Golden Valley Memorial Hospital

“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: 51509 Based on interview, record review and policy review, the hospital failed to ensure that an Emergency Medical Condition (EMC) was stabilized for one discharged patient (#20) of 20 Emergency Department (ED) records reviewed from 08/02/25 through 02/02/26. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital’s average monthly ED census over the past six months was 1,492. Findings Included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) Guidelines for Transfer,” revised 10/09/25, showed an EMC was a medical condition with sufficient severity (including severe pain, psychiatric [relating to mental illness] disturbances, symptoms of substance abuse [misuse of alcohol and/or other drugs], pregnancy/active labor) such that the absence of immediate medical attention could place the individual’s health at risk. The hospital may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge. If the patient is at reasonable risk to deteriorate due to the natural process of his/her medical condition, he/she is legally unstable as per EMTALA. Review of the hospital’s policy titled, “Refusal of Treatment - Against Medical Advice (AMA),” revised 07/15/19, showed: - Patients should sign a release form when they refuse the treatment offered by the physician in the ED. - Patients must be informed by the physician and/or the ED staff, the consequences of his refusal of treatment or advice. - Mental competence will be documented. - The ED will notify appropriate authorities of the patient’s departure, as appropriate. - Patient care and assessments which must be provided to the patient refusing treatment include: mental status and competence assessment, risks of leaving or refusal explained to the patient by the physician and/or ED staff, evidence of patient’s understanding of the risks of leaving or refusal of treatment, and notification of family and/or friend and/or the police department of the patient leaving the emergency room as appropriate. Review of the hospital’s policy titled, “Services to Mental Health Patients; Including 96-hour Hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others),” revised 12/26/23, showed: - For patients needing transfer to acute psychiatric hospitalization, a physician or telemedicine (telemed, remote delivery of healthcare services while the health care provider is at a separate location, including exams and consultations, through video and telephone communication) mental health professional would indicate the need for transfer for inpatient psychiatric care. - Medical stability must be documented by the physician. - For patients who are in urgent need of transfer (96-hour hold) (i.e. shares suicidal ideations (SI, thoughts of causing one’s own death) and/or homicidal ideations (HI, thought or attempts to cause another’s death), presents as a danger to himself, or others); nursing staff will contact attending physician regarding the patient’s behavior or statements that indicate self-harm or danger to others, Nursing staff or social services will contact mental health facilities to obtain acceptance for acute inpatient psychiatric care; witnesses of the patient’s behavior or verbal statements (staff, law enforcement and family members) will complete affidavits (a written statement confirmed by oath, for use as evidence in court) and list specific behaviors or statements by the patient that demonstrated the patient was at risk for self-harm (behavior that is harmful or potentially harmful to oneself) or a danger to others. Review of the hospital’s policy titled, “Management of Mental Health Patients,” revised 09/26/25, showed: - In the ED, the treating provider will perform a medical screening examination (MSE) and any required testing and treatment to stabilize the patient’s condition and for patient placement. The provider may perform the mental health assessment or use telemed psychiatry services. In addition to necessary medications, the ED provider will order the patient’s routine medications for administration while the patient remains in the ED. - The high-risk patient must remain in constant line-of-sight of the assigned one to one (1:1, continuous visual contact with close physical proximity) caregiver at all times. The caregiver will document the patient’s activity on the 1:1 Observation Flow Sheet. An SI/HI patient with 1:1 observation requires documentation every 15 minutes. - Provider documentation should include, at a minimum, an initial and ongoing physical and psychosocial (relating to the interrelation between social factors and individual thought and behavior) assessment performed at least every shift that includes the patient’s current status and the plan of care. The provider’s assessment should support initiation and ongoing 1:1 suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) or 1:1 routine precautions and any modification to the treatment plan during the course of the patient’s visit. Please refer to 2407 for further details.”

“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: 50151 Based on interview, record review and policy review the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for one discharged patient (#20) of 20 Emergency Department (ED) records reviewed from 08/02/25 through 02/20/26. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital’s average monthly ED census over the past six months was 1,492. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) Guidelines for Transfer,” revised 10/09/25, showed An EMC was a medical condition with sufficient severity (including severe pain, psychiatric [relating to mental illness] disturbances, symptoms of substance abuse [misuse of alcohol and/or other drugs], pregnancy/active labor) such that the absence of immediate medical attention could place the individual’s health at risk. The hospital may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge. If the patient is at reasonable risk to deteriorate due to the natural process of his/her medical condition, he/she is legally unstable as per EMTALA. Review of the hospital’s policy titled, “Refusal of Treatment - Against Medical Advice (AMA),” revised 07/15/19, showed: - Patients should sign a release form when they refuse treatment offered by the physician in the ED. - Patients must be informed by the physician and/or the ED staff, the consequences of his refusal of treatment or advice. - Mental competence must be documented. - The ED will notify appropriate authorities of the patient’s departure as appropriate. - Patient care and assessments must be provided to the patient refusing treatment and include: mental status and competence assessment, risks of leaving or refusal explained to the patient by the physician and/or ED staff, evidence of patient’s understanding of the risks of leaving or refusal of treatment, and notification of family and/or friend and/or the police department of the patient leaving the emergency room as appropriate. Review of the hospital’s policy titled, “Services to Mental Health Patients; Including 96-hour Hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others),” revised 12/26/23, showed: - For patients needing to transfer for an acute psychiatric hospitalization, a physician or telemedicine (telemed, remote delivery of healthcare services while the health care provider is at a separate location, including exams and consultations, through video and telephone communication) mental health professional would indicate the need for transfer for inpatient psychiatric care. - Medical stability must be documented by the physician. - For patients who are in urgent need of transfer such as a patient on a 96-hour hold who shares suicidal ideations (SI, thoughts of causing one’s own death) and/or homicidal ideations (HI, thought or attempts to cause another’s death), presents as a danger to himself, or others, nursing staff will contact the attending physician regarding the patient’s behavior or statements that indicate self-harm or danger to others. Nursing staff or social services will contact mental health facilities to obtain acceptance for acute inpatient psychiatric care. Witnesses of the patient’s behavior or verbal statements (staff, law enforcement and family members) will complete affidavits (a written statement confirmed by oath, for use as evidence in court) and list specific behaviors or statements by the patient that demonstrated the patient was at risk for self-harm (behavior that is harmful or potentially harmful to oneself) or a danger to others. Review of the hospital’s policy titled, “Management of Mental Health Patients,” revised 09/26/25, showed: - In the ED, the treating provider will perform an MSE, any required testing and treatment to stabilize the patient’s condition and find patient placement. The provider may perform the mental health assessment or use telemed psychiatry services. In addition to necessary medications, the ED provider will order the patient’s routine medications for administration while the patient remains in the ED. - The high-risk patient must remain in constant line-of-sight of the assigned one to one (1:1, continuous visual contact with close physical proximity) caregiver, at all times. The caregiver will document the patient’s activity on the 1:1 Observation Flow Sheet. A SI/HI patient with 1:1 observations requires documentation every 15 minutes. - Provider documentation should include, an initial and ongoing physical and psychosocial (relating to the interrelation between social factors and individual thought and behavior) assessment at least every shift that includes the patient’s current status and the plan of care. The provider’s assessment should support initiation and ongoing suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) or 1:1 routine precautions and any modification to the treatment plan during the course of the patient’s visit. Review of Patient #20’s ED visits from 08/02/25 through 02/02/26, showed, she arrived by EMS for treatment on 19 occasions. She was evaluated and transferred for psychiatric services due to SI with a plan to overdose on prescribed medications on 11 out of 13 of those visits. On 11/01/25 she was discharged home and on 01/01/26 she left AMA. Review of Patient #20’s first EMS record, dated 01/01/26, showed EMS C was dispatched to the patient’s home for an accidental overdose. Patient #20 was found standing on her porch with law enforcement. She reported that she was prescribed 450mg of lithium (a medication used in the treatment of certain psychiatric disorders) and that she took two pills before bed the night before as instructed and then accidentally took them again that morning. She was concerned the pills would interact negatively with the antibiotics she was prescribed for a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra). EMS C contacted poison control and was advised the patient would likely be sleepy but otherwise unaffected and could monitor symptoms at home with rest and hydration. After the consultation with poison control, Patient #20 reported she lied and had actually taken four lithium as an intentional overdose at approximately 6:30 AM, as an attempt at suicide and requested to go to GVMH for SI. An assessment showed she was A&Ox4, her Glasgow Coma Scale (GCS, estimates coma severity. The maximum score is 15 which indicates a fully awake patient) was 15 and her vital signs VS were within normal limits (WNL). Her blood glucose level (BG, sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health. Normal ranges are considered between 70 and 100. Normal range for a known diabetic is 80 to 180) level was 127 and an electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) showed a normal sinus rhythm (NSR, rhythm of a healthy heart). Her psychiatric assessment showed an intentional overdose/suicide attempt. The remainder of the assessment was unremarkable, and she was transferred to GVMH without incident. Care was transferred at 9:10 AM. Review of Patient #20’s first GVMH ED record, dated 01/01/26, showed: - At 9:07 AM, she was a 29-year-old female who arrived at the ED by EMS C for a lithium overdose. Her chief complaint was SI. - She had a medical history of bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows). - She was A&Ox4 and her VS were stable. - At 9:16 AM, she was noted to be a high suicide risk on the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person’s risk to self-inflicted harm and desire to end one’s life) and commented that she took four lithium pills that day. - The physician was notified of the screening result. - Patient #20 was placed on 1:1 observation and a psychiatric consult was ordered. - At 9:17 AM, Poison Control was contacted. A pharmacist recommended basic labs and fluids as well as initial lithium level and repeat level in four to six hours. - At 9:35 AM, IV fluids were administered. - Her bloodwork and EKG were unremarkable. - At 9:23 AM, her lithium level (therapeutic was 0.6 to 1.2) was 0.6. - At 1:20 PM, her lithium level was 0.9. - At 1:49 PM, a behavioral health assessment showed Patient #20 was a high suicide risk on the C-SSRS. Staff N, RN Telemed Behavioral Health (BH) assessor, noted the patient had presented for an intentional overdose and continued to have suicidal thoughts with a plan to overdose. Patient #20 reported that her husband’s support would prevent her from another suicide attempt. However, her husband was home during that day’s attempt. Patient #20 had poor impulse control, insight and judgement. Inpatient psychiatric hospitalization was recommended, and the patient was voluntary. A patient safety plan was not completed. - At 2:00 PM, Staff K, Charge RN, noted the patient stated, “I no longer have SI, my med attendant comes tomorrow, and I feel safe to go home.” - Staff K, spoke to the patient’s spouse who agreed the patient was safe to go home under his care. - The physician was notified and the patient signed out AMA. - At 2:12 PM, Patient #20 signed an AMA form that showed, “I don’t feel suicidal anymore.” - A 1:1 observation form showed observations were completed every 15 minutes from 9:15 AM to about 2:15 PM. - A report from Staff M, ED Physician, showed Patient #20 reported taking four tablets of her 450 milligram (mg) extended release lithium pills that morning. She initially reported to EMS C it was accidental and later admitted the overdose was intentional. - A medical-decision-making portion of the physician report showed that the BH assessment was completed and inpatient psychiatric care was recommended. The patient later told the ED care team that she was no longer suicidal. She denied any SI/HI or hallucinations. There were no affidavits on the patient’s chart to legally restrict her rights. Patient #20 had decided she was going to leave AMA, despite the recommendation for inpatient psychiatric treatment. She understood that the risks of the decision to leave AMA included death and/or permanent disability. - There were no affidavits found in the medical record. Review of Patient #20’s second EMS record dated 01/01/26, showed, EMS C was dispatched to the patient’s home for a suicidal person. At 7:50 PM, Patient #20 was found sitting on the porch with law enforcement and first responders. She reported “I am depressed, wanted to hurt myself, took six pills of lithium at 7:30 PM. I am grieving my grandpa. He passed away when I was two years old. I have tried to get counseling in the past, but they haven’t helped. I took the pills to kill myself. I took 4 pills of lithium earlier today.” She was A&Ox3. Her VS were stable and her EKG was unremarkable. During transport, Patient #20 reported dizziness. An affidavit was completed and care was transferred to GVMH ED at 8:40 PM. Review of Patient #20’s second ED record dated 01/01/26, showed: - At 8:39 PM, Patient #20 arrived by EMS C, for reports of a lithium overdose. - She reported that she took six of her 450 mg lithium tablets at 7:30 PM with the intent to kill herself. - She was noted to be high suicide risk on the C-SSRS. - The physician was notified of the screening result. - Patient #20 was placed on 1:1 observation and a psychiatric consult was ordered. - IV fluids and nausea medications were administered. - At 10:18 PM, her lithium level was 1.8 - A report from the ED physician showed, the patient did not show any signs of altered mental status (mental functioning ranging from slight confusion to coma) and only complained of nausea. - On 01/02/26, at 3:21 AM, her lithium level was 2.1 - At 6:00 AM, Patient #20 was admitted for observation on the intensive care unit (ICU, a unit where critically ill patients are care for). - At 7:04 AM, a behavioral health assessment showed Patient #20 was a high suicide risk on the C-SSRS. The telemed BH assessor noted there were written affidavits and a previous attempt to overdose. Involuntary inpatient psychiatric services were recommended. - On 01/03/26, at 11:24 AM, Patient #20 was transferred to an inpatient psychiatric facility. During a telephone interview on 02/04/26, Staff K, Charge RN, stated that she recalled Patient #20 and had reviewed the ED medical record for her first 01/01/26 visit. She recalled the patient was doing door dashes (delivery service for online orders) during that time. She was on her phone a lot and became increasingly anxious. Patient #20 decided to leave AMA when staff attempted to take her phone away. The patient didn’t make any suicidal statements or behaviors to her, or she would have completed an affidavit. Two affidavits were required to hold someone. The hospital could not hold a patient that was in their right mind without affidavits. Staff were encouraged to complete affidavits as best practice but there wasn’t a specific policy. Telemed psychiatry was contacted for BH initial evaluations only. The telemed assessors did not complete affidavits. During a telephone interview on 02/04/26 at 1:00 PM, Staff L, RN, stated that he recalled Patient #20 and had reviewed the medical record for 01/01/26. He recalled that the patient did not indicate she was suicidal to him. Therefore, he did not complete an affidavit. Patient #20 was mostly nonverbal while she was there. She could speak but chose not to. She would nod or give very non-comital responses during her assessment. He erred on the side of caution when he completed the C-SSRS. EMS C declined to provide an affidavit when the patient was brought in. All psychiatric patients were evaluated by telemed and a recommendation provided. Patients could not be held without affidavits. If there were affidavits, law enforcement would be notified but the patient still could not be held. During a telephone interview on 02/04/26 at 5:30 PM, Staff M, ED Physician, stated that he recalled Patient #20 and reviewed the medical record for 01/01/26. He reported that she was medically cleared, and a telemed BH assessment recommended voluntary inpatient psychiatric services. No one that assessed the patient that day determined an affidavit was warranted. He did not feel she met the threshold to have her rights taken away and made involuntary status (a legal process through which a person is hospitalized and treated for mental health disorders without their consent). She wasn’t in clear and present danger. Her story was unreliable and inconsistent. It was impossible to have had an overdose and lithium levels be therapeutic. He documented his discussion with Patient #20. She understood the risks of leaving AMA and signed the paperwork. Telemed BH assessors were not contacted a second time to evaluate patients. During a telephone interview on 2/10/26 at 9:30 AM, Staff N, RN and Telemed BH Assessor, stated that she did not recall Patient #20. A voluntary recommendation was made when a patient met criteria and was willing to seek additional assessments and or treatment. An involuntary recommendation was made when a patient met criteria but was not willing or did not have the mental capacity to make decisions. Recommendations were based on clinical judgement and were very patient specific. BH assessors could complete an affidavit, if deemed necessary. Other affidavits related to the incident would be considered in the recommendation if they were pertinent. Safety plans were completed if a patient met criteria and was going to be discharged home. Follow up calls for a patient change in condition could be completed but were not often received. During a telephone interview on 02/10/26 at 10:00 AM, Staff O, Paramedic for EMS C, stated that she was very familiar with Patient #20. She didn’t complete an affidavit for the patient on 01/01/26 because her behavior was not out of the norm. She was seen by EMS C three to four times a month for complaints of either a UTI or SI. She always stood on her porch and waited for them to arrive. Patient #20 had been given other resources to use but she always called for an ambulance and wanted to go to the ED. On that specific date, poison control was contacted due to the patient’s initial report that she had an accidental overdose. However, the patient ultimately reverted back to complaints of SI and requested to go to the ED. She believed the patient was mentally cognitive to make decisions but that her emotional cognition was volatile. She believed Patient #20 gained a lot of attention from her behavior and used it as a cry for help but wasn’t willing to accept the things she needed to do to get help. She believed Patient #20’s home situation was stable as her husband was always there to keep their small children. During a telephone interview on 02/11/26 at 3:40 PM, Staff P, ED and EMS Medical Director, stated that the C-SSRS was nurse driven and mandated 1:1 observation with physician notification. It was ultimately the provider’s discretion if a sitter was needed. The physician would order a BH assessment, however it wouldn’t be completed until the patient was medically cleared. It was not an expectation for a BH order to be placed in the computer, it was just verbalized to nursing staff. He was unsure of the difference between the four types of psychiatric/BH assessments listed in the hospital’s telemed contract (emergent or non-emergent psych consults and emergent or non-emergent BH assessments). He reported they were all used the same. He didn’t expect the telemed BH assessments to be completed by a physician and reported that most of the time it was a social worker or RN that performed the assessment. Once the telemed BH assessment was performed, the assessor discussed their recommendation over the phone with the physician. Sometimes they would call prior to the evaluation as well, if they needed additional details. Repeat telemed BH assessments weren’t an expectation. The telemed assessors didn’t provide affidavits. He wasn’t sure if they couldn’t, wouldn’t or just didn’t do them. The telemed BH assessors provided safety plans if the patient was expected to discharge. Doctors completed affidavits when deemed necessary. An affidavit should be completed if a patient made a statement directly to them or behaved in a way that could be documented. GVMH was a hands-off facility. Even if someone had affidavits or was involuntary status, they couldn’t be held. Law enforcement would be contacted to take the patient back if they were involuntary. Voluntary or involuntary status was very unique to each patient’s situation and history. Two patients could say the same thing, like “I feel suicidal,” but it could mean very different treatment and/or seriousness for someone who dealt with those feelings all the time and was getting treatment and had highs and lows versus someone who was experiencing it for the first time. A patient that was depressed could leave AMA. 51509”

“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: 47504 Based on interviews, record review, and policy review, the hospital failed to provide, within its capability and capacity, ongoing assessment and reassessment of a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#23) of 27 Emergency Department (ED) records reviewed from 08/03/24 to 03/05/25. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of hospital policy titled, “EMTALA Guidelines for Transfer,” dated 11/13/24, showed the Emergency Medical Treatment and Labor Act (EMTALA) required hospitals with Emergency Departments (ED) to provide a MSE to any individual who comes to the ED and requests such an examination, and prohibits hospitals with an ED from refusing to examine or treat individuals with an EMC. An EMC was defined as a medical condition with sufficient severity including severe pain, psychiatric (relating to mental illness) disturbances, symptoms of substance abuse, and pregnancy/active labor that the absence of immediate medical attention could place the individual’s health at risk. A MSE was defined as the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not. All patients shall receive a MSE that included providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. The MSE requirements include the ED Log entry, including disposition of patient, patient’s triage record, vital signs (VS, measurements of the body’s most basic functions), history, physical examination of affected systems and potentially affected systems, exam of known chronic conditions, necessary testing to rule out an EMC, notification and use of on-call staff and physicians to complete guidelines, diagnose and/or stabilize the patient, VS upon discharge and complete documentation of the MSE. Review of hospital policy titled, “Suicide Screening, Assessment & Prevention for Hospital Patients,” dated 06/26/24, showed the use of the Columbia Suicide Severity Rating Scale (C-SSRS, a scale to evaluate a person’s risk to self-inflicted harm and desire to end one’s life) was the standardized process for screening patients for suicide (to cause one’s own death) risk. Every patient has the right to a safe environment that is appropriate to their clinical condition, including those patients identified to be at risk for suicide. All patients presenting to the hospital who are being evaluated or treated for behavioral health conditions as their primary reason for care will be screened for suicide risk using the C-SSRS. Patients identified as high risk for suicide will be re-assessed every 12 hours or more often as indicated by their clinical condition. A low risk was defined as a wish to die or suicidal ideation (SI, thoughts of causing one’s own death) without a method, intent, plan or behavior, no reported history of SI or behavior. A medium risk was defined as SI with a method without a plan, intent or behavior in past month and no suicidal behavior within the last three months. A high risk was defined as SI with intent or intent with a plan in the past month, suicidal behaviors within the past month, answering yes to having thoughts and intention on acting on thoughts and started to work out the details of how to kill themselves. Review of hospital policy titled, “Standards of care for the Emergency Department,” dated 07/16/24, showed the patient should expect a triage assessment and a MSE by a licensed provider. Please refer to 2406 for further details.”

“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: 47504 Based on interviews, record review, and policy review, the hospital failed to provide, within its capability and capacity, ongoing assessment and reassessment during a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#23) of 27 Emergency Department (ED) records reviewed from 08/03/24 to 03/05/25. This failed practice had the potential to cause harm to all patients who presented to the ED. Findings included: Review of hospital policy titled, “EMTALA Guidelines for Transfer,” dated 11/13/24, showed the Emergency Medical Treatment and Labor Act (EMTALA) required hospitals with Emergency Departments (ED) to provide a medical screening examination to any individual who comes to the ED and requests such an examination, and prohibits hospitals with an ED from refusing to examine or treat individuals with an EMC. An EMC was defined as a medical condition with sufficient severity including severe pain, psychiatric (relating to mental illness) disturbances, symptoms of substance abuse, and pregnancy/active labor that the absence of immediate medical attention could place the individual’s health at risk. A medical screening exam was defined as the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not. All patients shall receive a MSE that included providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. The MSE requirements include the ED Log entry, including disposition of patient, patient’s triage record, vital signs (VS, measurements of the body’s most basic functions), history, physical examination of affected systems and potentially affected systems, exam of known chronic conditions, necessary testing to rule out EMC, notification and use of on-call staff and physicians to complete guidelines, diagnose and/or stabilize the patient, VS upon discharge and complete documentation of the MSE. Review of hospital policy titled, “Suicide Screening, Assessment & Prevention for Hospital Patients,” dated 06/26/24, showed the use of the Columbia Suicide Severity Rating Scale (C-SSRS, a scale to evaluate a person’s risk to self-inflicted harm and desire to end one’s life) was the standardized process for screening patients for suicide (to cause one’s own death) risk. Every patient has the right to a safe environment that is appropriate to their clinical condition, to including those patients identified to be at risk for suicide. All patients presenting to the hospital who are being evaluated or treated for behavioral health conditions as their primary reason for care will be screened for suicide risk using the C-SSRS. Patients identified as high risk for suicide will be re-assessed every 12 hours or more often as indicated by their clinical condition. A low risk was defined as a wish to die or suicidal ideation (SI, thoughts of causing one’s own death) without a method, intent, plan or behavior, no reported history of SI or behavior. A medium risk was defined as SI with a method without a plan, intent or behavior in past month and no suicidal behavior within the last three months. A high risk was defined as SI with intent or intent with a plan in the past month, suicidal behaviors within the past month, answering yes to having thoughts and intention on acting on thoughts and started to work out the details of how to kill themselves. Review of hospital policy titled, “Standards of care for the Emergency Department,” dated 07/16/24, showed the patient should expect a triage assessment and a MSE by a licensed provider. Review of the Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) D’s first trip report for Patient #23, dated 01/10/25 at 6:04 AM, showed she complained of SI and chest pain rated at a five on pain scale (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible). She was alert and oriented, calm and cooperative. She denied shortness of breath and VS were within normal limits. She had electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) leads still in place on her chest from a previous hospital visit. She stated she had a suicide plan but did not want to disclose it. An EKG was obtained which was unremarkable. She was transported to Hospital B (a nearby Acute Care Hospital) and care was transferred at 7:08 AM. Review of Patient #23’s Hospital B medical record, dated 01/10/25, showed the patient arrived via EMS complaining of chest pain and shortness of breath upon waking. She also reported to the EMS crew that she had suicidal thoughts with a plan but did not disclose the plan. She denied SI for the Hospital B staff, informing them that when EMS applied oxygen her SI, chest pain, and shortness of breath resolved. She was alert and oriented, her VS were stable, and CSSR-S was negative. Her bloodwork showed an elevated brain natriuretic peptide (BNP, blood test that measures levels of protein made by the heart and blood vessels that indicate heart failure) but was otherwise normal. She was given a dose of oral Lasix (medication used to treat water retention, swelling, and high blood pressure). She tested negative for respiratory viruses. Her EKG and chest x-ray (test that creates pictures of the structures inside the body-particularly bones) were unremarkable. Her assessment was normal, and her lung sounds were clear. She met with a social worker (SW) who contacted her husband to discuss her behavioral health assessment. SW documented that she believed the patient was malingering (to fake psychological or physical symptoms for secondary gains) and recommended discharge. Patient #23’s husband was agreeable to the safety plan. She was discharged with diagnoses of sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts) and anxiety about health. She was instructed to follow up with her primary care provider. Review of the EMS D’s, second trip report for Patient #23, dated 01/10/25 at 12:48 PM, showed EMS transported her for concerns of suicidal thoughts. When asked if she had a plan she said yes, but she had difficulty explaining the plan. She denied pain or discomfort. Her VS were stable, an EKG was unremarkable. She was transported to Golden Valley Hospital and care was transferred at 1:42 PM. Review of Patient #23’s medical record, dated 01/10/25, showed: - Patient #23 was a 57-year-old female who arrived at the ED at 1:54 PM for SI. - She stated that she felt like cutting herself. EMS informed the ED staff that the patient had been seen at another hospital earlier that day for chest pain and SI, but had been discharged home. - She had a past medical history of depression (extreme sadness that doesn’t go away) anxiety, delirium tremors (DT, a life threatening for of alcohol withdrawal), alcohol abuse, osteopenia (low bone mineral density), polycythemia (abnormally high red blood cells), and nicotine dependence. - Her VS were stable. - Her C-SSRS showed she was a moderate suicide risk and psychiatric rounding (frequent or constant observation [as described in the hospital’s policy]) was initiated. - She was alert and oriented, calm and cooperative. - Her bloodwork and EKG were unremarkable. - She was given a behavioral health evaluation which showed she had a history of multiple inpatient psychiatric admissions, the most recent being the previous week. She had an established psychiatrist (physician who specializes in mental health disorders) and was supposed to be seeing a therapist. She also had a pattern of coming to the ED immediately after being discharged because she was afraid she would harm herself at home. At the time of her assessment the patient denied SI and felt safe. Discharge was recommended. - The ED provider documented that she confronted the patient about her pattern of leaving an inpatient setting and immediately checking back into the ED. She suggested that her behavior didn’t seem to be working. The patient responded that she just didn’t like those facilities or the staff. They discussed the need for a long-term placement such as a nursing home. After the behavioral health screener recommended discharge, the patient stated that she did not feel safe any longer. The provider considered this manipulative behavior. The patient’s husband was educated to secure all sharp objects in the home, and he was agreeable to keeping her safe. - When the patient was signing her discharge instructions, she told the nurse she would “be back tomorrow.” Review of the EMS D’s third trip report for Patient #23, dated 01/11/25 at 9:23 AM, showed the patient had been discharged by both Golden Valley Hospital and Hospital B the previous day. She informed EMS that she intended to either cut herself or take all of the pills in her house to kill herself. She stated that she did not feel safe because she had options to kill herself. She had no other complaints and her transport was uneventful. Care was transferred to Golden Valley ED staff at 10:20 AM. Review of Patient #23’s medical record dated 01/11/25 showed she arrived to the ED at 10:25 AM. She told the triage nurse that since her visit the previous day “everything feels magnified.” She told EMS staff that she did not feel safe at home and had thoughts of cutting herself. Her VS were stable. A C-SSRS was not documented, but a depression screening showed severe depression. The ED provider documented that the patient was frequently evaluated at the hospital. She had received a complete mental health evaluation the day before and had resources available, such as a case worker and a therapist. He documented that she refused to use those resources and came in by EMS. The patient stated she was still not feeling well. He encouraged her to use the resources that had already been established and discharged her home at 10:47 AM. Her ED visit lasted a total of 22 minutes. Review of EMS D’s fourth trip report for Patient #23, dated 01/12/25 at 11:30 AM, showed she reported to EMS that she had taken too many of her prescribed medications. She disclosed that she had a history of chronic back pain that caused her to consider suicide. When asked how many pills she took, she was uncertain. The patient had a normal physical assessment, stable VS, and an unremarkable EKG. An IV was established and she was given fluids. Poison control was contacted and they advised EMS that the patient would require supportive care only. She might experience dryness, mood changes or lethargy. Care was transferred to Golden Valley ED staff at 12:19 PM. Review of Patient #23’s medical record dated 01/12/25-01/13/25 showed: - At 12:26 PM, she arrived at the ED for an intentional overdose on an unknown quantity of dicyclomine (a medication used to treat abdominal cramping and irritable bowel syndrome). - Her VS were stable. She was alert and oriented, in no acute distress. - A behavioral health assessment was completed and an inpatient psychiatric admission was recommended. - She was treated with calcium gluconate (used as protective agent in high blood potassium and counteract the effects for magnesium toxicity) and folic acid. Her home medications were provided while she awaited transfer. - Her EKG and bloodwork were unremarkable except for a calcium level of 7.6 (normal is 8.4-10.2). She was considered medically cleared for psychiatric admission. - On 01/13/25 at 10:47 AM, she was transferred for inpatient behavioral health care. During an interview on 03/05/25 at 1:00 PM, Staff N, Registered Nurse (RN), stated Patient #23 presented to the ED on multiple occasions for various complaints, including abdominal pain, chest pain and SI. At times, her answers would change when she was asked questions on the C-SSRS. She was unable to recall any specific information for the specific dates. During an interview on 03/05/25 PM at 11:00 AM, Staff T, Nurse Practitioner (NP), stated she assessed Patient #23 on 01/10/25. She had been seen at another hospital earlier that same day for chest pain and was discharged. She had called EMS and presented to the ED with complaints of SI. Patient #23 received a behavioral health assessment and was discharged with a safety plan in place. Her spouse was present and had agreed to the safety plan. It was the expectation that providers to obtain a behavioral health assessment on all patients that presented to the ED with SI complaints. During an interview on 03/05/25 at 1:15 PM, Staff W, RN, stated she had been instructed by Staff Q, ED physician, to put Patient #23 in fast track on 01/11/25. Fast track was where they placed patients that could quickly be assessed, treated and discharged. Staff Q assessed Patient #23, stated that she had not made a suicide attempt, nothing had changed and discharged the patient. During an interview on 03/05/25 at 2:00 PM, Staff Q, ED Physician, stated Patient #23 was seen frequently in the ED. On 01/11/25, she presented to the ED for SI. She had been evaluated the day before using tele-psychiatry services and had been discharged home with instructions to utilize her outpatient therapy. He stated “the charge nurse told me she was to go home and use her resources, we were not to get another behavioral health evaluation and they were not going to admit her again. So I let her go.” Patient #23 was instructed to use her outpatient resources. During an interview on 03/05/25 at 1:15 PM, Staff U, CN, stated that she had been Patient #23’s nurse on 01/11/25 and was present when Staff Q, ED Physician, assessed her. He asked Patient #23 a few questions and walked out. He stated “nothing had changed and to discharge her”. She did not tell Staff Q “Not do a behavioral health evaluation on Patient #23.” She told him Patient #23 had been seen the day before and had received one. As a nurse “I do not give orders to the physician, they are in charge of patient’s care.” During an interview on 03/05/25 at 2:50 PM, Staff I, NP, stated she had assessed Patient #23 multiple times. She stated “it was expected that providers obtain a behavioral health assessment if a patient has SI, no matter how many times they presented to the ED.” She assessed Patient #23 on 01/12/25 after she took a bottle of pills. Patient #23 received a behavioral health assessment and was transferred for inpatient behavioral health care. During an interview on 03/05/25 at 12:30 PM, Staff C, ED Director, stated Patient #23 was well known to ED staff and to the local EMS crews. She had psychiatric services available to her on an outpatient basis, including a dedicated person to assist her to her scheduled appointments. Patient #23 did not like to use these services because she does not like them. She had multiple admissions for inpatient care. She was seen in the ED 41 times in the last 12 months, for various complaints. She can be “very manipulative.” The ED provided behavioral health assessments 24 hours per day. The expectation was for all suicidal patients to receive a behavioral health assessment. During an interview on 03/05/25 at 3:00 PM, Staff R, ED Medical Director, stated Patient #23 was seen frequently in the ED. She was chronically suicidal and needed to be placed in an adult residential home. His expectation for ED staff were to utilize the C-SSRS. Patient #23 did not get assessed utilizing the C-SSRS on 01/11/25. Because of her chronic suicidal ideations “using the C-SSRS as a guide, was not accurate assessment” for her. If a provider was not utilizing the C-SSRS for whatever reason, he would expect the provider to document any deviations from hospital policy and to document the reason for making an exception. Staff Q, ED Physician, did not document his reason for not performing a C-SSRS assessment. Patient #23 did not receive a behavioral health consult on 01/11/25. Staff R was not aware that she had presented to the ED on that day with intensified thoughts of SI, which were worse than the ED visit on 01/10/25. He had not reviewed the record. He was not sure why Staff Q had indicated that he was instructed by Staff U, CN, to not obtain a behavioral health assessment for Patient #23. He expected the ED physician to make that decision based on his own assessment, not to rely on nursing recommendations.”