around P #1 or why the nurse did not want to see him. A phone interview with CMHC Director (Director) (FF) took place on 4/2/24 at 10:00 a.m. Director FF said she was the Director of the CMHC where P #1 was routinely seen for follow up appointments. Director FF said on 3/20/24, P #1 came with his father for a routine visit. Director FF said during the visit, P #1 decompensated, became very loud, and argued with his father. Director FF said P #1 made verbal threats; became psychotic (a state that the person loses a sense of reality) with loud cursing in the office. Director FF said P #1 could not be redirected and the doctor signed a 1013 for his safety. Director FF said once the doctor gave the 1013 order, Manager DD called the facility for placement. Director FF said facility staff told Manager DD to bring the patient. Director FF said once they got the okay from the facility, they called the police who arrived with an Officer and a Mental Health Counselor. Director FF said P #1 calmed down once the police arrived and they took him without incident to the facility. Director FF said later that evening, Co-Responder AA called to report that the facility did not accept P #1. Director FF said she asked why but she never got a clear answer as to why the facility turned the patient down. During an interview with Intake Nurse (RN) (GG) on 4/2/24 at 10:21 a.m. in a private office. RN GG said she worked in the Intake Department and had been a nurse for 25 years. RN GG said when patients presented either voluntarily or involuntarily (1013), she assessed them in the back. RN GG explained her assessment consisted of the level of care the patients needed and she transmitted her findings to the facility’s doctor who then decided to admit the patients or referred them to outpatient services. RN GG recalled P #1 was transferred from an outpatient clinic. RN GG acknowledged that received a call from a clinic about P#1 and the person asked her for her name. She said after she gave the caller her first name, then the caller asked for her last name. RN GG said that was curious to her that someone asked her for her first and her last name. RN GG said the caller told her about P#1 and 1013. RN GG said approximately one hour later, P#1 arrived and did not have a packet. RN GG explained that when the facility accepted a 1013 patient, they completed a packet for the patient before his/her arrival. RN GG recalled that she could not find any paperwork for P#1. RN GG said Co-Responder AA showed her a 1013 and her name was on the form as the accepting nurse. RN GG said she went to talk to Intake Counselor JJ about the patient. RN GG said they had a system called Concord where transferring facilities sent all patient information before a patient arrived if they (facility) had accepted the patient. RN GG said P #1’s name did not appear on the system. Intake RN GG explained that she was aware of the EMTALA obligations to give an assessment to anybody who presented to the facility and requested services. Intake RN GG said she received annual training that included EMTALA. An interview with the facility’s Director of Nursing (DON) HH took place on 4/2/24 at 11:10 a.m. in a private office. DON HH said she had been a nurse for ten years and at the facility for a month in her role. DON HH said she was not aware of the P#1, but staff were aware that any person who presented at the facility, anywhere on campus who needed an assessment medical or mental should receive such assessment until a doctor could decide the person’s disposition. DON HH explained that even in the case of serious medical emergencies such as labor or a heart attack they must take the patient, do their best, and arrange for transfer. Director HH said regardless of the circumstances, they must provide a Medical Screening Exam (MSE) and stabilize the patient at a minimum. She said we can’t just say we don’t deliver babies here; we do our best and call 911. DON HH said the same applied for a patient on a 1013, they must provide the MSE and let the doctor know of the 1013 and the details of the intake. DON HH said the only reason to refer a 1013 was if the patient was not medically cleared and needed immediate medical treatment and they were still required to make transportation arrangements. DON HH said the facility had a provider on-call 24/7 for the Intake RN to reach out to and it was inexcusable to turn a 1013 patient down. Director HH said the completion of a packet for a 1013 patient was part of the process but the most important part of the 1013 protocol was to accommodate the patient and take care of paperwork later. DON HH said RN GG had not followed the facility’s policy regarding EMTALA. DON HH said that staff just completed a “Skilled Fair” training and such training addressed EMTALA law. A phone interview with the CMHC Psychiatrist (MD) II took place on 4/2/24 at 11:49 a.m. MD II stated P #1 had been receiving outpatient services for some time but at another location. MD II said P #1 was just released from jail and came to her office for a routine follow up appointment. MD II explained that while in the office, P#1 became irritable, paranoid, and difficult to redirect. MD II said she decided P #1 was a significant risk to himself and others. M II said she tried to explain to P#1 that he needed inpatient treatment. MD II said P #1 flatly refused to voluntarily go to the hospital and she put the patient on a 1013 because P #1 needed higher level of care in a different environment than at home. An interview took place with Intake Counselor JJ on 4/2/24 at 2:30 p.m. in a private office. Intake Counselor JJ recalled that she arrived at work around 6 p.m. the evening that P#1; did not know anything about P #1’s case. Intake Counselor JJ said RN GG told her about a phone call she received earlier from someone asking for her but did not tell her why. Intake Counselor JJ said when the front desk called and told them there was a 1013, she went and told Co-Responder AA that she just came in and did not know anything about P #1. Intake Counselor JJ said she asked the escorts of P #1 about the paperwork; Co-responder AA showed her the 1013 form with RN GG’s name on the form as the accepting staff member. Intake Counselor JJ recalled that the 1013 was the only paperwork accompanying P#1. Intake Counselor JJ said she then went to the back to check the system they used for all accepting patients (Concord), and she told Co-transporter AA that she would need to check the bed status as well. The transferring CMHC also needed to be for some details because all she got was a 1013 form. Intake Counselor JJ said she called the front desk, and the receptionist told her the staff left with the patient (P #1). Intake Counselor JJ said she was working at the facility for two years and she understood they operated like a hospital, and they could not turn down people who came in the lobby for help. She said they were supposed to give an assessment to everyone. A follow up interview with Director CC took place on 4/3/24 at 12:43 p.m. in a private office about two missing charts (P #7 and P #17). Director CC explained that sometimes patients arrive, and once staff start asking routine questions, the patient decides to leave. Director CC stated that patients had the right to refuse treatment and the facility could not hold a patient unless there was a signed 1013 or the patient appeared psychotic. Director CC went on to state that this happened frequently. He also explained that if a person left, the patient’s name would be on the EMTALA log, but an account could not be created. Patients that arrive and then refuse treatment are documented as ‘Refused Services’. Director CC acknowledged that P#7 and P#17 were documented as being referred to outpatient services and staff could not locate a medical record. Director CC stated that P#7 and P#17 should have an MSE on file because the doctor was the only person that could make referrals. A follow up phone interview with MD BB took place on 4/3/24 at 2:00 p.m. regarding P #7 and P #17 who did not have an assessment but only outpatient referral. MD BB explained there was always an intake assessment done before a patient was to receive a referral for outpatient services. MD BB said there should always be a full assessment; such assessment could be completed by the nurse, Counselor, or the Director of Admissions but there must be an assessment before a patient can be referred to outpatient services. Review of 20 additional medical records revealed that two patients, P #7, and P #17 were included on the facility’s sign in log and noted as having outpatient referrals. No other records or documentation on P#7 or P#17 were located. A review of the facility’s EMTALA log revealed that P #7 arrived at the facility on 1/31/24. Upon request of P#7’s medical record, the facility failed to produce a medical record. A note was provided that indicated P#7 was referred to outpatient services with no evidence of an MSE. A review of the facility’s EMTALA log revealed that P #17 arrived at the facility on 11/10/23. Upon request of P#17’s medical record, the facility failed to produce a medical record. A note was provided that indicated P#17 was referred to outpatient services with no evidence of an MSE.”