Faith Community 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: 45847 . Based on record review and interview the facility failed to abide by the provider’s agreement that required a hospital to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on record review and interview the facility failed to provide an appropriate Medical Screening Examination (MSE) when one of 20 patients (Patient #1) did not receive a psychiatric evaluation after presenting to the emergency department (ED) via EMS (emergency medical services) with police while under a Detention Warrant (DW) order following a suicide attempt and showing signs of self-harm. EMS and the DW noted that Patient #1 had attempted suicide. The medical record noted in the physician Critical Care Notes that Patient # had a “high probability of life-threatening deterioration due to current ER diagnoses”. The patient left the facility via police escort to seek treatment at Hospital B. Patient #1 was hospitalized for seven days on an order of protective custody for an acute psychiatric emergency medical condition. . Based on record review and interviews, the facility failed to provide an appropriate transfer for one of 20 (Patient #1) patients whose records were reviewed. Patient #1 did not receive an appropriate transfer to an acute psychiatric care facility when they failed to: . 1. Notify the receiving hospital, and verify the receiving facility had available space and qualified personnel for Patient #1’s transfer or secure an accepting physician. . 2. Indicate the risks and benefits of transfer in writing. . 3. Complete the physician certification with a summary of risks and benefits. . 4. Send the receiving facility all medical records related to the emergency medical condition for Patient #1 who was being transferred for inpatient care at the psychiatric facility. . Cross Reference to: Tag A-2406 - 42 CFR §489.24 (a) (c) Appropriate Screening Examination. Tag A2409 §489.24(2) Appropriate Transfer .”

“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: 45847 . Based on record review and interview the facility failed to provide an appropriate Medical Screening Examination (MSE) when one of 20 patients (Patient #1) did not receive a psychiatric evaluation after presenting to the emergency department (ED) via EMS (emergency medical services) with police while under a Detention Warrant (DW) order following a suicide attempt and showing signs of self-harm. EMS and the DW noted that Patient #1 had attempted suicide. The medical record noted in the physician Critical Care Notes that Patient # had a “high probability of life-threatening deterioration due to current ER diagnoses”. The patient left the facility via police escort to seek treatment at Hospital B. Patient #1 was hospitalized for seven days on an order of protective custody for an acute psychiatric emergency medical condition. . Findings include: Medical Record Review at Facility A: Patient #1, a 31-year-old male, arrived at the emergency department (ED) at Facility A on August 20, 2024, at 11:04 PM via emergency medical services (EMS) following a suicide attempt by hanging and police followed the EMS truck with a detention warrant. Patient #1 was assessed at 11:27 PM by Staff #13 (ED Physician). The total time in the ED was one hour and 21 minutes. The time from arrival to medical screening assessment (MSE) was 24 minutes. The MSE did not indicate any physical evidence of trauma to Patient #1’s neck from his suicide attempt, and that “medical clearance prior to transfer to psychiatric hospital by law enforcement” was anticipated. The MSE documented, “He (Patient #1) has been cleared medically for transfer by me (ED Physician).” . A review of the document titled History of Present Illness for Patient #1 completed on 8/20/2024 by Staff #13, ED Physician reflected the following: “Patient brought to ED by law enforcement for medical clearance prior to transfer to (Facility B, a Psychiatric inpatient facility) for psychiatric care related to a suicide attempt. The following information is obtained via online Interpreter: The patient states he attempted to hang himself tonight but did so knowing that the rope he was using would break before he would actually be harmed. Instead of dying he “Just wanted to get some attention.” He states he has been sad since his grandfather passed away ...” . A review of the ...Critical Care Time note reflected the following: “Critical care Time: No Attestation: If acknowledged above, then critical care time applies. Upon my evaluation, this patient had a high probability of life-threatening deterioration due to current ER diagnoses, which required my direct attention, intervention, and management. The critical care time provided is exclusive of separately billable procedures. My time included direct patient care, review of labs and radiology, obtaining history from and counseling the patient and/or the family, discussion with consultants and/or other medical personnel, documentation, and monitoring for potential decompensation ...” . A review of the Discharge Plan completed by Staff #13 revealed the following: “ ...Discharge Time First Seen By Provider: 08/20/ 24 23:27 Time Spent With Patient: 12 Patient Disposition: Law Enforcement ED Status: With Nurse Discharge Diagnosis: Suicide attempt Condition: Fair Discharge Comments: Patient was evaluated for medical clearance prior to transfer to psychiatric hospital by law enforcement. The patient was evaluated and not found to have any significant medical issues. He has been cleared medically for transfer by me ...” . The medical record for Patient #1 did not indicate if any physical evidence of trauma to Patient #1’s neck from his suicide attempt. The medical screening examination (MSE) documented by Staff #13 documented, “ ...He (Patient #1) has been cleared medically for transfer by me (Staff #13) ...”, However, there was no evidence in the medical record to indicate that the patient received a psychiatric evaluation for his psychiatric medical condition.” . There was no Emergency Detention order from law enforcement provided by Facility A for Patient #1. Law enforcement arrived with and remained with Patient #1 for the entirety of his time at Facility A. . Medical Record Review at Facility B: Patient #1, a 31-year-old male, arrived at Facility B’s Emergency Department (ED) on August 21, 2024, at 1:33 AM. The total time in the ED was three hours and 39 minutes. The time from arrival to medical screening assessment (MSE) at 2:12 AM was 33 minutes. The physical assessment documented redness to Patient #1’s neck. It was documented in both the MSE (2:12 AM) and in the initial suicide risk assessment (5:39 AM) that Patient #1 did express suicidal intent. Patient #1 was also admitted to drinking 6 beers prior to this event but did not appear intoxicated during the MSE. . Labs were ordered and obtained at 2:16 AM and Patient #1’s toxicology screen (this screen tests for the amount of drugs, alcohol, or other chemicals in a person’s blood, urine, saliva, sweat or breath) revealed that he was positive for methamphetamines although he denied drug use. A computed tomography (CT) Angiogram (this examines blood vessels and other structures) of the neck and head were ordered and obtained at 3:40 AM showed only a small amount of left mastoid fluid, no injury following his hanging/self-imposed strangulation. . The medical record at Facility B indicated that the Detention Warrant became an Order of Protective Custody the morning of August 22, 2024, but there was not a time stamp. The Behavioral Health Physician Assistant’s screening at 9:16 AM noted the following: “ ... (Patient #1) is a 31 y.o. year old patient who has a past medical history of No known health problems. and presents under Legal Status: DW-Detention Warrant due to concern about harm to self. Per warrant: “Subject did attempt to hang himself with a wire on a tree and admitted to doing so - family members stated he facetimed them with a noose around his neck” Spanish interpreter used ID #351449 (Patient #1) states that he only tried to hang himself for attention after he and his wife got into an argument about something she was telling their children. He states that he knew that the wire was too thin and would break so he does not believe this was a true suicide attempt. Patient expresses an understanding that what he did was wrong and states that he will not do it again. Patient states that he enjoys making his wife angry, and this was an attempt at that. He states that he did not intend to harm himself. He states I chose a weak cable because I he knew it would not cut him and it would break. He states I would of taking pills or walked in front of a semi-truck about trying to kill myself. He adamantly denies any suicidal ideation substance/plan. Denies any symptoms of depression. Denies HI (homicidal ideation) and AVH (audio or visual hallucinations). No symptoms of mania anxiety or psychosis noted either. He initially denies any drug use although his urine drug screen is positive for methamphetamine. He admits to drinking 6 beers too and was intoxicated during this. He denies daily alcohol use. On exam, he is alert and oriented x 4. He appears guarded and to be minimizing his struggles. He does not appear acutely intoxicated, manic, or psychotic ...” Patient #1 remained in the psychiatric unit at Facility B for seven days of treatment before he was released. . Policy Review: The “Mental Health AMA Policy”, last reviewed and implemented 12/2024, was reviewed and found to state on page 1 and 2 of 2: “ ...Procedure Diagnosis and or situations included but are not limited to 1. Attempted suicide, suicidal ideation 2. Overdose of street drugs, personal medications, any medications, ETOH use 3. Non- compliance of routine psych medications 4. Mental instability 5. Bi-polar disorder 6. Schizophrenia 7. Any medical condition that causes neurological impairment - Attending physician/provider, Mental Health Consultant, Family members and Law Enforcement Authorities must be involved with the discharge of these guest/patients. - The mental stability must be ascertained. - Guest with these diagnoses will not be allowed to sign an AMA form and be allowed to leave building unescorted. *Rationale: Overall safety is the obligation of Faith Community Hospital during these types of episodes. - Discharge will be allowed when the guest/patient, provider, family member or mental health consultant is in agreement with a safety plan as well as an established medical and or mental health plan. *Rationale: A plan must be established to assure patient safety and medical issues. - Elopement: In the event a guest/patient elopes all of the above individuals will be notified as soon as elopement has been noted ...” . The “Code of Conduct Policy” (which was provided as Facility A’s EMTALA Policy), last reviewed and implemented on 12/2024, was reviewed and found to state on page 3 of 11: “ ...Patients are only transferred in compliance with federal and state EMTALA statutory and regulatory provisions ...” There was no further documented process for transfers within the document. The “Code of Conduct Policy” did not contain any specifics for what a medical screening exam (MSE) was, define an emergency medical condition (EMC), define stabilizing treatment, or define who was approved to be a qualified medical provider (QMP) for completing an MSE, or a specific process for appropriate transfers from the Emergency Department (ED), nor was a process provided within any of the other policies provided. . Facility A’s “Bylaws of the Medical Staff”, last reviewed and implemented on 05/23/2022, were reviewed. The “Bylaws of the Medical Staff” did not contain any specifics for what a medical screening exam (MSE) was, define an emergency medical condition (EMC), who was approved to be a qualified medical provider (QMP) for completing an MSE, or a specific process for appropriate transfers, nor was a process provided within any of the policies provided. . Interviews: During interviews throughout the day on October 1, 2024, were conducted with the Chief Nursing Officer (Staff #1). When Staff #1 was asked if she remembered Patient #1 and had reviewed the findings, she acknowledged that she did. When Staff #1 was asked if she saw a psychiatric screening in the patient medical record, she replied that there was no psychiatric screening and that she had initiated re-training through the ED regarding patients in presumed police custody and had spoken to law enforcement. .”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 45847 . Based on record review and interviews, the facility failed to provide an appropriate transfer for one of 20 (Patient #1) patients whose records were reviewed. Patient #1 did not receive an appropriate transfer to an acute psychiatric care facility when they failed to: . 1. Notify the receiving hospital, and verify the receiving facility had available space and qualified personnel for Patient #1’s transfer or secure an accepting physician. . 2. Indicate the risks and benefits of transfer in writing. . 3. Complete the physician certification with a summary of risks and benefits. . 4. Send the receiving facility all medical records related to the emergency medical condition for Patient #1 who was being transferred for inpatient care at the psychiatric facility. . Findings included: Medical Record Review at Facility A: Patient #1, a 31-year-old male, arrived at the emergency department (ED) at Facility A on 08/20/2024, at 11:04 PM via emergency medical services (EMS) following a suicide attempt by hanging. Patient #1 was assessed at 11:27 PM by Staff #13 (ED Physician). The total time in the ED was one hour and 21 minutes. The time from arrival to medical screening assessment (MSE) was 24 minutes. The MSE did not indicate any physical evidence of trauma to Patient #1’s neck from his suicide attempt, and that “medical clearance prior to transfer to psychiatric hospital by law enforcement” was anticipated. The MSE documented, “He (Patient #1) has been cleared medically for transfer by me (ED Physician).” . A review of the document titled History of Present Illness for Patient #1 completed on 08/20/2024 by Staff #13, ED Physician reflected the following: “Patient brought to ED by law enforcement for medical clearance prior to transfer to (Facility B, a Psychiatric inpatient facility) for psychiatric care related to a suicide attempt. The following information is obtained via online Interpreter: The patient states he attempted to hang himself tonight but did so knowing that the rope he was using would break before he would actually be harmed. Instead of dying he “Just wanted to get some attention.” He states he has been sad since his grandfather passed away ...” . A review of the ...Critical Care Time note reflected the following: “Critical care Time: No Attestation: If acknowledged above, then critical care time applies. Upon my evaluation, this patient had a high probability of life-threatening deterioration due to current ER diagnoses, which required my direct attention, intervention, and management. The critical care time provided is exclusive of separately billable procedures. My time included direct patient care, review of labs and radiology, obtaining history from and counseling the patient and/or the family, discussion with consultants and/or other medical personnel, documentation, and monitoring for potential decompensation ...” . A review of the Discharge Plan completed by Staff #13 revealed the following: “ ...Discharge Time First Seen By Provider: 08/20/2024 23:27 Time Spent With Patient: 12 Patient Disposition: Law Enforcement ED Status: With Nurse Discharge Diagnosis: Suicide attempt Condition: Fair Discharge Comments: Patient was evaluated for medical clearance prior to transfer to psychiatric hospital by law enforcement. The patient was evaluated and not found to have any significant medical issues. He has been cleared medically for transfer by me ...” . The medical record for Patient #1 did not indicate if any physical evidence of trauma to Patient #1’s neck from his suicide attempt. The medical screening examination (MSE) documented by Staff #13 documented, “ ...He (Patient #1) has been cleared medically for transfer by me (Staff #13) ...”. . There was a discharge comment completed by Staff #3 on 08/21/2024 at an unknown time stating the following: “(Patient #1) Patient was evaluated for medical clearance prior to transfer to psychiatric hospital by law enforcement. The patient was evaluated and not found to have any significant medical issues. He has been cleared medically for transfer by me.” . Patient #1 was transferred by law enforcement from Facility A to Facility B on 08/21/2024 at 12:25 AM for continued stabilization of a psychiatric medical condition. . There was no evidence documented that a receiving hospital was contacted or that there was verification that the receiving facility had available space, There was no documentation that qualified personnel accompanied Patient #1 during the transfer or that Facility A had secured an accepting physician. There was no documentation that the risks and benefits of transfer had been explained to Patient #1. There was no physician certification with a summary of risks and benefits documented. There was no documentation that Facility A sent the receiving facility all medical records related to the emergency medical condition for Patient #1 who was being transferred for inpatient care at the psychiatric facility. . There was no Emergency Detention order from law enforcement provided by Facility A for Patient #1. Law enforcement arrived with and remained with Patient #1 for the entirety of his time at Facility A. . Medical Record Review at Facility B: Patient #1, a 31-year-old male, arrived at Facility B’s Emergency Department (ED) on August 21, 2024, at 1:33 AM. The total time in the ED was three hours and 39 minutes. The time from arrival to medical screening assessment (MSE) at 2:12 AM was 33 minutes. The physical assessment documented redness to Patient #1’s neck. It was documented in both the MSE (2:12 AM) and in the initial suicide risk assessment (5:39 AM) that Patient #1 did express suicidal intent. Patient #1 was also admitted to drinking 6 beers prior to this event but did not appear intoxicated during the MSE. . Labs were ordered and obtained at 2:16 AM and Patient #1’s toxicology screen (this screen tests for the amount of drugs, alcohol, or other chemicals in a person’s blood, urine, saliva, sweat or breath) revealed that he was positive for methamphetamines although he denied drug use. A computed tomography (CT) Angiogram (this examines blood vessels and other structures) of the neck and head were ordered and obtained at 3:40 AM showed only a small amount of left mastoid fluid, no injury following his hanging/self-imposed strangulation. . The medical record at Facility B indicated that the Detention Warrant became an Order of Protective Custody the morning of August 22, 2024, but there was not a time stamp. The Behavioral Health Physician Assistant’s screening at 9:16 AM noted the following: “ ... (Patient #1) is a 31 y.o. year old patient who has a past medical history of No known health problems. and presents under Legal Status: DW-Detention Warrant due to concern about harm to self. Per warrant: “Subject did attempt to hang himself with a wire on a tree and admitted to doing so - family members stated he facetimed them with a noose around his neck” Spanish interpreter used ID #351449 (Patient #1) states that he only tried to hang himself for attention after he and his wife got into an argument about something she was telling their children. He states that he knew that the wire was too thin and would break so he does not believe this was a true suicide attempt. Patient expresses an understanding that what he did was wrong and states that he will not do it again. Patient states that he enjoys making his wife angry, and this was an attempt at that. He states that he did not intend to harm himself. He states I chose a weak cable because I he knew it would not cut him and it would break. He states I would of taking pills or walked in front of a semi-truck about trying to kill myself. He adamantly denies any suicidal ideation substance/plan. Denies any symptoms of depression. Denies HI (homicidal ideation) and AVH (audio or visual hallucinations). No symptoms of mania anxiety or psychosis noted either. He initially denies any drug use although his urine drug screen is positive for methamphetamine. He admits to drinking 6 beers too and was intoxicated during this. He denies daily alcohol use. On exam, he is alert and oriented x 4. He appears guarded and to be minimizing his struggles. He does not appear acutely intoxicated, manic, or psychotic ...” Patient #1 remained in the psychiatric unit at Facility B for seven days of treatment before he was released. . Policy Review: Facility A’s “Bylaws of the Medical Staff”, last reviewed and implemented on 05/23/2022, were reviewed. The “Bylaws of the Medical Staff” did not contain a definition of an emergency medical condition (EMC), provide a specific process for appropriate transfers, nor was a process provided within any of the policies provided. . Facility A’s policy titled, “Policy on Decompensation Patients and Patient Transfers”, last reviewed and implemented on 05/2024, were reviewed. The two-page document did not address transfers from the Emergency Department (ED) out of the facility or provide a procedure for transferring patients outside the hospital. . The “Code of Conduct Policy” (which was provided as Facility A’s EMTALA Policy), last reviewed and implemented on 12/2024, was reviewed and found to state on page 3 of 11: “ ...Patients are only transferred in compliance with federal and state EMTALA statutory and regulatory provisions ...” There was no further documented process for transfers within the document. The “Code of Conduct Policy” did not contain any specifics that define an emergency medical condition (EMC) or define a specific process for appropriate transfers from the Emergency Department (ED), nor was a process provided within any of the other policies provided. . Interviews: During interviews throughout the day on October 1, 2024, were conducted with the Chief Nursing Officer (Staff #1). When Staff #1 was asked if she remembered Patient #1 and had reviewed the findings, she acknowledged that she did. When Staff #1 was asked if this case was thought to be an appropriate transfer, she replied that it was not an appropriate transfer and that she had initiated re-training through the ED regarding patients in presumed police custody and had spoken to law enforcement. .”