Based on record review, review of hospital policies, patient/family interview, and staff interview, it was determined the hospital failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. This resulted in the lack of an appropriate MSE for 1 of 17 minor patients (#1). Findings include: Refer to A2406 as it relates to the failure of the hospital to provide an appropriate medical screening examination.

Based on record review, policy review, patient/family interview, and staff interview, it was determined the hospital failed to ensure an MSE was provided to 1 of 17 ED patients (Patient #1) who were minors and whose records were reviewed. This had the potential to result in patients with undiagnosed emergency medical conditions. Findings include: The policy "Consent for Medical Treatment" was approved on 11/15/17. It stated, "Who May Give Informed Consent?...a person of 14 years of age or older may provide Informed Consent to treatment for mental illness." Another hospital policy "Emergency Medical Treatment and Labor Act (EMTALA) Compliance," approved 5/12/17, stated "Any individual who comes to Saint Alphonsus (the "Hospital") seeking an examination and treatment of a potential emergency medical condition will receive a screening examination to determine the existence of any emergency medical condition..." These policies were not followed: Patient #1 was a [AGE] year old female who presented to the ED at 9:29 PM on 2/23/18, for evaluation of her behavioral health status. Patient #1 was brought in by her parents following an encounter with police. Patient #1's record included a triage note on 2/23/18 at 9:36 PM, signed by the triage RN. The triage note stated Patient #1's mother claimed the girl was a danger to others. The note further stated the girl was discharged 8 days ago from a behavioral health facility. The triage note also stated "Pt's mother and step father [are] extremely agitated after being told they have to stay with pt." The note stated the mother said, "I am not going to sit here and watch her be pampered." The triage note included Patient #1's vital signs and allergies. There was no documentation of psychiatric, abuse, or social assessments. The note did not clarify how Patient #1 was a danger to others. Patient #1's record documented her acuity as "Emergent," but did not include a complete triage or nursing assessment. There was no documentation an assessment was performed of Patient #1's psychiatric status. The record did not state if Patient #1 was a danger to herself or others. The triage RN documented in her progress notes Patient #1's parents were becoming more upset and at 9:52 PM "Step father and mother increasingly agitated after being told they can't drop off pt and leave." From 9:36 PM to 9:52 PM, 16 minutes, there was no further documentation of assessment by the RN. At 10:15 PM, the triage RN documented "Pt upset not wanting to leave with mother but resolved to go." Patient #1's record documented she had LWBS at 10:17 PM, 48 minutes after she presented to the ED for evaluation. There was no documentation in Patient #1's record she was taken to an ED room for evaluation by a provider. There was no documentation of an MSE by a qualified person. Patient #1's medical record included a "CONSENT TO MEDICAL CARE AND PATIENT SERVICES AGREEMENT" signed by her mother at 9:34 PM on 2/23/18. Patient #1's medical record included an "INFORMED CONSENT TO REFUSE OFFERED SERVICES" form. The form was signed by a witness at 10:12 PM on 2/23/18, but there was no signature by Patient #1 or her parents. During a phone interview beginning at 11:45 AM on 4/05/18, the Charge RN stated he was the charge nurse on the evening of 2/23/18, and was called over the radio to provide assistance in triage. He stated the triage RN informed him the parents of Patient #1 told her they "could not handle her anymore" and were told by police they "could drop her off and leave." The Charge RN stated Patient #1's father told him he wanted to "drop her off and go." He stated he told the parents he wanted to talk with the LCSW in the ED to verify they could do that. The Charge RN stated he spoke with the LCSW and she informed him the parents of Patient #1 could not leave her in the ED. He stated he went back to the triage area with the LCSW and she informed the parents if they wanted her evaluated they could not leave. The Charge RN stated he spoke with Patient #1 and asked her whether she was suicidal or wanted to hurt other people and she stated she did not. He stated Patient #1 also told him she did not know why she was there and she did not want to be in the ED. The Charge RN confirmed the conversations mentioned above were not documented in Patient #1's record. During an interview via phone beginning at 4:15 PM on 4/05/18, the RN who triaged Patient #1 stated she called Patient #1 into the triage room and her parents did not initially come into the room with her. She stated she asked the parents to come into the triage room and when she asked Patient #1 why she was there, Patient #1 did not answer. The RN stated Patient #1's mother told her Patient #1 wanted to harm other family members and she wanted to "drop her off." She stated she informed Patient #1's mother she could not leave the patient there because she was a minor. The RN stated the father, or stepfather-she was unsure of the relationship-would come in the room and state something then step out again. The RN stated the mother left the triage room and she asked Patient #1 if she wanted to hurt her family and she stated "No." The RN stated she went and got the Charge RN, and he spoke with Patient #1 and her mother. The RN stated the Charge RN informed Patient #1's parents they must be present for the patient to be evaluated. She stated after the parents of Patient #1 spoke with the Charge RN, another staff member informed her Patient #1 was out in the waiting room alone and her parents had left. The RN stated she informed Patient #1 not to leave the waiting room and she went to talk with the Charge RN. She stated the staff member came back in the ED to inform her Patient #1's parents had returned and Patient #1 did not want to leave with them. The RN stated Patient #1's mother told her "Let's go" but Patient #1 told the RN she did not want to go with them. The RN stated she told Patient #1 "This is your family, you have to go with them" and Patient #1 stated "Fine." The RN stated she was not aware at that time of the policy regarding minors 14 and older being able to consent for their own evaluation and treatment. During a phone interview beginning at 11:45 AM on 4/09/18, Patient #1's mother stated she had a police officer come to her house. She stated the officer told her she could take Patient #1 to the ED and not have to stay with her. Patient #1's mother stated at the ED she was informed she had to stay with her daughter for her to be evaluated. Patient #1's mother stated she made it clear to staff that she did want Patient #1 evaluated and treated. She stated staff told her their policy was her daughter had to be 16 or older to stay without a parent or guardian. The hospital failed to provide an MSE to Patient #1.

Based on staff interview, review of IDAPA state rules, and review of hospital documents, it was determined the hospital failed to ensure physicians (MDs and DOs) provided supervision of PAs, who provided care to patients in the ED, as described in their Delegation of Services Agreement. This deficient practice had the potential to directly impact the care of all patients receiving treatment in the ED. Findings include: IDAPA 22.01.03.029.03 includes the delegation of service agreement between the PA and Supervising Physician. It states: "03. Delegation of Services Agreement. Each licensed physician assistant and graduate physician assistant shall maintain a current copy of a Delegation of Services (DOS) Agreement between the licensee and each of his supervising physicians...(3-16-04)." The delegation of services agreement for 4 of the 10 PAs who work in the ED was requested. The hospital provided documents titled "Delegation of Services Agreement" for each of the 4 PAs. Under the section titled "MEDICAL SERVICES REVIEW" the documents stated, " ... a daily review of Physician Assistant's care and prescribing practice will occur due to the usual customary interaction by the Physician Assistant and physician during working hours. A sampling of not less than ten patients' medical records per month are reviewed by the supervising physician on an ongoing basis." Documentation of the medical record reviews for the 4 PAs was requested. The hospital provided documentation the Supervising Physicians completed 10 medical record reviews per quarter for each PA. The supervising physicians did not complete reviews of 10 medical records per month as required by the delegation of services agreements. A Supervising Physician for PAs was interviewed on 4/09/18 beginning at 3:10 PM. He stated he was the Physician Liaison to the PAs, which included responsibility for education, evaluation, and reviewing of the PAs' charts. When asked how many and how often he reviewed medical records of the PAs he supervised, he stated he reviewed a total of 10 records per quarter for each PA. The ED Medical Director was interviewed on 4/09/18 beginning at 5:14 PM. When asked how many PAs he supervised he stated he thought it was 3. When asked which PAs he supervised, he stated he would have to look because there had been recent changes. He also stated that medical record reviews were delegated to the Physician Liaison and he would look at the charts if a concern or issue was identified by the Physician Liaison. The Supervising Physicians did not provide oversight to the PAs in the ED as required by the hospitals delegation of services agreement.