Based on record review and review of EMTALA policies, the facility failed to ensure the policies for the provision of the Medical Screening Examination (MSE) with sufficient assessment and/or testing to determine if the patient has an Emergency Medical Condition (EMC) was followed for 2 of 30 sampled patients (Patient 1 and 2). The sample was drawn from 9/10/17 through 4/16/18. This failure placed all emergency patients requesting to be seen at risk of harm due to being discharged with an untreated/unstabilized EMC. Based on facility provided data from 10/1/17 through 3/18/18, the facility saw an average of 4,967 emergency patients per month. Findings are: A. Review of facility policy titled"Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department - EMTALA - Creighton University Medical Center - Bergan Mercy" last revised 03/2018 states the MSE "is the process required to determine with reasonable clinical confidence whether an EMC does or does not exist." "An appropriate MSE can include a wide spectrum of actions ranging from a simple process only involving a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures." The policy states that for an "individual manifesting behavioral or psychiatric symptoms, the MSE consists of both a medical and behavioral/psychiatric health screening. B. Electronic Medical Record (EMR) review revealed Patient 1 arrived by rescue squad to the Emergency Department (ED) on 9/10/17 at 11:27 AM accompanied by law enforcement personnel. The record notes under "History of Present Illness" that the patient was brought for evaluation after being found destroying property on a nearby college campus. The patient was "demonstrating bizarre behavior, police report he was walking around at one point with a steering wheel from a car he was pretending he was driving; reportedly the patient was knocking over property and attempting to light pieces of property on fire." The patient's speech was not making sense and it was believed by law enforcement that the patient was under the influence of illegal drugs. On arrival the patient was unable to answer questions. There were no signs of trauma. The patient was "poorly kempt, foul-smelling, arrived to the emergency department in wet clothing." Medical history from previous visits to the facility included Anxiety, Bipolar disorder and hypertension. Historical medications included psychiatric medications to treat psychosis. The patients Blood Pressure (BP) was elevated at 179/117 at 11:45 AM. Normal BP is 120/80. Temperature, pulse, respiration and Oxygen saturation were normal throughout the ED visit. Nursing monitored the BP through out the stay with the BP remaining elevated. Prior to discharge at 8:45 PM the patient's BP was 174/124, pulse 68, respirations 19, Oxygen saturation 98 % and pain 0/10. The medical provider was notified of the elevated BP and again informed of the elevation prior to discharge. At 11:28 AM, Nurse Practitioner "A" noted the patient "is calm, not demonstrating impulsive behavior. The patient's speech and comprehension is consistent with being under the influence of mind altering substances." NP A noted the patient was discussed with the ED Medical Doctor MD "B" at 11:37 AM. NP A ordered a urine drug screen which was reported at 6:55 PM as negative. The Comprehensive Metabolic Panel found the AST, a test to detect liver damage was elevated at 44 (normal 10 -40). Ethanol level collected at 4:45 PM was less than 10 indicating the patient was not under the influence of alcohol. No further testing was ordered for the patient. At 11:44 AM the patient Progress notes stated the patient was "yelling and making threatening gestures toward hospital staff. Security and Law enforcement were at the bedside." At 11:57 the notes stated the patient "is suspicious of health care provider activity in his room. The patient is handcuffed to the bed. Security and law enforcement personnel are present in the patient's doorway." The patient was given Ativan (a drug used for anxiety, alcohol withdrawal) 2 milligrams (mg) and Haldol (a antipsychotic medication) 5 mg by injection at 11:56 AM. By 12:11 PM the patient was calm and was given food and fluids. 1:03 PM BP was 156/86. The patient was given Clonidine ( a drug to treat elevated BP) at 4:24 PM (BP recorded at 4:08 PM was 160/101). At 2:46 PM the patient was noted as "awake, vitals normal, speech clear, thoughts remain disorganized, comprehension and current situation is poor." At 6:20 PM NP A documented discussion with MD B regarding the laboratory results. The plan was to discharge the patient when he was able to ambulate. At 8:02 PM the patient was discharged with an elevated BP and a diagnosis of [DIAGNOSES REDACTED]. The discharge instructions included follow up with primary care provider as soon as possible on 9/11/17 and "discuss management of chronic health conditions, blood pressure re-check." The patient was also to schedule an appointment with a Psychiatrist "to be evaluated as soon as possible by a mental health care professional to address mental health disorder." The patient told the nurse he was ready for discharge and had a safe place to go. Discharge instructions included Altered Mental Status, Mild neurocognitive disorder, Hypertension, Confusion an Bipolar Disorder. Interview with Nurse Practitioner (NP) A on 4/17/18 at 4:45 PM revealed the NP's initial differential diagnosis for Patient 1 was acute organic (physical) psychosis versus chemical psychosis. When the drug screen and alcohol levels were found to be normal the PA ordered a head CT scan and an ammonia level. [Patients with liver problems can have a build up of ammonia in the blood resulting in confusion. Psychosis is an abnormal condition of the mind that results in difficulties telling what is real and what is not.] The NP stated he wanted to do a full work up. After discussion with ED MD B the NP stated that the MD did not want further studies done and to just give the patient Ativan and Haldol and monitor him. The NP confirmed that the patient was acutely psychotic and with no evidence of traumatic injury he would have wanted to admit the patient. The NP confirmed the ED has a psychiatrist on call and that calling the psychiatrist would have been appropriate. The NP stated that normally he orders serum (laboratory) tests and admits patients for acutely psychotic symptoms. The NP stated that MD B wanted the patient discharged when able to ambulate and that is what was done. When asked if the patient had an EMC related to the profound hypertension the NP responded "Yes." Interview with the ED Medical Director MD C on 4/17/18 at 4 PM revealed that a patient with an elevated BP and exhibiting bizarre behaviors, the provider should review the patient for end organ function by ordering kidney function tests and an EKG (electronic tracing of the heart's electrical activity which can indicate heart problems). Calling the psychiatrist on call would have enabled the provider to get a psychiatric diagnosis of [DIAGNOSES REDACTED]"patient may have had an EMC at discharge." Review of the on call list dated 9/10/17 revealed an attending psychiatrist and resident were on call. The facility did have an inpatient psychiatric bed available on 9/10/17 per facility provided records. C. Review of patient # 2's EMR revealed the patient arrived in the ED by rescue squad on 9/14/17 at 2:55 PM. Review of the Omaha Fire Department EMS record dated 9/14/17 noted EMS were called in response to a patient fainting at the airport. The patient was found lying on the ground inside the airport terminal. Alert to place and time. The patient stated she walked to the airport from a women's homeless shelter (distance of 2.4 miles) because the shelter "would not help her." The patient complained of dehydration and not having food since 10:30 AM. The patient had a 1/2 full water bottle in hand. BP was 98/palpated, respirations 12 and Oxygen saturation 98 %. EMS started an IV and gave a fluid bolus with transport to the ED. Enroute the patient stated that "Creighton was going to intentionally kill her. She asked the EMS to check her ID to be sure the last firefighter to look at it did not alter it. Once in the ED the staff nurse was notified of possible mental illness. After transfer of care the nurse stated the patient had made comments that the EMS staff were "waterboarding her on the way to the hospital." Initial vital signs were obtained in the ED at 3:09 PM. BP was 125/71, pulse 93, respirations 18, Oxygen saturation was 100%. The oral temperature was normal at 98.1 degrees Fahrenheit. The patient was alert, speech clear and obeyed commands per nursing documentation. The EMR historical data included a medical history of [DIAGNOSES REDACTED][[DIAGNOSES REDACTED] is a disease in which the body does not produce enough steroidal hormones - requiring treatment with daily steroids which if not provided could result in Addisonion Crisis and death). Adrenal Crisis symptoms include vomiting/diarrhea/dehydration, low BP, syncope -loss of consciousness and inability to stand, low blood sugar, confusion, psychosis, slurred speech, lethargy, low sodium levels, high potassium levels, low calcium levels, convulsions and fever.] She also had a history of SIADH (syndrome of inappropriate antidiuretic hormone). Other historical diagnoses included [DIAGNOSES REDACTED]. The Invega Sustena was prescribed by a psychiatrist currently on staff on 3/3/16. The ED resident saw the patient at 3:04 PM. Nursing documentation by RN E on 9/14/17 at 3:52 PM noted the patient saying she did not trust Creighton because "they don't train their people appropriately." The patient refused treatment and requested to be taken to Lakeside, an acute care hospital several miles away. The provider explained that to be taken to Lakeside the staff needed to obtain some blood work and then could attempt transfer. The patient refused and called the provider a liar and that she did not want any treatment from this facility. Patient informed that she could receive treatment or she would need to leave. The nurse documented the patient was presented with AMA (Against Medical Advice) paperwork and refused to sign. She was informed that refusing treatment could lead to further injury and or death, which she stated she understood. Security was then called who witnessed the refusal. The last vitals were documented at 3:15 with BP 106/70 pulse 90 and Oxygen saturation of 100%. Review of the AMA papers provided to the patient on 9/14/17 at 3:15 PM included the patient was informed of the dangers and possible risk of leaving against medical advice including but not limited to "further injury and or death." Review of physician notes by the ED Resident on 9/14/17 noted the patient's extensive psychiatric history and [DIAGNOSES REDACTED]. On arrival the patient was "afebrile and vital signs were stable. She was alert and oriented to self, place and time. The patient refused to cooperate with the exam." The notes stated "Myself, nurse and attending [name of MD F] tried extensively to reason with the patient and asked her to allow us to take care of her, work her up, and treat her acute issues. However, pt [patient] refused our care. Continuously stated that she wants to go to Lakeside and 'I do not consent for anyone at Creighton to treat me or assess me." There was no physical exam documented noting the patient's refusal. The ED notes stated the "Patient lucid, did not express SI [suicidal ideation] or HI [homicidal ideation]." Review of physician notes by ED MD F dated 9/14/17 at 3:57 PM also noted that the patient was "fully lucid alert and understood her circumstances." "Patient stated the only way she would be treated as [sic] if she was going to Lakeside." The MD advised her that if they were able to find something abnormal on her blood work that they could get her admitted at Lakeside. The exam was only visual as the patient would not allow the provider to touch her. She was able to move all extremities very well and push herself up in bed with her hands and legs. The Glasgow Coma Score (assessment of consciousness) was normal at 15. She denied SI and HI. Vitals were stable. MD F discussed with the patient her history of adrenal problems (Addison's), SIADH, and mental disorder which the patient responded that this was erroneous and accused him of lying. Attempts to allow other practitioners to examine her also failed. We explained that she will have to follow up with her own physician. Review of physician on call lists identified a psychiatrist was on call for the facility. Review of psychiatric inpatient bed availability found on 9/14/17 beds were not available. The patient did not receive a mental health exam by a psychiatrist to assist the physicians in obtaining information necessary to determine if the patient had an EMC. Interview with RN E on 4/18/18 at 8 AM confirmed multiple staff attempted to gain her cooperation but patient # 2 continued to refuse care because we were associated with Creighton. The nurse felt the patient was competent to make the AMA decision. When the patient refused to leave the ED room Security was called, patient requested a wheelchair and was taken outside the ED by Security. Phone interview with ED MD F on 4/18/18 at 2:10 PM revealed they were looking for an excuse to place the patient under Emergency Protective Custody (EPC -involuntary psychiatric hold placed by police to involuntary admit a patient to a psychiatric facility). He confirmed the patient did not have heat stroke. We asked her about stress, psychiatric problems, suicide thoughts she answered questions appropriately and was lucid and alert. There "was no inkling of [a] psychiatric problem." No issues psychiatrically she could walk and talk. When we told her we could not transfer her to Lakeside she wanted a taxi voucher to Lakeside hospital. We don't do that. We explained the risks of SIADH, Addison's and mental health issues left untreated and the patient still refused. He confirmed the psychiatrist on call was not called to assist in evaluating the patient stating there was "no indication to call the psychiatrist, the patient was lucid and alert, no threat to self or others, not in acute psychosis." ED MD F confirmed the patient made statements about CUMC (Creighton) physicians inadequate to care for her and that the MD's at Lakeside were better. The MD did not feel the patient had an EMC at discharge.

Based on record review, staff and provider interviews and review of the facility EMTALA policies, the facility failed to ensure 2 of 30 sampled patients (Patient 1 and 2) received a Medical Screening Examination (MSE) with sufficient assessment and/or testing to determine if the patient had an Emergency Medical Condition (EMC). The sample was drawn from 9/10/17 through 4/16/18. This failure places all emergency patients requesting to be seen at risk of harm due to being discharged with an untreated/stabilized EMC. Based on facility provided data from 10/1/17 through 3/18/18 the facility saw an average of 4,967 emergency patients per month. Findings are: A. Electronic Medical Record (EMR) review revealed Patient 1 arrived by rescue squad to the Emergency Department (ED) on 9/10/17 at 11:27 AM accompanied by law enforcement personnel. The record notes under "History of Present Illness" that the patient was brought for evaluation after being found destroying property on a nearby college campus. The patient was "demonstrating bizarre behavior, police report he was walking around at one point with a steering wheel from a car he was pretending he was driving; reportedly the patient was knocking over property and attempting to light pieces of property on fire." The patient's speech was not making sense and it was believed by law enforcement that the patient was under the influence of illegal drugs. On arrival the patient was unable to answer questions. There were no signs of trauma. The patient was "poorly kempt, foul-smelling, arrived to the emergency department in wet clothing." Medical history from previous visits to the facility included Anxiety, Bipolar disorder and hypertension. Historical medications included psychiatric medications to treat psychosis. The patient's Blood Pressure (BP) was elevated at 179/117 at 11:45 AM. Normal BP is 120/80. Temperature, pulse, respiration and Oxygen saturation were normal throughout the ED visit. Nursing monitored the BP through out the stay with the BP remaining elevated. Prior to discharge at 8:45 PM the patient's BP was 174/124, pulse 68, respirations 19, Oxygen saturation 98 % and pain 0/10. The medical provider was notified of the elevated BP and again informed of the elevation prior to discharge. Review of the Physical Examination documented by Nurse Practitioner "A" at 11:28 AM noted the patient "is calm, not demonstrating impulsive behavior." The patient's speech and comprehension is consistent with being under the influence of mind altering substances. NP A noted the patient was discussed with the ED Medical Doctor MD "B" at 11:37 AM. NP A ordered a urine drug screen which was reported at 6:55 PM as negative. The Comprehensive Metabolic Panel found the AST, a test to detect liver damage was elevated at 44 (normal 10 -40). Ethanol level collected at 4:45 PM was less than 10 indicating the patient was not under the influence of alcohol. No further testing was ordered for the patient. At 11:44 AM the patient Progress notes stated the patient was "yelling and making threatening gestures toward hospital staff. Security and Law enforcement were at the bedside." At 11:57 the notes notes stated the patient "is suspicious of health care provider activity in his room." "The patient is handcuffed to the bed. Security and law enforcement personnel are present in the patient's doorway." The patient was given Ativan (a drug used for anxiety, alcohol withdrawal) 2 milligrams (mg) and Haldol (a antipsychotic medication) 5 mg by injection at 11:56 AM. By 12:11 PM the patient was calm and was given food and fluids. 1:03 PM BP was 156/86. The patient was given Clonidine ( a drug to treat elevated BP) at 4:24 PM (BP recorded at 4:08 PM was 160/101). At 2:46 PM the patient was noted as "awake, vitals normal, speech clear, thoughts remain disorganized, comprehension and current situation is poor." At 6:20 PM NP A documented discussion with MD B regarding the laboratory results. The plan was to discharge the patient when he was able to ambulate. At 8:02 PM the patient was discharged with elevated BP and a diagnosis of [DIAGNOSES REDACTED]. The discharge instructions included follow up with primary care provider as soon as possible on 9/11/17 and "discuss management of chronic health conditions, blood pressure re-check." The patient was also to schedule an appointment with a Psychiatrist "to be evaluated as soon as possible by a mental health care professional to address mental health disorder." The patient told the nurse he was ready for discharge and had a safe place to go. Discharge instructions included Altered Mental Status, Mild neurocognitive disorder, Hypertension, Confusion and Bipolar Disorder. Interview was conducted on 4/18/18 at 8:30 AM with Registered Nurse D, who was Patient 1's nurse from admission to shift end at 7:41 PM. RN D reviewed the EMR prior to the interview. The nurse said that on admission the patient was not combative but rambling speech and would not answer questions appropriately. The patient mumbled and was disoriented to place, situation. The BP was elevated and the provider was aware. After the Ativan and Haldol, the patient was calmer and was able to eat. RN D said the patient did not have any home medications listed for elevated blood pressure. The EMR system pulls into the current record historical diagnoses and medications prescribed for the patient. When RN D's shift ended the patient was more lucid. The plan was that once the patient "could walk without falling and stable, he would be discharged ." The nurse stated that with the BP of 174/124 at discharge that she would not feel comfortable discharging the patient. She would have expected the patient to have been given medication and monitoring until it was down. RN D was aware NP A wanted to order further testing to evaluate the patient but ED physician on duty did not. Interview with Nurse Practitioner (NP A) on 4/17/18 at 4:45 PM revealed the NP's initial differential diagnosis for Patient 1 was acute organic (physical) psychosis versus chemical psychosis. When the drug screen and alcohol levels were found to be normal the NP ordered a head CT scan and an ammonia level. [Patients with liver problems can have a build up of ammonia in the blood resulting in confusion. Psychosis is an abnormal condition of the mind that results in difficulties telling what is real and what is not.] The NP stated he wanted to do a full work up. After discussion with ED MD B the NP stated that the MD did not want further studies done and to just give the patient Ativan and Haldol and monitor him. The NP confirmed that the patient was acutely psychotic and with no evidence of traumatic injury he would have wanted to admit the patient. The NP confirmed the ED has a psychiatrist on call and that calling the psychiatrist would have been appropriate. The NP stated that normally he orders serum (laboratory) tests and admits patients for acutely psychotic symptoms. The NP stated that MD B wanted the patient discharged when able to ambulate and that is what was done. When asked if the patient had an EMC related to the profound hypertension the NP responded "Yes." Interview with the ED Medical Director MD C on 4/17/18 at 4 PM revealed that a patient with an elevated BP and bizarre behaviors should be examined for end organ function by ordering kidney function tests and an EKG (electronic tracing of the heart's electrical activity which can indicate heart problems). Calling the psychiatrist on call would have enabled the provider to get a psychiatric diagnosis of [DIAGNOSES REDACTED]"patient may have had an EMC at discharge." Review of the on call list dated 9/10/17 revealed an attending psychiatrist and resident were on call. The facility did have an inpatient psychiatric bed available on 9/10/17 per facility provided records. B. EMR revealed Patient 2 arrived in the ED by rescue squad on 9/14/17 at 2:55 PM. Review of the Omaha Fire Department EMS record dated 9/14/17 notes the EMS was in response to a patient fainting at the airport. The patient was found lying on the ground inside the airport terminal. Alert to place and time. The patient stated she walked to the airport from a women's homeless shelter (distance of 2.4 miles) because the shelter "would not help her." The patient complained of dehydration and not having food since 10:30 AM. The patient had a 1/2 full water bottle in hand. BP was 98/palpated, respirations 12 and Oxygen saturation 98 %. EMS started an IV and gave a fluid bolus with transport to the ED. Enroute the patient stated that "Creighton was going to intentionally kill her. She asked the EMS to check her ID to be sure the last firefighter to look at it did not alter it. Once in the ED the staff nurse was notified of possible mental illness. After transfer of care the nurse stated the patient had made comments that the EMS staff were "waterboarding her on the way to the hospital." Initial vital signs were obtained in the ED at 3:09 PM. BP was 125/71, pulse 93, respirations 18, Oxygen saturation was 100%. The oral temperature was normal at 98.1 degrees Fahrenheit. The patient was alert, speech clear and obeyed commands per nursing documentation. The EMR historical data included a medical history of [DIAGNOSES REDACTED][[DIAGNOSES REDACTED] is a disease in which the body does not produce enough steroidal hormones - requiring treatment with daily steroids which if not provided could result in Addisonion Crisis and death). Adrenal Crisis symptoms include vomiting/diarrhea/dehydration, low BP, syncope -loss of consciousness and inability to stand, low blood sugar, confusion, psychosis, slurred speech, lethargy, low sodium levels, high potassium levels, low calcium levels, convulsions and fever.] She also had a history of SIADH (syndrome of inappropriate antidiuretic hormone). Other historical diagnosis included Psychosis, mood disorder, schizophrenia, and history of suicide and self inflicted injury. Historical medications included Florinef and Prednisone, steroids prescribed for Addison's and Invega Sustena (used to treat schizophrenia). The Invega Sustena was prescribed by a psychiatrist currently on staff on 3/3/16. The ED resident saw the patient at 3:04 PM. Nursing documentation by RN E 9/14/17 at 3:52 PM noted the patient saying she did not trust Creighton because "they don't train their people appropriately." The patient refused treatment and requested to be taken to Lakeside, an acute care hospital several miles away. The provider explained that to be taken to Lakeside the staff needed to obtain some blood work and then could attempt transfer. The patient refused and called the provider a liar and that she did not want any treatment from this facility. Patient informed that she could receive treatment or she would need to leave. The nurse documented the patient was presented with AMA (Against Medical Advice) paperwork and refused to sign. She was informed that refusing treatment could lead to further injury and or death, which she stated she understood. Security was then called who witnessed the refusal. The last vitals were documented at 3:15 with BP 106/70 pulse 90 and Oxygen saturation of 100%. Review of the AMA papers provided to the patient on 9/14/17 at 3:15 PM included information indicating the patient was informed of the dangers and possible risk of leaving against medical advice including but not limited to "further injury and or death." Review of physician notes by the ED Resident on 9/14/17 noted the patient's extensive psychiatric history and [DIAGNOSES REDACTED]. On arrival the patient was "afebrile and vital signs were stable." She was alert and oriented to self, place and time. The patient refused to cooperated with the exam. The notes state "Myself, nurse and attending [name of MD F] tried extensively to reason with the patient and asked her to allow us to take care of her, work her up, and treat her acute issues. However, pt [patient] refused our care. Continuously stated that she wants to go to Lakeside and 'I do not consent for anyone at Creighton to treat me or assess me'." There was no physical exam documented noting the patient's refusal. The ED notes stated the "Patient was lucid, did not express IS [suicidal ideation] or HI [homicidal ideation]." Review of physician notes by ED MD F dated 9/14/17 at 3:57 PM stated that the patient was "fully lucid alert and understood her circumstances." "Patient stated the only way she would be treated as [sic] if she was going to Lakeside." The MD advised her that if they were able to find something abnormal on her blood work that they could get her admitted at Lakeside. The exam was only visual as the patient would not allow the provider to touch her. She was able to move all extremities very well and push herself up in bed with her hands and legs. The Glasgow Coma Score (assessment of consciousness) was normal at 15. She denied SI and HI. Vitals were stable. MD F discussed with the patient her history of adrenal problems (Addison's), SIADH, and mental disorder which the patient responded that this was erroneous and accused him of lying. Attempts to allow other practitioners to examine her also failed. We explained that she will have to follow up with her own physician. Review of physician on call lists identified a psychiatrist was on call for the facility. Review of psychiatric inpatient bed availability found on 9/14/17 beds were not available. Interview with RN E on 4/18/18 at 8 AM confirmed multiple staff attempted to gain her cooperation but the patient continued to refuse care because we were associated with Creighton. The nurse felt the patient was competent to make the AMA decision. When the patient refused to leave the ED room Security was called, patient requested a wheelchair and taken outside the ED by Security. Phone interview with ED MD F on 4/18/18 at 2:10 PM revealed they were looking for an excuse to place the patient under Emergency Protective Custody (EPC -involuntary psychiatric hold placed by police to involuntary admit a patient to a psychiatric facility). He confirmed the patient did not have heat stroke. We asked her about stress, psychiatric problems, suicidal thoughts she answered questions appropriately and was lucid and alert. There "was no inkling of [a] psychiatric problem." No issues psychiatrically she could walk and talk. When we told her we could not transfer her to Lakeside she wanted a taxi voucher to Lakeside hospital. We don't do that. We explained the risks of SIADH, Addison's and mental health issues left untreated and the patient still refused. He confirmed the psychiatrist on call was not called for assistance in evaluating the patient, stating there was "no indication to call the psychiatrist, patient was lucid and alert, no threat to self or others, not in acute psychosis." ED MD F confirmed the patient made statements about CUMC (Creighton) physicians inadequate to care for her and that the MD's at Lakeside were better. The MD did not feel the patient had an EMC at discharge. Review of facility document titled "Risk 360 Event Detail Report" by Security on 9/14/17 at 3:25 PM revealed the patient was refusing care and refusing to leave. 2 officers spoke with her. She was refusing to leave after attempts by both officers to get her to leave so OPD officers were called and she was taken to jail at 4:02 PM for refusing to leave the premises (trespassing). Interview with Omaha Police Officer (OPD) G on 4/18/18 at 11:35 AM revealed that the officer was working Security at the ED on 9/14/17 and spoke with Patient 2. The officer said they "pleaded with her to cooperate and let staff treat her." She was alert and aware of what we were asking. We told her if she did not leave we would call on duty officers to pick her up and take her to jail. The officer called 911 and had them arrest her up for trespassing. The officer stated Patient 2 did not show any signs she was suicidal, homicidal or gave them any reason to initiate an EPC hold on the patient.

Based on medical record review and review of EMTALA policies, the facility failed to ensure the policies for the provision of the Medical Screening Examination (MSE) with sufficient assessment and/or testing to determine if the patient has an Emergency Medical Condition (EMC) was followed for 1 of 30 sampled patients (Patient 15). The sample was drawn from 3/4/17 through 5/4/17. This failure places all emergency patients requesting to be seen at risk of harm due to being discharged with an untreated/stabilized EMC. Based on facility provided data from 11/2016 to 4/2017 the facility saw an average of 2,600 emergency patients per month. Findings are: A. Record review of the facility policy titled " Policies and Procedures for the Examination, Treatment, and Transfer of Individuals who "come to the the Emergency Department" last revised 11/2016 under the section titled "Medical Screening Examination" notes that a MSE will be provided to all unscheduled patients requesting examination or treatment for a medical condition or who has had a request made on their behalf or if based on the individual's appearance or behavior, the individual appears to need an examination or treatment for a medical condition. The MSE is to be performed by a physician or Qualified Medical Person (QMP) identified as a Physician, Nurse Practitioner, or Physician Assistant for those who presented to the emergency room (ER) for treatment. The QMP will determine with reasonable clinical confidence if the patient has an EMC utilizing the services within the capabilities of the hospital. The policy notes that the MSE is an "ongoing process." Monitoring of the individual will continue until the individual is stabilized, admitted to the hospital , transferred if the patient requires care and treatment that exceeds the hospital capabilities, is discharged or expires. The policy states "The MSE process must be documented in the medical record." B. Review of the Electronic Medical Record for Patient 15 revealed the patient came to the ER on 3/3/17 at 5:05 AM with a chief complaint of "being poisoned" by previous spouse. The initial vitals at admission demonstrated an elevated BP of 171/105. Temperature was 98.4 F, Pulse elevated at 111 and Respirations of 20. Advanced Practice Registered Nurse (APRN) B documented the patient was not taking any medications. Laboratory testing and a urine drug screen were done. The patient was noted to be acutely paranoid, delusional, anxious with rapid speech, and wringing her hands. The medical record did not contain evidence APRN B performed a mental health evaluation or requested a mental health professional conduct a mental health evaluation prior to the patient's discharge. The patient's Blood Pressure was not reassessed prior to discharge to determine if the patient had an emergency medical condition. Refer to A 2406 for details.

Based on record review, staff and provider interviews and review of the facility EMTALA policies, the facility failed to ensure 1 of 30 sampled patients (Patient 15) received a Medical Screening Examination (MSE) with sufficient assessment and/or testing to determine if the patient had an Emergency Medical Condition (EMC). The sample was drawn from 3/4/17 through 5/4/17. This failure places all emergency patients requesting to be seen at risk of harm due to being discharged with an untreated/stabilized EMC. Based on facility provided data from 11/2016 to 4/2017 the facility saw an average of 2,600 emergency patients per month. Findings are: A. Review of the medical record showed Patient # 15 presented to the Emergency Department (ED) on 3/3/17 at 5:05 PM stating that her ex-husband and her entire family were working together to try and poison her, she states her family was trafficking diamonds, money, and drugs. Vital signs (VS) obtained during the triage process showed an abnormaly elevated blood pressure 171/105 (normal 120/80) and a higher than normal heart rate 111 (normal 70-100). At 5:34 pm, the Advanced Practice Registered Nurse (APRN)-B examined patient # 15 and documented the patient was very delusional and at times anxious, but was agreeable to be evaluated in the ED for possible underlying intentional poisoning. Further documentation showed the patient requested that staff contact law enforcement so she could file a report of suspicious activity and items stolen from her apartment. ARNP B documented patient # 15 stated she was in a psychiatric facility and a group home while living in a different State and that "they were trying to kill me when I was there too." The patient denied any medication use or any medical problems. Under the medical record heading "Review of Systems", ARNP B documented "When specifically asked, patient denies delusions or paranoia." Under the medical record heading "Physical Exam", "Psychiatric:", ARNP B documented "Patient exhibits very grandiose and paranoid behavior." "Patient denies homicidal or suicidal thinking." "Patient is currently obsessing about others trying to harm her by poisoning." At 5:56 pm, the ED nurse documented contact with local law enforcement who stated that they had been called to patient # 15's address twice that day. The ED nurse further documented she explained that the patient requested reports to be filed and that ED staff were concerned that she may need a psychiatric evaluation but that "we don't feel she will be willing to accept it." At 6:16 pm, results of the lab tests showed that patient # 15 tested positive for Cannabinoid (marijuana). At 6:30 pm, the ED nurse noted police had come to the ED to speak with patient # 15. At 7:33 pm, documentation in the medical record indicated patient # 15 was diagnosed with "Paranoia" and discharged with instructions to locate a primary care doctor for follow-up. Patient education at discharge included: The patient was to follow up with a primary care provider in one to two days for re-evaluation, and that she should return to the emergency department for any other emergent concerns or worsening condition. APRN-B informed the patient that she may have pre-hypertension or hypertension (high blood pressure) based on a blood pressure reading in the emergency department. Review of the Nurses' Notes and the Vital Sign flow sheet revealed no further blood pressure or pulse checks other than the check performed during triage were obtained on 3/3/17. B. Interview with Registered Nurse (RN)-C on 5/9/17 at 1:50 PM acknowledged that the patient's blood pressure and pulse was elevated during the triage process. RN-C verified that Patient 15's VS should have been re-checked before discharge. Interview with APRN-B on 5/10/17 at 9:55 AM revealed that Patient 15's chief concern was that she had been poisoned. The patient was very anxious with rapid speech, sitting forward and wringing her hands. Patient 15 was cooperative with the testing and with the police department. The police department determined that the patient was not eligible for emergency protective custody (EPC) and the patient was not deemed a danger to self or others. The APRN-B reviewed the patient's VS and discussed the possibility of pre-hypertension/ hypertension with the patient and reviewed the patient's case with the Emergency Department physician in charge. The patient was agreeable to follow up with a primary care physician. APRN-B verified that repeat VS would be necessary if the patient's condition deteriorated or at discharge. APRN-B was unable to find another set of VS for Patient 15 before discharge and stated that the patient's blood pressure was elevated and should have been rechecked before discharge. Interview with RN-D, Patient 15's Primary Nurse, on 5/10/17 at 10:20 AM revealed that after Triage the nurse assumed care of Patient 15. The RN stated the patient was not screened for depression or suicide even though the patient exhibited anxious/ paranoid behaviors. The patient was restless and pacing even into the hallway. RN-D stated that normally VS were reassessed at the time of discharge. RN-D did not assist Patient 15 back into the examination room on discharge to reassess her VS because she was unsure if the patient would talk to the nurse and her attitude was aloof towards RN-D. According to the Mayo Clinic Website dated 11/10/15 revealed that a Normal Blood Pressure reading was the top number (systolic) 120 and the bottom number or (diastolic) of below 80. A top number of 160 or more and a bottom number of 100 or more may indicate a Stage 2 hypertension. C. Review of the facility completed Data Base Worksheet showed the hospital's capabilities and capacity included emergency psychiatric services, Adult inpatient and Adult outpatient psychiatric services. The facility had a Psychiatric inpatient facility which included on-call psychiatrists for evaluation and treatment in their dedicated emergency department. The evidence in the medical record indicated patient # 15 did not receive within the hospital's capabilities and capacity, a medical screening examination sufficient to determine whether an emergency medical condition existed. The hospital failed to re-evaluate patient # 15's elevated blood pressure prior to discharge, her stated history of mental health illness while living in another state, the factors contributing to her persecutory delusions, the conviction or veracity of her delusions, her intent to take adverse action or her risk for deterioration including harm to self or others, sufficient to determine whether or not an emergency medical conditon existed.