Based on review of hospital policy and procedure, medical record reviews, staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24. The findings include: 1. The hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 13 sampled DED patients (Patient # 6) who presented to the hospital for evaluation and treatment status post 2 falls and was discharged home; and 1 of 4 DED obstetrical patients who presented to the hospital for evaluation and treatment and was discharged home (Patient #29) without receiving an appropriate medical screening examination by a qualified medical personnel. ~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A 2406. 2. The hospital's Dedicated Emergency Department (DED) physician failed to provide within the capabilities of the staff and facilities available at the hospital further medical examination and treatment as required to stabilize a patient's Emergency Medical Condition (EMC) for 1 of 13 sampled DED (Patient # 6) who presented to the hospital for evaluation and treatment and were discharged home; and 1 of 4 DED obstetrical patients who presented to the hospital for evaluation and treatment and was discharged home (Patient #29). ~ Cross refer to §489.24(d)(1-3) Stabilizing Treatment, Tag A 2407.

Based on hospital policy and procedure review, medical record reviews, Medical Staff Rules and Regulations review, staff and physician interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 13 sampled DED patients (Patient # 6) who presented to the hospital status post 2 falls for evaluation and treatment and was discharged home; and 1 of 4 DED obstetrical patients who presented to the hospital for evaluation and treatment and was discharged home (Patient #29) without receiving an appropriate medical screening examination by a qualified medical personnel. The findings include: Review on 08/17/2017 of hospital policy "EMTALA, Medical Screening & Stabilization, Refusal of Treatment" revised 10/2016 revealed "1 All individuals who arrive at the Emergency Department (ED) seeking medical treatment will receive a MSE to ascertain whether an Emergency Medical Condition exists. This screening will include diagnostic or therapeutic services routinely available... 2. Triage is not a MSE...5. Obstetrical patients presenting to the ED: a. < 20 weeks gestation will receive a MSE in the ED b. > 20 weeks gestation with a pregnancy related complaint will receive a MSE in the L&D Suite. c. > 20 weeks gestation with a non- pregnancy related complaint will receive a MSE in the ED....3. Stabilized for DISCHARGE means that it has been determined, within reasonable medical probability, that an individual has reached the point where his/her continued care, including diagnostic work-up and treatment, could be reasonably performed on an outpatient basis. The individual should be given a plan for appropriate follow up care with discharge instructions. a. An individual may also be discharged from the ED for admission as an inpatient..." The facility's a policy and procedure titled, "Admission to Labor and Delivery Including Medical Screening Examination", LD 460.02, initial Approval 04/79, last revised 02/14 was reviewed. The policy and procedure specified in part, "Purpose: The purpose of this policy is to outline the steps involved in the assessment and care of inpatients and outpatients in the Labor and Delivery Department including medical screening requirements...Procedure: ...2. Registered Nurses in Labor and Delivery completing the Medical Screening Exam must have completed the fetal monitoring competency requirements." Review of the Medical Staff Rules and Regulations, revised April 4, 2011 revealed in part, "1.15 Persons Qualified to Conduct Medical Screening Examinations those persons, other than Emergency Medicine Department Physicians/and or admitting physicians, who are qualified to conduct a "medical screening examination "... are physician assistants, midwives, nurse practitioners, Registered Nurses from Labor and Delivery department who meet the requirements for fetal monitoring." 1. Closed medical record review on 08/16/2017 of Patient #6 revealed a [AGE] year old female who presented to Hospital A's (Nash General Hospital) DED on 06/26/2017 at 2042 via wheelchair for a chief complaint of "patient fell down stairs leaving hospital". Record review revealed triage began at 2053 with vital signs BP 150/92; heart rate 80; respiratory rate: 16; SpO2 (oxygenation) : 100%. Record review revealed "Assess/Tx Level of Consciousness: Alert; Orientation Assessment: Identifies self, Not oriented to place ... " Record review revealed the patient was transported to CT scan at 2150. Record review revealed " ED Adult Neuro Assessment at 2151 Neuro Muscular: Characteristics of Speech: Clear; Gait Quality: unable to assess; ED Neuro Assessment Add Note: Fall walking down stairs, positive LOC (Loss of Consciousness). Patient does not remember fall. Patient not oriented to year, place, time. Patient has cuts to bilateral elbows, swelling to R side of head and back side of head ... Glasgow Coma Score: 14 ... " The patient was discharged home on 06/27/2017 at 0032 in a wheelchair in the care of her son and daughter with discharge and follow up instructions given. Review of ED Physician Note on 06/26/2017 at 2255 revealed "Basic Information: History Limitation: Cognitive impairment ... History of Present Illness: Patient is a [AGE]-year-old female with a PMH including [DIAGNOSES REDACTED], hypertension, and aortic valve defect presenting to the ED with a chief complain of head pain onset today secondary to a fall. Per daughter, the patient was visiting her husband at the heart center, when she went down 3-5 steps of stairs while holding on to the rail. The patient bumped against the wall and then tumbled sideways while hitting her head on every step and denies LOC. Family reports patient having a large bump on the back of her head and right side of face. Patient fell yesterday and her glasses cut under her right eye and reopened today secondary to fall. Patient also complains of left ear pain and pain over her whole head. She has not taken any pain medication prior to arrival. Patient denies right hip pain and back pain. Patient is on Plavix (Medication- Blood Thinner) ... Physical Examination: General: Alert, no acute distress, well nourished, calm cooperative ... Head: Normocephalic, contusion right zygomatic arch area, On exam: Right temporal, hematoma, no abrasion, no laceration, On exam: Mild parietal (midline) hematoma, no abrasion, no laceration ... Musculoskeletal: Normal ROM, normal strength, no swelling, no deformity ...Right, arm hematoma ... Right elbow, skin tear and hematoma, no bleeding ... Left elbow, skin tear, Lower extremity: Bilateral, hip no tenderness ...Neurological: Alert and oriented to person, place, time and situation ...normal coordination observed, Gait: Normal (by observation). Medical Decision Making: Radiology results: Reported at 06/26/2017 2242, Computed tomography (CT) reviewed radiologist ' s report, emergency physician interpretation ... Head: No acute intracranial hemorrhage, herniation or [DIAGNOSES REDACTED]. Multiple sites of scalp hematoma without underlying fracture. Confluent and patchy area of supratentorial white matter hypodensity, nonspecific, but most likely sequela of chronic microvascular changes. Face: No acute facial fracture. No intraorbital hematoma. Bilateral lens replacements. Slight asymmetric fullness of the right base of tongue, oropharyngeal tonsil, likely due to positioning. C- Spine: No acute fracture or traumatic malalignment. No prevertebral soft tissue swelling ...Pain Status: Headache Improved. Notes: Recheck on patient. Discussed with patient work up, relevant results, and plan for discharge. Patient was given ED warnings, discharge instructions, and follow up instructions. Patient understands and agrees with plan for discharge. Patient was informed and verbalizes understanding to return to ER immediately if symptoms worsen, persist, worsen, new symptoms or follow up cannot be obtained. Any questions have been addressed. Patient feels comfortable going home at this time ... Patient has been stable and is at her normal baseline ... " Review of an Outpatient MRI of the Brain with and without contrast report from Hospital A on 06/28/2017 at 1246 revealed IMPRESSION: 1. On DWI sequence, increased signal within the left occipital lobe is consistent with recent demyelination versus acute infarct; no gadolinium enhancement at this level is noted. 2. Scalp hematomas the largest of which is noted within the scalp of the posterior parietal region .... " Closed medical record review of Patient #6 DED visit to Hospital B on 06/29/2017 at 1042. Revealed the patient had a chief complaint of "stroke symptoms". Record review revealed "Chief Complaints Updated: + Stroke Symptoms (Pt fell down some stairs at the hospital on Monday (6/26/2017) but cannot remember how or why she fell . Pt went to see her doctor and had an MRI. Per pt "the doctor said I had a hematoma and an infarct and said I needed to go to a hospital so my family said to come here." Pt also states that family was going to drive her but she was having trouble walking." Record review of ED Physician Notes revealed "Medical Decision Making: 1119 discussed with primary care physician. He will fax brain MRI results. There is concern for acute left occipital infarct versus demyelination this area [sic]. We'll plan for admission for syncope and possible acute stroke on MRI done yesterday ... Record review revealed the patient was discharged from Hospital B on 07/03/2017. Telephone interview with EDRN #1 on 08/16/2017 at 1830 revealed she remembers the patient and family. Interview revealed the patient could not remember the fall, nor if she felt dizzy prior to the fall. Interview revealed the daughter witnessed the fall and per the conversation with the nurse and the daughter the patient "just stopped and fell ." Interview revealed the daughter doesn't feel she tripped. Interview revealed the patient was confused on arrival but back to baseline which was alert and oriented to person, place and time at discharge. Interview revealed the patient ambulated around the nurses' station with assistance prior to discharge. The interview also revealed the nurse failed to document the ambulation of the patient as well as the updated mental status prior to patient discharge from Nash General hospital on [DATE]. Telephone interview with Physician #1 on 08/16/2017 at 2005 revealed during her assessment of the patient, she was alert, orient to person, family, time but not to events of the fall. Interview revealed the patient had a previous fall the day prior. Interview reveled the patient had equal strength in all four extremities. Interview revealed all radiology reports were negative. Interview revealed she discussed how important follow up was and what signs and symptoms to monitor for possible head injury. Interview revealed physician did not ambulate the patient nor trial ambulate the patient prior to discharge. Interview revealed she believes the MSE was appropriate and patient was stable for discharge. The facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's emergency department for patient #6 on 6/26/2017. 2. Closed medical record review on 08/17/2017 of Patient #29 revealed a [AGE] year old female gravida 1 (number of pregnancies) ; Para 0 (pregnancies carried beyond 20 weeks) 35 weeks in gestation who presented to Labor and Delivery on 06/30/2017 at 2037 and triaged at 2046 with a stated complaint of "Blood pressures elevated and decreased fetal movement". Record review revealed the patient has a history of hypertension since the age of 13. Record review revealed the patient denies contractions, leakage of fluid, urge to push and vaginal bleeding. Record review revealed the patient was placed on a Continuous External Fetal monitor at 2107 with a fetal heart rate baseline of 145 and the patient's vital signs were BP 117/77; heart rate 101; respiratory rate 20; Temperature 36.7 C. Record review of pain assessment revealed "left side pain since arrival" rates 5/10= moderate pain. Record review revealed no vaginal exam performed. Record review revealed OBMD #1 was notified at 2148 "(Information Provided to Clinician) Pt's c/o (complaint of) increased BP yesterday and today 140/96 and 145/95; decreased fetal movement; denies cx (contractions) lof (leakage of fluid) or bleeding; fhr wnl (fetal heart rate within normal limits); one variable notes; fhr pattern; bp;s neg dipstick; left side pain; on Procardia for chronic htn since [AGE] ... Response from Clinician ... See physician orders." Record review revealed Orders entered 6/30/2017 at 2148 by OBRN #1- Physician orders: Order Admission: Plan L& D Observation; Order: Communication Order: (Pt may have 1gm of Tylenol if she wants it); Order: Discharge Patient; Order: Fetal Heart Monitor External; Order: Perinatal Care Quality Measures; Order: Vital Signs ..." Record review revealed all orders were electronically signed by OBMD#1 on 07/01/2017 0101. Record review revealed BP at 2152 113/76; heart rate 91. Record review revealed the patient was discharged at 2212 with instructions for Third Trimester Pregnancy. Record review revealed no discharge diagnosis or physician noted documented in the medical record. Telephone interview on 08/17/2017 at 1410 with OBMD #1 revealed she did not come in to evaluate Patient #29. Interview revealed she does not give a diagnosis on any patient she does not evaluate nor does she go back and review the charts once orders are given on patients the Labor and Delivery nurses contact her for. Interview revealed if the nurses request her to come in and evaluate the patient, she will. Interview revealed she is not aware a diagnosis needs to be documented in a record where a Labor and Delivery Registered Nurse performs a MSE. The facility failed to ensure that an appropriate medical screening examination was provided by a physician or a nurse practitioner to determine whether or not an emergency medical condition existed for Patient #6 on 6/30/2017. According to the facility's Medical Staff Rules and Regulations Labor and Delivery Nurses conduct medical screening examinations who meet the requirements for fetal monitoring. Telephone interview on 08/17/2017 at 1440 with OBRN #1 revealed she was the nurse for Patient #29. Interview revealed the L&D unit sees all patients greater than 20 weeks in gestation. Interview revealed sometimes we request the MD to come in and sometimes we don't. Interview revealed we work the patients up and if all results are normal we call the physician and let them know and send the patients home. Interview revealed they do not write diagnosis on the medical records. Interview revealed if she requests a MD to come see the patient, they will. Interview on 08/17/2017 at 1610 with OBMD #2 revealed he does not give a diagnosis for patients he does not personally evaluate on the L&D in conjunction with the Nurses who perform the MSEs. Interview revealed he feels the nurses are competent to evaluate simple complaints other than labor checks in consultation with the OB on call. Interview revealed he would come in and evaluate a patient if needed.

Based on hospital policy and procedure review, medical record reviews, staff and physician interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide within the capabilities of the staff and facilities available at the hospital further medical examination and treatment as required to stabilize a patient's Emergency Medical Condition (EMC) for 1 of 13 sampled DED (Patient # 6) who presented to the hospital for evaluation and treatment and were discharged home; and 1 of 4 DED obstetrical patients who presented to the hospital for evaluation and treatment and was discharged home (Patient #29). The findings include: Review on 08/17/2017 of hospital policy "EMTALA, Medical Screening & Stabilization, Refusal of Treatment" revised 10/2016 revealed "1 All individuals who arrive at the Emergency Department (ED) seeking medical treatment will receive a MSE to ascertain whether an Emergency Medical Condition exists. This screening will include diagnostic or therapeutic services routinely available... 2. Triage is not a MSE...5. Obstetrical patients presenting to the ED: a. < 20 weeks gestation will receive a MSE in the ED b. > 20 weeks gestation with a pregnancy related complaint will receive a MSE in the L&D Suite. c. > 20 weeks gestation with a non- pregnancy related complaint will receive a MSE in the ED....3. Stabilized for DISCHARGE means that it has been determined, within reasonable medical probability, that an individual has reached the point where his/her continued care, including diagnostic work-up and treatment, could be reasonably performed on an outpatient basis. The individual should be given a plan for appropriate follow up care with discharge instructions. a. An individual may also be discharged from the ED for admission as an inpatient..." 1. Closed medical record review on 08/16/2017 of Patient #6 revealed a [AGE] year old female who presented to Hospital A ' s DED on 06/26/2017 at 2042 via wheelchair for a chief complaint of " patient fell down stairs leaving hospital " . Record review revealed triage began at 2053 with vital signs BP 150/92; heart rate 80; respiratory rate: 16; SpO2 (oxygenation) : 100%. Record review revealed "Assess/Tx Level of Consciousness: Alert; Orientation Assessment: Identifies self, Not oriented to place ... " Record review revealed he patient was transport to CT scan at 2150. Record review revealed " ED Adult Neuro Assessment at 2151 Neuro Muscular: Characteristics of Speech: Clear; Gait Quality: unable to assess; ED Neuro Assessment Add Note: Fall walking down stairs, positive LOC. Patient does not remember fall. Patient not oriented to year, place, time. Patient has cuts to bilateral elbows, swelling to R side of head and back side of head ... Glasgow Coma Score: 14 ... " The patient was discharged home on 06/27/2017 at 0032 in a wheelchair in the care of her son and daughter with discharge and follow up instructions given. Review of ED Physician Note on 06/26/2017 at 2255 revealed " Basic Information: History Limitation: Cognitive impairment ... History of Present Illness: Patient is a [AGE]-year-old female with a PMH including [DIAGNOSES REDACTED], hypertension, and aortic valve defect presenting to the ED with a chief complain of head pain onset today secondary to a fall. Per daughter, the patient was visiting her husband at the heart center, when she went down 3-5 steps of stairs while holding on to the rail. The patient bumped against the wall and then tumbled sideways while hitting her head on every step and denies LOC. Family reports patient having a large bump on the back of her head and right side of face. Patient fell yesterday and her glasses cut under her right eye and reopened today secondary to fall. Patient also complains of left ear pain and pain over her whole head. She has not taken any pain medication prior to arrival. Patient denies right hip pain and back pain. Patient is on Plavix ... Physical Examination: General: Alert, no acute distress, well nourished, calm cooperative ... Head: Normocephalic, contusion right zygomatic arch area, On exam: Right temporal, hematoma, no abrasion, no laceration, On exam: Mild parietal (midline) hematoma, no abrasion, no laceration ... Musculoskeletal: Normal ROM, normal strength, no swelling, no deformity ...Right, arm hematoma ... Right elbow, skin tear and hematoma, no bleeding ... Left elbow, skin tear, Lower extremity: Bilateral, hip no tenderness ...Neurological: Alert and oriented to person, place, time and situation ...normal coordination observed, Gait: Normal (by observation). Medical Decision Making: Radiology results: Reported at 06/26/2017 2242, Computed tomography (CT) reviewed radiologist ' s report, emergency physician interpretation ... Head: No acute intracranial hemorrhage, herniation or [DIAGNOSES REDACTED]. Multiple sites of scalp hematoma without underlying fracture. Confluent and patchy area of supratentorial white matter hypodensity, nonspecific, but most likely sequela of chronic microvascular changes. Face: No acute facial fracture. No intraorbital hematoma. Bilateral lens replacements. Slight asymmetric fullness of the right base of tongue, oropharyngeal tonsil, likely due to positioning. C- Spine: No acute fracture or traumatic malalignment. No prevertebral soft tissue swelling ...Pain Status: Headache Improved. Notes: Recheck on patient. Discussed with patient work up, relevant results, and plan for discharge. Patient was given ED warnings, discharge instructions, and follow up instructions. Patient understands and agrees with plan for discharge. Patient was informed and verbalizes understanding to return to ER immediately if symptoms worsen, persist, worsen, new symptoms or follow up cannot be obtained. Any questions have been addressed. Patient feels comfortable going home at this time ... Patient has been stable and is at her normal baseline ... " Review of an Outpatient MRI of the Brain with and without contrast report from Hospital A on 06/28/2017 at 1246 revealed IMPRESSION: 1. On DWI sequence, increased signal within the left occipital lobe is consistent with recent demyelination versus acute infarct; no gadolinium enhancement at this level is noted. 2. Scalp hematomas the largest of which is noted within the scalp of the posterior parietal region .... " Closed medical record review of Patient #6 DED visit to Hospital B on 06/29/2017 at 1042. Revealed the patient had a chief complaint of " stroke symptoms " Record review revealed " Chief Complaints Updated: + Stroke Symptoms (Pt fell down some stairs at the hospital on Monday but cannot remember how or why she fell . Pt went to see her doctor and had an MRI. Per pt " the doctor said I had a hematoma and an infarct and said I needed to go to a hospital so my family said to come here. " Pt also states that family was going to drive her but she was having trouble walking. " Record review of ED Physician Notes revealed " Medical Decision Making: 1119 discussed with primary care physician. He will fax brain MRI results. There is concern for acute left occipital infarct versus demyelination this area [sic]. We ' ll plan for admission for syncope and possible acute stroke on MRI done yesterday ... Record review revealed the patient was discharged from Hospital B on 07/03/2017. Telephone interview with EDRN #1 on 08/16/2017 at 1830 revealed she remembers the patient and family. Interview revealed the patient could not remember the fall, nor if she felt dizzy prior to the fall. Interview revealed the daughter witnessed the fall and per the conversation with the nurse and the daughter the patient " just stopped and fell . " Interview revealed the daughter doesn ' t ' feel she tripped. Interview revealed the patient was confused on arrival but back to baseline which was alert and oriented to person, place and time at discharge. Interview revealed the patient ambulated around the nurses ' station with assistance prior to discharge. The interview also revealed the nurse failed to document the ambulation of the patient as well as the updated mental status prior to patient discharge. Telephone interview with Physician #1 on 08/16/2017 at 2005 revealed during her assessment of the patient, she was alert, orient to person, family, time but not to events of the fall. Interview revealed the patient had a previous fall the day prior. Interview reveled the patient had equal strength in all four extremities. Interview revealed all radiology reports were negative. Interview revealed she discussed how important follow up was and what signs and symptoms to monitor for possible head injury. Interview revealed physician did not ambulate the patient nor trial ambulate the patient prior to discharge. Interview revealed she believes the MSE was appropriate and patient was stable for discharge. The facility failed to ensure that patient #6 was stabilized on 6/26/2017 prior to discharge. 2. Closed medical record review on 08/17/2017 of Patient #29 revealed a [AGE] year old female gravida 1 (number of pregnancies) ; Para 0 (pregnancies carried beyond 20 weeks) 35 weeks in gestation who presented to Labor and Delivery on 06/30/2017 at 2037 and triaged at 2046 with a stated complaint of " Blood pressures elevated and decreased fetal movement " . Record review revealed the patient has a history of hypertension since the age of 13. Record review revealed the patient denies contractions, leakage of fluid, urge to push and vaginal bleeding. Record review revealed the patient was placed on a Continuous External Fetal monitor at 2107 with a fetal heart rate baseline of 145 and the patient ' s vital signs were BP 117/77; heart rate 101; respiratory rate 20; Temperature 36.7 C. Record review of pain assessment revealed " left side pain since arrival " rates 5/10= moderate pain. Record review revealed no vaginal exam performed. Record review revealed OBMD #1 was notified at 2148 " (Information Provided to Clinician) Pt ' s c/o (complaint of) increased BP yesterday and today 140/96 and 145/95; decreased fetal movement; denies cx (contractions) lof (leakage of fluid) or bleeding; fhr wnl (fetal heart rate within normal limits); one variable notes; fhr pattern; bp;s neg dipstick; left side pain; on Procardia for chronic htn since [AGE] ... Response from Clinician ... See physician orders. " Record review revealed Orders entered 6/30/2017 at 2148 by OBRN #1- Physician orders: Order Admission: Plan L& D Observation; Order: Communication Order: (Pt may have 1gm of Tylenol if she wants it); Order: Discharge Patient; Order: Fetal Heart Monitor External; Order: Perinatal Care Quality Measures; Order: Vital Signs ... " Record review revealed all orders were electronically signed by OBMD#1 on 07/01/2017 0101. Record review revealed BP at 2152 113/76; heart rate 91. Record review revealed the patient was discharged at 2212 with instructions for Third Trimester Pregnancy. Record review revealed no discharge diagnosis or physician noted documented in the medical record. Telephone interview on 08/17/2017 at 1410 with OBMD #1 revealed she did not come in to evaluate Patient #29. Interview revealed she does not give a diagnosis on any patient she does not evaluate nor does she go back and review the charts once orders are given on patients the Labor and Delivery nurses contact her for. Interview revealed if the nurses request her to come in and evaluate the patient, she will. Interview revealed she is not aware a diagnosis needs to be documented in a record where a Labor and Delivery Registered Nurse performs a MSE. Telephone interview on 08/17/2017 at 1440 with OBRN #1 revealed she was the nurse for Patient #29. Interview revealed the L&D unit sees all patients greater than 20 weeks in gestation. Interview revealed sometimes we request the MD to come in and sometimes we don ' t. Interview revealed we work the patients up and if all results are normal we call the physician and let them know and send the patients home. Interview revealed they do not write diagnosis on the medical records. Interview revealed if she requests a MD to come see the patient, they will. Interview on 08/17/2017 at 1610 with OBMD #2 revealed he does not give a diagnosis for patients he does not personally evaluate on the L&D in conjunction with the Nurses who perform the MSEs. Interview revealed he feels the nurses are competent to evaluate simple complaints other than labor checks in consultation with the OB on call. Interview revealed he would come in and evaluate a patient if needed. The facility failed to ensure that on 6/29/2017 patient #29 was stabilized prior to discharge on 6/30/2017, as evidenced by no evaluation was conducted by an advanced nurse practitioner or physician.

Based on policy and procedure reviews, job description reviews, medical record reviews, hospital documentation reviews, staff and physician interviews, the hospital failed to comply with 42 CFR §489.24. The findings include: The Dedicated Emergency Department (DED) physician failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize 1 of 9 patients with psychiatric emergent medical conditions (#4). ~ cross refer to 489.24(d)(1-3) Stabilizing Treatment, Tag A2407.

Based on policy and procedure reviews, job description reviews, medical record reviews, hospital documentation reviews, staff and physician interviews the Dedicated Emergency Department (DED) physician failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize 1 of 9 patients with psychiatric emergent medical conditions (#4). The findings include: Review of hospital policy "EMTALA, Medical Screening & Stabilization, Refusal of Treatment PC 210.59", revised 06/2011 revealed "E. Stabilization 1. If an Emergency Medical Condition exists, medical treatment, within the capabilities of the staff and facilities routinely available ("Capacity"), will be provided to stabilize the individual prior to consideration of discharge, admission or transfer...Stabilized for DISCHARGE means that it has been determined, within reasonable medical probability, that an individual has reached the point where his/her continued care, including diagnostic work-up and treatment, could be reasonably performed on an outpatient basis...b. Psychiatric patients are stable for discharge when they are considered to be stable and no longer considered to be a threat to themselves and/or others. Such patients must be given Crisis hotline information at discharge. c. Substance abuse patients (who presented as dangerous to self or others) are considered to be stable for discharge when they are considered to be stable and no longer considered to be a threat to themselves and/or others". Review of the hospital's job description for the psychiatric mental health nurse practitioner revealed "works under the direct supervision of a Medical Staff member (s) of (Name of hospital) for the medical acts performed." 1. Closed DED medical record review from Hospital A of Patient #4 revealed a [AGE] year old patient presenting to the DED on 09/16/2013 at 2200 for a chief complaint of altered mental status. Record review revealed the patient arrived via ambulance after being found lying on the road. Record review revealed law enforcement officer told the Triage nurse they had spoken with the patient's mother and the mother suspected heroin abuse. Record review revealed patient #4 was an acuity level of 2, (emergent) and ESI level of 2. Review of the triage documentation revealed the patient had received Narcan (medication to reverse the affects of narcotics) intravenously prior to arriving at the hospital. Record review revealed the patient had a history of substance abuse, anxiety, paranoid schizophrenia and post-traumatic stress disorder. Review of the MSE (Medical Screening Examination) at 2200 performed by the DED physician (MD #1) revealed the patient presented with altered mental status with an unknown onset. Further review of the MSE revealed the patient was "obviously intoxicated, level of consciousness: uncooperative. Psychiatric: Judgement impaired by intoxication. Record review revealed the patient used cocaine and alcohol 3 to 5 times per week. Record review revealed vital signs at triage were heart rate 77, respiratory rate 17 and blood pressure 114/78. Record review revealed the patient had "garbled words, imprecise slurred" speech and unsteady gait. Review of the record revealed a CAT Scan of the head was completed showing "no evidence of acute intracranial pathology". Record review revealed X-rays were completed of the patients' left hand revealing no fractures and of the chest showing normal findings. Review of nursing documentation on 09/17/2013 at 0335 revealed the patient "remains somewhat drowsy, easily arousible, denies taking any drugs, admits to ETOH (alcohol) earlier and denies SI/HI (suicidal/homicidal ideation's)." Review of the labs revealed the ETOH level was 94.1 ( High per the range) on 09/17/2013 at 0049 and positive for cannabis. Record review revealed documentation by nursing staff on 09/17/2013 at 0407 the patient had talked with someone about picking her up and the "MD agrees to discharge if and when transport arrives." Review of the DED physician documentation at 0547 revealed the patient's condition was improved and the patient was discharged . Record review revealed no documentation of a psychiatric assessment of the patient prior to discharge. Closed DED medical record review from Hospital B revealed Patient #4 was DOA (dead on arrival) to the DED on 09/19/2013 at 1635. Telephone interview on 12/30/2015 at 1445 with the County's Register of Deeds Office revealed the death certificate for Patient #4 read, "Cause of Death: Amitriptyline (anti-depressant) Toxicity. Other: Depression, PTSD (post-traumatic stress disorder). Manner of Death: Suicide". Review of the hospital's census for the behavioral health unit revealed the census for 09/16/2013 was 32. Interview on 12/30/2015 at 1100 revealed the unit is at capacity with 32 patients. Interview on 12/30/2015 at 1350 with Hospital A's DED Medical Director (MD #2) revealed behavioral health patients are seen initially by the DED physician and a psychiatric consult is obtained if the physician is unable to determine if the patient is a danger to self or others. Interview revealed the medical director started at Hospital A in December 2013 and did not have knowledge of Patient #4. The hospital's failure posed an immediate and serious threat to Patient #4's health and safety by failure to provide within the hospital's capabilities, for further appropriate stabilization for patient #4, who had a emergent psychiatric medical condition. Review on 12/30/2015 of an EMTALA "Action Plan" and supporting documentation revealed the following corrective actions implemented by hospital staff prior to the on-site EMTALA investigation survey: Immediately after the September 2013 survey and before the December 2015 survey (both of which resulted from the same September 2013 complaint) and prior to the receipt of the December 2015 survey statement of deficiencies, a Hospital task force (1) reviewed EMTALA policies, (2) addressed EMTALA training and (3) implemented monitoring to ensure compliance. Specifically, the Chief Executive Officer (CEO) organized an interdisciplinary task force comprised of the Chief Nursing Officer (CNO), Associate Chief Nursing Officer (ACNO), Chief Medical Officer (CMO), VP of Quality and Patient Safety (Physician), Director of Quality/Performance Improvement, Accreditation/Regulatory Coordinator, Director of ED, Director of Behavioral Health Services, the Medical Director of Emergency Services and outside expert EMTALA legal counsel to address and mitigate concerns identified during the surveys. The Task Force reviewed the findings related to providing Stabilizing Treatments for Behavioral Health patients and patients with behavioral health concerns, as appropriate. The following actions were taken with effective dates as noted below: 1. Policy PC 210.26 - " EMTALA " (see Exhibit A) was reviewed in January 2014 and again on 01/31/2016 and was deemed appropriate. 2. Policy PC 210.59 - " EMTALA Medical Screening and Stabilization, Refusal of Treatment " (See Exhibit B) was revised. Education was provided and the policy was made effective 5/1/2014. The policy was reviewed again in January 2016 and deemed appropriate. 3. Policy ECC 450.22 - " Triage and Admission Care of Emergency Department Patients " (See Exhibit C, Section B:#3a) - Was reviewed and revised in February 2014 to include a process for utilization of Nursing Assessment Tools for Identification of Substance Abuse and Behavioral Health concerns. The policy was reviewed again in January 2016 and deemed appropriate. 4. Policy PC 210.01 - " Care for the Behavioral Health Patient " (see Exhibit D) - Was revised February 2014 to describe the process for identification and management of the behavioral health patient in the ED. The policy was updated to include comprehensive RN assessment screening tools for substance abuse, alcohol abuse and suicide risk for all ED patients (13 years and above). Any positive screens generate an automatic referral for a Behavioral Health assessment which will include a more comprehensive screening to include the DAST 20 tool (See Exhibit E) by the Behavioral Health Specialist. The results of the screening assessment tools are immediately accessible in the Electronic Health Record for the use of the responsible Licensed Independent Practitioner. The RN will also initiate an " ED Triage - Behavioral Health Protocol " . (See Exhibit F) Completion Date was 02/28/2014. 5. Initiation of ED Triage Mandatory Documentation Tools in our electronic medical record in which a scoring threshold specified by our policy will generate an automatic referral to the Behavioral Health Specialist. · The CAGE-AID Assessment tool (See Exhibit G) is completed on all patients >18 years of age, assessing alcohol use and illegal/prescription drug use for non-medical reasons. Effective April 2014 · The CRAFFT Assessment tool (See Exhibit H) is completed on all patients > 13 for having a drug or alcohol related disorder. Effective April 2014 6. A Physician Power Note template " Psych/Suicide/Drug/ ETOH " was developed and implemented in our electronic health record in February 2014 to assist in relevant documentation of the Behavioral Health patient. (See Exhibit I). 7. In October 2015, a Behavioral Health Service Line Lean Team was initiated due to increased behavioral health patient volumes, to formalize an on-going method to pro-actively evaluate our Behavioral Health Services provided to our patients. The team is focused on the physical environment, policies/procedures, staff training and current evidence-based care. · To improve the accuracy of suicide risk assessment a decision was made to adopt the Columbia-Suicide Severity Rating Scale in March 2016 (See Exhibit J). TRAINING: Various educational/training efforts have been conducted and completed from January 2014 through present day including: 1. " Emergency Services and EMTALA Training " was provided for Licensed Independent Practitioners 02/15/2014 and RN's and completed by February 15th, 2014 (See Exhibit K) by outside EMTALA expert legal counsel. 2. EMTALA Training video was also added to RN/CNA hospital general orientation agenda in April 2014. (See copy of agenda - Exhibit M) 3. Annual EMTALA training is assigned as part our organization ' s annual compliance module and is assigned to all staff. 4. 2015 ED Provider Training was conducted through the independent ED physician group. Each provider completed the on-line EMTALA Compliance Training Program (See Exhibit O). This education activity is approved for 1.0 AMA PRA Category 1 Credits. 5. In February 2016, additional EMTALA training (See Exhibit K) was provided to Emergency Department/Women ' s Center Registered Nurses and Licensed Independent Practitioners. 6 " Behavioral Health Specialist Training on Assessment of Behavioral Health Patients in the ED " (See Exhibit N) was provided and completed in February 2014. 7. " Care of the BHS Patient in the ED " (including the CAGE-AID Assessment Tool - exhibit G and the CRAFFT Assessment Tool - exhibit H) was provided to ED RN's in 2014. This education was updated with current processes/tools and was provided to ED RN staff March 31, 2016 through April 10, 2016. (See Exhibit L). 8. Columbia-Suicide Severity Rating Scale (see Exhibit J) education was conducted in the January 2016 and February 2016 ED Staff Meetings. MONITORING: A minimum of 70 ED patient records (which is statistically valid for a population size of > 500 cases) will be audited per month to assess compliance with the identification of patients with behavioral concerns. The monitors will include compliance with RN assessments/ Behavioral Health Specialist assessments and Provider documentation of substance abuse and/or psychiatric concerns. The audits (See Exhibit P)will be conducted by the ED Manager/designee and the Director of Behavioral Health Services/designee. Monthly audits will be conducted for a minimum of 3 months or greater until an average of 90% compliance is achieved and maintained 4 consecutive months. Results will be reported to the Corporate Officers Group and the Board Quality Leadership Council on a monthly basis. Deficiencies will be reported by the appropriate Manager/Director to the Chief Nursing Officer, Chief Medical Officer and Vice President for Quality and Patient Safety, as indicated for intervention. Continued deficiencies by any specific individual will result in a disciplinary process. NC 72