Chi Health Lakeside

“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: 48575 Based on policy and procedure review, medical record review, and staff interviews, the facility failed to follow the Emergency Medical Treatment and Labor Act (EMTALA) policy to provide a complete medical screening exam (MSE) to rule out an psychiatric emergency medical condition (EMC) by a qualified medical professional (QMP) prior to discharge for 1 (Patient 13) out of 20 emergency department (ED) sampled patients. This failed practice has the potential to cause harm to any patient who presents to the facility ED for care and treatment. According to facility provided data the ED sees an average of 2313 patients per month for the past 6 months. See citations A2406 and A2407, that also resulted in A2400 to be not met.”

“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: 48575 Based on EMTALA policy review, medical record review, staff interviews and medical staff interviews, the facility failed to provide a mental health evaluation by a QMP after an acute behavioral dysregulation event to rule out an psychiatric EMC of after discharged for 1 (Patient 13) out of 20 emergency department (ED) sampled patients. This failed practice has the potential to cause harm to any patient who presents to the facility ED for care and treatment. According to facility provided data the ED sees an average of 2313 patients per month for the past 6 months. See citations A2400 and A2407, that also resulted in A2406 to be not met. Findings include: A. Review of facility policy, Emergency Medical Treatment and Labor Act (EMTALA), approved 12/11/2024, revealed once the MSE is completed and the physician or Qualified Medical Person (QMP) determines that the individual does not have an EMC or the EMC has been stabilized, treated and discharged as clinically appropriate with a plan for appropriate follow-up care and discharge instructions. An MSE is defined as the process of examination and evaluation of the individual required to determine the presence of an EMC by a QMP. An EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy. A QMP is defined as a licensed individual on the hospital property with appropriate clinical privileges, or others as may be set forth in the Medical Staff Bylaws or Rules and Regulations.” B. Review of the electronic medical record (EMR) revealed Patient 13 (P13) presented to the acute care hospital ED on 10/5/2025 at 8:06 PM via car, with a chief complaint of “having trouble getting through the day,” mental health evaluation. P13 past medical history included but was not limited to attention deficit hyperactivity disorder (ADHD), depression, psychiatric illness, and trauma. Review of the EMR revealed P13’s medical screening exam (MSE) at 9:02 PM included a physical exam, a mental health exam, and medical clearance toxicology lab testing (a blood sample is collected to check any toxic levels in the individual). P13 mental health exam revealed thoughts of self-harm, a past medical history of self harm, and no current plan to commit suicide. P13 was unable to contract for safety (a safety plan decided between a QMP and the patient and or representative made to ensure the patient is safe from suicidal and homicidal thoughts prior to discharge from a hospital). Physician-A ordered Zyprexa (medication that balances brain chemistry to help regulate mood, behaviors and thoughts), with a plan to calm the patient and help P13 sleep. Review of the EMR revealed the Registered Nurse (RN) administered Zyprexa by mouth at 9:17PM to P13 per physician order. The medical record lacked documentation of P13 being reassessed to determine the effectiveness of the medication. Review of the EMR revealed the Registered Nurse (RN) administered Zyprexa by mouth at 9:17PM to P13 per physician order. Review of the EMR revealed Physician-A documented at 11:58PM that P13 would like to return home and has no intention of hurting herself or others. Encouraged patient to call providers in the morning to discuss any change in her ongoing management. Return precautions discussed. The patient will follow up with provider as instructed and return to the ED for any worsening symptoms or any new symptoms. The patient verbalized understanding and in agreement. P13 walked out of the ED at 1:31AM. Review of the nursing documentation revealed RN-A documented on 10/6/2025 at 1:18AM that P13 was coming out to the nurses station crying, angry and refusing to leave. Review of the nursing documentation revealed P13 ambulated out of the ED with a steady gait at 1:31AM, and requested to talk to the house supervisor, that was notified. The EMR lacked documentation of registration, and evaluation to determine if P13 has an EMC as well as provide stabilizing treatment after P13 experienced a behavioral dysregulation event in the ED on 10/6/2025 at 1:18AM. The medical record lacked documentation of registration, evaluation to determine if P13 had an EMC as well as provide stabilizing treatment after P13 experienced a behavioral dysregulation event in the ED on 10/6/2025 at 1:18am. C. During an interview on 1/22/2026 at 10:31AM with Registered Nurse A (RN-A) revealed they did not recall if a physician was notified of P13 coming to the nurses station crying, angry and refusing to leave the ED at 1:18AM on 10/6/2025. During an interview on 1/26/2026 at 10:56AM with Registered Nurse-D (RN-D) recalled P13 was sitting in the ED lobby with discharge paperwork in hand during the conversation with P13 on 10/6/2025. RN-D revealed P13 was upset, angry and fixated on the care RN-B gave while in the ED. RN-D revealed they offered additional care for P13 register to be seen again in the ED. RN-D did not recall if they notified Physician-A after the conversation with P13 in the facility ED lobby on 10/6/2025 after 1:31AM. RN-D revealed P13 appeared safe, left the ED after the conversation, and did not have any further contact with P13. During an interview with Physician-B on 1/22/2026 at 2:23PM revealed Physician-A was not notified of P13 refusing to leave the ED on 10/6/2025 at 1:18AM.”

“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: 48575 Based on EMTALA policy review, medical record review, staff interviews and medical staff interview, the facility failed to ensure a mental health evaluation was provided to rule out a psychiatric emergency medical condition (EMC) after an acute behavioral dysregulation event (behavior with the potential to harm to self or others) after discharged for 1 (Patient 13) of 20 emergency department (ED) sampled patients. This failed practice has the potential to cause negative outcomes for any patient who presents to the facility ED for care and treatment. According to facility provided data the ED sees an average of 2313 patients per month for the past 6 months. See citations A2400 and A2406, that also resulted in A2407 to be not met. Findings include: A. Review of facility policy, Emergency Medical Treatment and Labor Act (EMTALA), approved 12/11/2024, revealed once the MSE is completed and the physician or Qualified Medical Person (QMP) determines that the individual does not have an EMC or the EMC has been stabilized, treated and discharged as clinically appropriate with a plan for appropriate follow-up care and discharge instructions. An MSE is defined as the process of examination and evaluation of the individual required to determine the presence of an EMC by a QMP. An EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy. A QMP is defined as a licensed individual on the hospital property with appropriate clinical privileges, or others as may be set forth in the Medical Staff Bylaws or Rules and Regulations. B. Review of the electronic medical record (EMR) revealed Patient 13 (P13) presented to the acute care hospital ED on 10/5/2025 at 8:06 PM via car, with a chief complaint of “having trouble getting through the day,” mental health evaluation. P13 past medical history included but was not limited to attention deficit hyperactivity disorder (ADHD), depression, psychiatric illness, and trauma. Review of the EMR revealed P13’s medical screening exam (MSE) at 9:02 PM included a physical exam, a mental health exam, and medical clearance toxicology lab testing (a blood sample is collected to check any toxic levels in the individual). P13 mental health exam revealed thoughts of self-harm, a past medical history of self harm, and no current plan to commit suicide. P13 was unable to contract for safety (a safety plan decided between a QMP and the patient and or representative made to ensure the patient is safe from suicidal and homicidal thoughts prior to discharge from a hospital). Physician-A ordered Zyprexa (medication that balances brain chemistry to help regulate mood, behaviors and thoughts), with a plan to calm the patient and help P13 sleep. Review of the EMR revealed the Registered Nurse (RN) administered Zyprexa by mouth at 9:17PM to P13 per physician order. The medical record lacked documentation of P13 being reassessed to determine the effectiveness of the medication. Review of the EMR revealed Physician-A documented at 11:58PM that P13 would like to return home and has no intention of hurting herself or others. Encouraged patient to call providers in the morning to discuss any change in her ongoing management. Return precautions discussed. The patient will follow up with provider as instructed and return to the ED for any worsening symptoms or any new symptoms. The patient verbalized understanding and in agreement. P13 walked out of the ED at 1:31AM. Review of the nursing documentation showed RN-A documented on 10/6/2025 at 1:18AM that P13 was coming out to the nurses station crying, angry and refusing to leave. Review of the nursing documentation showed RN-B documented on 10/6/2025 at 1:30AM that P13 ambulated out of the ED with a steady gait. Requested to talk to the house supervisor, who was notified. The medical record lacked documentation of registration, and evaluation to determine if P13 had an EMC as well as provide stabilizing treatment after P13 experienced a behavioral dysregulation event in the ED on 10/6/2025 at 1:18AM. C. During an interview on 1/22/2026 at 10:31AM with Registered Nurse A (RN-A) revealed they did not recall if a physician was notified of P13 coming to the nurses station crying, angry and refusing to leave the ED at 1:18AM on 10/6/2025. During an interview with Physician-B on 1/22/2026 at 2:23PM revealed Physician-A was not notified of P13 refusing to leave the ED on 10/6/2025 at 1:18AM. During an interview on 1/26/2026 at 10:56AM with Registered Nurse-D (RN-D) recalled P13 was sitting in the ED lobby with discharge paperwork in hand during the conversation with P13 on 10/6/2025. RN-D revealed P13 was upset, angry and fixated on the care RN-B gave while in the ED. RN-D revealed they offered additional care for P13 register to be seen again in the ED. RN-D did not recall if they notified Physician-A after the conversation with P13 in the facility ED lobby on 10/6/2025 after 1:31AM. RN-D revealed P13 appeared safe, left the ED after the conversation, and did not have any further contact with P13.”