Liberty 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: 39354 Based on interview, record review and policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#3) of 22 Emergency Department (ED) records reviewed from 11/01/23 through 04/29/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an Emergency Medical Condition (EMC). 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 emergency medical condition) Requirements Policy,” dated 01/29/24, showed the following: - Any individual who comes to the hospital ED requesting examination or treatment, or if someone has requested care on the individual’s behalf, shall be provided with an appropriate MSE. - The MSE shall include ancillary services. - If a patient withdraws their request, a trained staff member shall discuss further medical examination and/or treatment required to identify and stabilize an EMC, including the risks and/or benefits for continued treatment. - Staff shall attempt to complete an Against Medical Advice (AMA) form. If the patient refuses to sign the AMA form, it should be documented. Review of the hospital’s policy titled, “AMA Policy,” dated 04/11/22, showed if a patient chooses to refuse or withdraw treatment and/or diagnostic studies AMA, or expresses a desire to leave the hospital, staff shall notify the attending physician, the nursing supervisor, and staff request that the patient discuss the decision with the physician. Documentation of the discussion should include the reason for refusal, the risks and benefits of continued treatment, discharge instructions, any follow up visits or referrals, and any prescriptions provided. An AMA form should be completed. If the patient refuses to sign, then two witnesses should sign the AMA form acknowledging that refusal. Please refer to A-2406 for additional 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: 39354 Based on interview, record review and policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#3) of 22 Emergency Department (ED) records reviewed from 11/01/23 through 04/29/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an Emergency Medical Condition (EMC). 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 emergency medical condition) Requirements Policy,” dated 01/29/24, showed the following: - Any individual who comes to the hospital ED requesting examination or treatment, or if someone has requested care on the individual’s behalf, shall be provided with an appropriate MSE. - The MSE shall include ancillary services. - If a patient withdraws their request, a trained staff member shall discuss further medical examination and/or treatment required to identify and stabilize an EMC, including the risks and/or benefits for continued treatment. - Staff shall attempt to complete an Against Medical Advice (AMA) form. If the patient refuses to sign the AMA form, it should be documented. Review of the hospital’s policy titled, “AMA Policy,” dated 04/11/22, showed if a patient chooses to refuse or withdraw treatment and/or diagnostic studies AMA, or expresses a desire to leave the hospital, staff shall notify the attending physician, the nursing supervisor, and staff request that the patient discuss the decision with the physician. Documentation of the discussion should include the reason for refusal, the risks and benefits of continued treatment, discharge instructions, any follow up visits or referrals, and any prescriptions provided. An AMA form should be completed. If the patient refuses to sign, then two witnesses should sign the AMA form acknowledging that refusal. Review of Patient #3’s medical record, dated 11/15/23, showed the following: - He was a 48-year-old male with a history of mental health issues, who presented to the ED at 9:28 PM for a mental health screening related to abnormal behavior. His daughter indicated his behavior included moving all their belongings from inside their house to the outside. He had also been caught trespassing; sitting in the back of a store, in the breakroom, watching television. - He indicated that he had quit taking his psychiatric (relating to mental illness) medications two weeks prior. - He denied any suicidal (SI, thoughts of causing one’s own death) or homicidal (HI, thoughts or attempts to cause another’s death). - On 11/16/23 at 3:58 AM, Staff J, Registered Nurse (RN), documented that Patient #3 had requested to leave AMA, was offered anti-anxiety medication, and agreed to stay for evaluation. - On 11/16/23 at 4:08 AM, Staff J, RN, documented that Patient #3 had eloped (when a patient makes an intentional, unauthorized departure from a medical facility). - No AMA or psychiatric evaluation was documented. Review of Patient #3’s medical record, dated 11/16/23, showed the following: - He returned to the ED at 4:19 AM requesting a mental health evaluation. - He had presented earlier in the evening for evaluation, but had eloped. - He indicated that he had quit taking his psychiatric medications two weeks prior. - He denied any SI or HI. - At 5:26 AM, Staff J, RN, documented, that he had left AMA, eloped. - No AMA or psychiatric evaluation was documented. Review of Excelsior Springs Police Department report dated 11/16/23, showed the following: - At 9:19 AM, police were dispatched to Patient #3’s home due to Patient #3 stating there were people in his house and they would not leave. The only person at the patient’s home was his significant other. - At 9:23 AM, police were on scene at the patient’s house. - At 9:47 AM, the police were in route to Hospital B with Patient #3. - At 9:58 AM, the police arrive at Hospital B with Patient #3. Review of Patient #3’s medical records from Hospital B, showed the following: - He was a 48-year-old male with a history of mental health issues, who presented to the ED on 11/16/23 for psychiatric issues. - He had a psychiatric evaluation with a recommendation of inpatient psychiatric treatment as he was a danger and could not make medical decisions. After 20 hours of attempting to find inpatient placement, no placement was found, and he was discharged on 11/17/23 at 10:53 AM. - ED staff walked him to an outpatient behavioral health clinic for assessment and treatment. No Depakote (a medication used to treat seizures [excessive activity in the brain which causes uncontrolled jerking movements]) level was obtained during the 11/16/23 ED visit. - He returned to the ED the next day on 11/18/23, received a psychiatric evaluation with recommendations again for inpatient treatment. A Depakote level was obtained and showed lower than therapeutic levels. - Patient #3 was transferred to an inpatient psychiatric hospital on 11/19/23. Review of Patient #3’s medical record, dated 11/19/23 through 11/27/23 from Hospital C, showed the following: - He was a 48-year-old male with a history of mental health issues, who was admitted due to increased manic (elevated or excited mood or behavior) symptoms as well as bizarre behavior. - The patient was seen for a psychiatric evaluation and the patient stated that his family wanted to see him ok. - He was placed on a secured behavior unit, in order to be monitored closely. - He completed individual and group therapy and mental health medications were prescribed and adjusted as necessary. - As treatment progressed, medications were stabilized, and the patient demonstrated improved mood stability and decreased symptoms of mania. - On 11/27/23, the patient was discharged to home with a plan to follow up with Hospital B. During an interview on 04/29/24 at 2:07 PM, Staff G, ED RN, stated that if a patient wanted to leave AMA, the provider would be notified, and the risks of leaving would be discussed with the patient. AMA paperwork would be filled out. If the patient was determined not to be a danger to themselves or others and could make their own decisions, then the patient would be allowed to leave. If the patient was determined to be a harm to themselves or others, security would be called, and the patient would be detained for safety. During a telephone interview on 05/01/24 at 7:20 AM, Staff J, ED RN, stated that she remembered Patient #3. The patient went back and forth about leaving or staying. She reviewed the benefits of staying with him. She felt he was not a harm to himself or others, could make his own decisions, and he wanted to leave; so she allowed him to leave. She was also his nurse on 11/16/23 when he returned to the ED. He stated he wanted to leave again, she left to go notify the provider, and when she returned, Patient #3 had left. She felt that he was not a harm to himself or others and could make his own decisions. During a telephone interview on 05/02/24 at 10:00 AM, Staff K, ED Physician, stated that she remembered Patient #3. His daughter brought him to the ED to be checked out because he was not acting himself. Staff K cared for him on 11/15/23 and 11/16/23. The patient was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation), calm, cooperative, answered questions appropriately, and could make his own decisions. He was not a harm to himself or others. When he wanted to leave, she talked with him about staying and he still wanted to leave. She had no reason to hold him if he wanted to leave. The patient was safe to leave on his own. During an interview on 04/29/24 at 2:12 PM, Staff I, ED Physician, stated that if she was notified of a patient wanting to leave AMA, she would go and speak with the patient about the risk of leaving and try to convince the patient to stay. If the patient insisted that they leave, she would assess the patient and determine if the patient was able to make their own decisions or was a harm to themselves or others. If it was determined the patient was stable, could make their own decisions, and was not a harm to themselves or others they would be allowed to leave. During an interview on 04/30/24 at 12:51 PM, Staff E, Director of Emergency Services, stated that if a patient wanted to leave AMA, the nursing staff should notify the physician and fill out the proper AMA paperwork. The staff were trained to educate patients on the risks of leaving AMA. If a patient could make their own decisions, was in stable condition, and was not a harm to themselves or others; the patient would be allowed to leave. After reviewing Patient #3’s medical record, he felt the staff acted appropriately. The staff educated the patient on leaving AMA, the patient was not a harm to himself or others, and could make his own decisions; so the staff did the right thing and let the patient leave.”