Aurora Psychiatric Hospital

“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: 53566 Based on record review and interview, the facility failed to complete an appropriate MSE (Medical Screening Exam) for 1 (Patient #9) of 20 patients in a total universe of 20 medical records reviewed. A review of the facility policy titled “EMTALA (Emergency Medical Treatment and Active Labor Act) Policy” last revised 09/22/2025 revealed, “...Dedicated Emergency Department: any department or building of the hospital, regardless of whether it is located on or off the main campus, that meets at least one of the following requirements:...3. during the calendar year immediately preceding the calendar year in which determination is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment...Emergency Medical Condition: 1. A medical condition manifesting itself by acute symptoms of sufficient severity...including...psychiatric disturbances and/or symptoms of substance abuse such that the absence of immediate medical attention could reasonably be expected to result in either: a. placing the health of the patient...in serious jeopardy...3. With respect to a patient with psychiatric symptoms: a. That acute psychiatric symptoms are manifested; or b. That the patient expresses suicidal or homicidal thoughts or gestures and is determined to be a danger to self or others...Medical Screening Examination (MSE): an examination performed by a licensed physician or a Qualified Medical Person to determine with reasonable clinical confidence whether an Emergency Medical Condition does or does not exist. Depending on the patient’s presenting symptoms, an appropriate Medical Screening Examination can involve a wide spectrum of activities ranging from...only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures...” A review of Patient #9’s medical record revealed that on 2/21/2026 at 8:13 PM, Patient #9 presented to Hospital A in police custody following an altercation with family. Patient #9 expressed suicidal intent with a plan but was uncooperative with further assessment or treatment. Intake RN M contacted Psychiatrist K to discuss the partial intake assessment, and Psychiatrist K determined that Patient #9 was a danger to herself and/or others and recommended inpatient treatment. Patient #9’s mother (her legal guardian) was not present and could not be reached, so local police placed Patient #9 on a Chapter 51 hold (involuntary mental health commitment) and transported her to Hospital B. A review of facility document “Hospital Designation of Qualified Medical Personnel (QMP)” last reviewed 6/16/2025 revealed, “...F. MSE Components. The MSE must be individualized and thorough, and may include, but is not limited to:...c. Vital Signs and General Appearance Assessment...d. Patient Safety Assessment (e.g. firearms, suicide, self-harm, recent ingestion of alcohol or drugs)...e. History of presenting illness including psychiatric, medical...recent surgical history and alcoholic subtance use history. f. Mental status examination...K. Physical examination as indicated by presentation - Medical evaluation for potential underlying causes of psychiatric symptoms (e.g. infection, intoxication, withdrawal, head injury)...” A review of “Intake Assessment Summary” written on 2/21/20-26 at 8:13 PM by Intake RN M revealed that Patient #9 had a history of schizoaffective disorder and polysubstance abuse. She was initially cooperative with the intake assessment but became “...paranoid and hostile...” and “...verbalized...in front of staff and police that she wanted to kill herself with a knife...” The note revealed no evidence of Patient #9’s vital signs, a physical exam, or a complete mental health evaluation. During an interview on 9/6/2026 at 9:20 AM, Intake Services RN J stated the intake process for all patients includes meeting with a Registered Nurse (RN) for an MSE and triage, vital signs, review of significant history, and review of presenting complaint(s). Intake Services RN J stated the RN or Intake Counselor then does a mental health assessment and speaks to the on-call to discuss findings and determine the appropriate level of care for the patient. Intake Services RN J stated that other than vital signs, RNs do not perform a physical assessment and “can’t lay hands on patients in Intake Services.” Intake Services RN J stated the on-call psychiatrist does not come to Intake Services to see patients and is consulted only by phone.”