St Mark’s 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: 46232 Based on interview and record review, it was determined that the hospital failed to meet the requirements for Emergency Medical Treatment and active labor act (EMTALA). Specifically, for one of 20 sampled patients who presented to the emergency department (ED), the hospital allowed the police officer to remove a patient from the ED prior to providing an appropriate medical screening examination (MSE). (Patient Identifier: 10) Findings include: The hospital’s policies for EMTALA stated that the hospital must provide an appropriate MSE within the capability of the hospital’s ED, including ancillary services routinely available to the dedicated emergency department (DED), to determine whether or not an emergency medical condition (EMC) existed for an individual who had such a request made on his or her behalf; or an individual whom a prudent layperson observer would conclude from the individual’s appearance or behavior needs a MSE. A MSE shall be provided to determine whether or not the individual is experiencing an EMC. A MSE is required when the individual arrives on the hospital property, either in the DED or property other than the DED, and no request is made for evaluation or treatment, but the appearance or behavior of the individual would cause a prudent layperson observer to believe that the individual needed such examination or treatment. On 10/19/2024, patient 10 was taken to the ED by police after police found him wandering in the streets, appearing intoxicated, and making threats of wanting to end his life. The arresting officer (AO) intended to pink sheet (a temporary involuntary commitment of a person believed to be mentally ill and poses a substantial risk of harm to themselves or others) patient 10, but ended up arresting him and taking him to jail prior to a MSE being completed. On 12/4/24 at 10:00 AM, an interview was conducted with the Arresting Officer (AO). The AO stated patient 10 wanted to hurt themselves by walking into traffic. The AO stated that patient 10 was having a mental crisis and was intoxicated and she believed that played into patient 10’s suicidal ideation (SI). The AO stated patient 10 was a danger to themselves because they had a plan and had a way to carry out their SI plan. The AO stated patient 10 was taken to the ED because they were in need of help and had intended to pink sheet the patient, but the facility would not hold the patient there. The AO stated they started to fill out the pink sheet but then had it shredded when they ended up taking patient 10 to jail instead. The AO stated patient 10 had not been violent. The AO stated a female nurse informed them there was not enough staff for a one on one observation and staff were unwilling to stay in the room with patient 10 and was told if patient 10 walked out of the room, it was not the ED staff’s problem. The AO stated they had briefly explained to the doctor what was going on with patient 10 but had not had enough time to make a plan before patient 10 tried to walk out of the room. The AO stated they had to charge patient 10 with public intoxication in order to take them to jail and place patient 10 on a suicidal hold. The hospital was in violation of the EMTALA requirement by allowing the officer to take possession of patient 10 and remove him from the ED prior to providing an appropriate MSE to determine if an EMC existed and if patient 10 required stabilizing treatment. Refer to tag 2406”

“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: 46232 Based on interviews and record review, it was determined that the hospital did not provide an appropriate medical screening examination (MSE) to determine whether or not an emergency medical condition (EMC) existed for a patient on hospital property. Specifically, a patient who was intoxicated and attempting to run into traffic was brought in by police for suicidal ideation and was not examined by a person qualified by hospital bylaws or rules and regulations to determine whether or not an EMC existed. (Patient Identifier: 10) Findings include: 1. Review of the police report dated 10/19/2024 revealed patient 10 was found to be walking into oncoming traffic and stated they wanted to end their life. The police arrived and observed patient 10 to have glassy eyes, slurred speech, unsteady gait and having a strong smell of alcohol. The police reported patient 10 was uncooperative and when asked about their mental health, patient 10 responded they needed help and wanted to “end it.” Police decided based on patient 10’s statement and behavior that patient 10 was a danger to themselves and others and were intent on pink sheeting (a temporary involuntary commitment of a person believed to be mentally ill and poses a substantial risk of harm to themselves or others) patient 10 for their safety. The police stated they were concerned about patient 10’s safety because they had a way to carry out their plan of walking into traffic. On 12/4/24 at 10:00 AM, an interview was conducted with the Arresting Officer (AO). The AO stated patient 10 wanted to hurt themselves by walking into traffic. Patient 10 was having a mental crisis and was intoxicated and the AO stated they believed that played into patient 10’s suicidal ideation (SI). The AO stated patient 10 was a danger to themselves because they had a plan and had a way to carry out their SI plans. The AO stated patient 10 was taken to the emergency department (ED) because they were in need of help and had intended to pink sheet (a temporary involuntary commitment of a person believed to be mentally ill and poses a substantial risk of harm to themselves or others) them but the facility would not hold the patient there. The AO stated they started to fill out the pink sheet but then had it shredded when they took patient 10 to jail. The AO stated this specific ED had informed them not to bring in uncooperative patients due to limited staffing. The AO stated every time they brought in a pink sheeted patient, the ED staff gave them grief. The AO stated they have left with patients before due to the amount of grief they had received from staff. The AO stated patient 10 had not been violent. The AO stated a female nurse informed them there was not enough staff for a one on one observation and staff were unwilling to stay in the room with patient 10, and was told if patient 10 walked out of the room, it was not the ED staff’s problem. The AO stated they had briefly explained to the doctor what was going on with patient 10 but had not had enough time to make a plan before patient 10 tried to walk out of the room. The officer stated they started to fill out the pink sheet paper work but was unable to finish it because the situation had become a “fiasco.” The AO stated they took their subject (patient 10) into custody and transported him to jail instead. 2. Patient 10’s record review was completed for the emergency department (ED) visit on 10/19/2024. It was documented patient 10 arrived at the ED at 8:33 PM with a diagnosis of suicidal ideation. Patient 10 was discharged at 8:37 PM and the discharge disposition documented patient 10 had left without being seen. Patient 10’s discharge destination was jail. A discharge note documented patient 10 had been taken to jail with police. It should be noted Patient 10 was only in the ED for four minutes. 3. On 12/3/2024, an interview was conducted with a registered nurse (RN). The RN stated every patient [who presents to the ED for emergency care] must be seen and receive a MSE. On 12/3/2024, an interview was conducted with patient 10’s primary nurse (PN). The PN stated staff needed to make sure every patient had a MSE completed to determine if they were safe to be discharged. The PN stated that in the ED, they were not allowed to deny care to anyone. Police had brought patient 10 to the ED due to safety concerns. The patient was altered in some way and had been attempting to walk into traffic. The PN stated that during the short course of patient 10’s stay, he had become frustrated and uncooperative, was handcuffed, and transported to jail after a short time in the ED. The PN stated they followed the police department’s lead in these cases. On 12/4/2024 at 11:54 AM, an interview was conducted with a Detective familiar with the difficulties taking patients to this particular ED. The Detective stated about 1.5 years ago they were told by their department that the ED in question was not staffed for certain patients, and have since tried to avoid taking patients to that ED. On 12/5/2024, an interview was conducted with RN 2. RN 2 stated patient 10 was brought in by the police. RN 2 stated patient 10 became aggressive and posturing towards staff. RN 2 stated patient 10’s situation was unique because a pink sheet had not been completed when they arrived at the emergency room. RN 2 stated the police officer was in the process of filling out the pink sheet while at the facility, when patient 10 became verbally aggressive and was arrested and taken to jail. RN 2 stated patients were never turned away from the ED and they often saw uncooperative patients there. RN 2 stated the police placed a patient under a pink sheet if they had concern the patient may self harm themselves. RN 2 stated when a patient is brought in pink sheeted, they honor the pink sheet no matter what and the patient had a mandatory hold until they were evaluated by a medical doctor and crisis worker and cleared medically. 4. The hospital’s EMTALA (Emergency Medical Treatment and Labor Act) policy was reviewed and included the following: “...G. If a law enforcement official brings a person who is exhibiting behavior that suggests that he or she is intoxicated to the DED (dedicated emergency department) for drawing of the blood alcohol and asks for an MSE, or if a prudent layperson observer would believe that the individual needed examination or treatment for a possible EMC, then an MSE must be performed. This is required because some medical conditions could present behaviors similar to those of an inebriated individual.” 5. In summary, the ED was in violation of the EMTALA requirement by allowing the officer to take possession of patient 10 and remove him from the ED prior to providing an appropriate MSE to determine if an EMC existed and if patient 10 required stabilizing treatment.”