**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 18018 Based on interview, record review, policy review, and surveillance video recording review, the hospital failed to provide a Medical Screening Exam (MSE) for one patient (#1), within the hospital's capability/capacity to determine if an Emergency Medical Condition (EMC) existed when the patient was within 250 yards of the hospital's Emergency Department (ED) entrance. A total of 22 ED medical records were reviewed of patients that presented to the hospital's ED seeking care/treatment, out of a sample selected from [DATE] through [DATE]. These failures by the hospital had the potential to affect all patients that presented to the hospital's ED seeking medical care/treatment. The hospital's ED saw an average of 2,250 emergency visits per month over the past 10 months. Findings included: Review of the hospital's policy titled, EMTALA (Emergency Medical Treatment and Labor Act) Medical Screening Examination and Stabilization Policy, dated [DATE], showed the following directives for staff: - EMTALA obligation is triggered when an individual arrives on the hospital property, either in the Dedicated Emergency Department (DED) or property other than the DED, and no request is made for evaluation or treatment, but the appearance or behavior of the individual would cause a prudent layperson to believe that the individual needed such examination or treatment. - The hospital must perform an MSE to determine if an EMC exists. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital. Review of the surveillance video recording showed: - A man walked across the ED parking lot in the direction of the hospital's ED entrance. As he walked towards the ED entrance, he put his right hand over his chest. - After the man stepped up on the curb, he stumbled forward a couple of steps, with both arms stretched out in front of him, he lowered his body down and sat on the ground while leaning against a transformer box. - The man then slumped forward, placed his hands on the ground, lowered his body down and rested his face on the ground with his legs bent in a fetal position. - As Staff J, off-duty ED Physician, walked to his car, he looked in the direction of where the man laid, however, Staff J did not go to where the man laid but continued to walk to his car. - Staff J opened the driver's door, reached into his left pants pocket, pulled out a phone, placed it up to his right ear, shut the driver's door and faced in the direction where the man laid as he talked on the phone. - Staff J then opened the driver's door, removed his stethoscope from around his neck and placed the stethoscope into the car and shut the door. - Staff J then proceeded to walk in the direction to where the man laid. - When Staff J approached the man, he did not make physical contact with the man down on the ground. - Staff E, Security Officer, arrived and walked to where the man was, kneeled down next to the body and appeared to touch the man. - Staff I, Paramedic/ED Technician, arrived and went directly to the body, squatted down next him, appeared to be checking for a pulse and then rolled the man over onto his back. - Staff J and Staff I appeared to be engaged in a conversation and then Staff I placed a sheet over the man. - Emergency Medical Services (EMS, ambulance), local police, and fire/rescue arrived to the ED parking lot. Staff J, off-duty ED Physician, was observed on the surveillance video recording removing his stethoscope before he walked over to the location where the man laid face down on the ground approximately 20 feet from where his car was parked. Review of the surveillance video recording showed that Staff J never made physical contact with the man to see if the man required any type of first aide or if the man presented with an emergency condition. Based on interviews conducted with: - Staff A, Chief Executive Officer; - Staff D, Registered Nurse (RN), Director of Emergency Services; - Staff E, Security Officer; - Staff G, RN, ED Charge Nurse; - Staff H, RN, ED Nurse; - Staff F, RN, House Supervisor; and - Staff I, Paramedic/ED Technician Staff reported that Staff J, off-duty ED Physician, used his authority as a medical physician to prevent hospital staff from providing care, treatment or to transfer the man found down into the ED. Staff reported that Staff J informed them that he was in charge, he was a physician and it was his call therefore, staff did not feel that they had the authority to not follow Staff J's orders when he ordered staff not to touch the body because it was a crime scene. During a telephone interview on ,d+[DATE] at 4:30 PM, Staff J, off-duty ED Physician stated that: - When he walked out of the ED side door to where his car was parked, he glanced over in the direction of the transformer box and thought he saw something. - When he reached his car, he noticed what he saw was a body lying face down next to the transformer. - He wanted to ensure the environment was safe before he approached the body, so he retrieved his cell phone, called the ED and requested for Security and the response team to respond to a body that was down on the ground next to the transformer box. - When he saw Staff E, Security Officer, exit the ED entrance, he started to walk to the location of the body. - When he reached the body, he noticed blood coming from the man's nose and mouth. - He did not perform a pulse check on the downed man because he did not have gloves on to touch the body and he stood approximately six inches away from the body as he made his initial assessment. - He shone a light from his phone onto the man and noticed the body had lividity (reddish- to bluish-purple discoloration of the skin due to the settling and pooling of blood following death). - When the body was rolled over, he observed the body had lividity and trauma to the forehead and nose and at that point he believed it was a crime scene, however, Staff J did not initiate any type of care/treatment. - The man was deceased so no cardiopulmonary resuscitation (CPR, a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest) was required. - The delay in treatment for the downed man was due to it being nighttime and concern for his (Staff J) safety, so he requested for security to come to the scene before he approached the body. - He did not know if the person on the ground experienced a drug overdose, was intoxicated, or a homeless person sleeping and without knowing what the situation presented he thought the person could possibly attack and harm him. - He was the only qualified provider on the scene and it was his call not to start CPR based on his assessment of the patient. During an interview on [DATE] at 9:26 AM, Staff C, ED Physician, ED Medical Director, stated: - He received a telephone call from Staff J, off-duty ED Physician, at approximately 10:40 PM ([DATE]) and Staff J reported to him that he found a man down and the body was dead, very dead and had lividity. - Staff J reported that he was not moving the body because he believed it was a crime scene. - He believed Staff J had performed a MSE on the downed man to rule out if an EMC existed. - Even if the scene was a crime scene, he expected Staff J to render medical care/treatment while preserving the environment if it was a crime scene. - After Staff J determined the environment was safe, he expected Staff J to proceed with performing a medical assessment since Staff J was a medical physician and was present on the scene, he expected Staff J to render care within the scope of his medical practice. 39089

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 18018 Based on interview, record review, policy review, and surveillance video recording review, the hospital failed to provide a Medical Screening Exam (MSE) for one patient (#1), within the hospital's capability/capacity to determine if an Emergency Medical Condition (EMC) existed when the patient was found face down on the ground within 250 yards of the hospital's Emergency Department (ED) entrance. The hospital's failure to provide the patient with a MSE placed the patient at increased risk for determining if an EMC existed. A total of 22 ED medical records were reviewed of patients selected from the ED Central Log that presented to the hospital's ED seeking care/treatment, out of a sample selected from [DATE] through [DATE]. These failures by the hospital had the potential to affect all patients that presented to the hospital's ED seeking medical care/treatment. The hospital's ED saw an average of 2,250 emergency visits per month over the past 10 months. Findings included: Review of the hospital's policy titled, EMTALA (Emergency Medical Treatment and Labor Act) Medical Screening Examination and Stabilization Policy, dated [DATE] showed the following directives for staff: - EMTALA obligation is triggered when an individual arrives on the hospital property, either in the Dedicated Emergency Department (DED) or property other than the DED, and no request is made for evaluation or treatment, but the appearance or behavior of the individual would cause a prudent layperson observer to believe that the individual needed such examination or treatment. - The hospital must perform an MSE to determine if an EMC exists. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital. A physician examines all individuals whose conditions or symptoms require physician examination. Observation on [DATE] at 11:01 AM, of the ED parking lot showed that it was approximately 60 feet from the ED side door that Staff J, off-duty ED Physician, exited to where his car was parked in the ED parking lot and approximately 20 feet from his parked car to the location where the body was observed. Review of the surveillance video recording showed: - A man walked across the ED parking lot in the direction of the hospital's ED entrance and as he walked, he put his right hand over his chest. - After the man stepped up on the curb, he stumbled forward a couple of steps, with his arms stretched out in front of him, he lowered his body down and sat on the ground while leaning against the transformer box. - The man then slumped forward, placed his hands on the ground, lowered his body down and rested his face on the ground with his legs bent in a fetal position. - Approximately seven and a half minutes later, Staff J, off-duty ED Physician, appeared in view of the surveillance video recording and walked to his car. - As Staff J walked to his car, he looked in the direction of where the man laid, however, Staff J did not go to the man but continued to walk to his car. - When Staff J reached his car, he opened the driver's door, turned and looked in the direction of where the man was, reached into his left pants pocket, pulled out a phone and for approximately one minute and three seconds looked down at the phone, then placed the phone up to his ear, turned and faced the direction of the man on the ground as he appeared to talk on the phone. - After approximately 36 seconds, Staff J opened the driver's door, removed his stethoscope from around his neck and placed the stethoscope into the car and shut the door. - Staff J then proceeded to walk to where the man was located. - When Staff J reached the man, he did not make any physical contact/touch the man, for example, he did not assess to see if the man had a pulse, heartbeat, or was breathing. - Staff E, Security Officer (SO), arrived, walked to where the man laid, appears to be talking to Staff J, then kneeled down and appeared to touch the man. - Staff I, Paramedic/ED Technician, arrived, went directly to the man, squatted down next to him, rolled him over onto his back and appeared to touch the man's neck area. - Emergency Medical Services (EMS, ambulance), local police, and fire/rescue arrived to the ED parking lot. Review of the EMS Pre-Hospital Care Report dated [DATE] showed that: - At 11:47 PM, EMS was dispatched for a man found down on hospital property and was enroute to the scene at 11:49 PM. - At 11:51 PM, EMS arrived on the scene and there was no CPR or life-saving procedures being performed on the patient when EMS arrived. - EMS received report that the patient was found lying supine (lying horizontally with face and torso facing up), he was not breathing and did not have a pulse. - At 11:54 PM, EMS placed a four lead cardiac monitor (device that detects heart activity) on the patient and the monitor showed the patient did not have any cardiac activity. - The patient was covered in a sheet and left in the custody of local police. During a telephone interview on ,d+[DATE] at 4:30 PM, Staff J, off-duty ED Physician stated that: - When he walked out of the ED side door to where his car was parked, he glanced over in the direction of the transformer box and thought he saw something. - When he reached his car, he noticed what he saw was a body lying face down next to the transformer. - He wanted to ensure the environment was safe before he approached the body, so he retrieved his cell phone, called the ED and requested for Security and the response team to respond to a body that was down on the ground next to the transformer box. - When he saw Staff E, Security Officer, exit the ED entrance, he started to walk to the location of the body. - When he reached the body, he noticed blood coming from the man's nose and mouth. - He did not perform a pulse check on the downed man because he did not have gloves on to touch the body and he stood approximately six inches away from the body as he made his initial assessment. - He shone a light from his phone onto the man and noticed the body had lividity (reddish- to bluish-purple discoloration of the skin due to the settling and pooling of blood following death). - When the body was rolled over, he observed the body had lividity and trauma to the forehead and nose and at that point he believed it was a crime scene, so he did not initiate any type of care/treatment because he believed the man was deceased so no CPR was indicated/required. - He was the only qualified provider on the scene and it was his call not to start CPR based on his assessment of the patient. The surveillance video recording of approximately 45 minutes showed Staff J, off-duty ED Physician, failed to: - Make timely contact with the man down on the ground per hospital policies when he delayed approaching the man for approximately two minutes and 15 seconds after he first observed him. - Perform an adequate assessment when he failed to physically touch the patient and asses for a pulse, respirations, heartbeat, or other trauma that could have caused the man to be down on the ground. During an interview on [DATE] at 3:00 PM and on [DATE] at 11:05 AM, Staff A, Chief Executive Officer, (CEO), stated and acknowledged that based on the hospital's surveillance video recording, Staff J, off-duty ED Physician, did not provide care/treatment for the man found face down on the ground by the transformer box and delayed in providing medical care/treatment for the man when he used his authority to prevent other staff from helping the man or allowing staff to bring the man into the hospital's ED. During a telephone interview on [DATE] at 1:04 PM and during an interview on [DATE] at 9:26 AM, Staff C, ED Physician, ED Medical Director, stated: - His expectation was that any person that presents to the hospital's ED or on hospital premises would receive a hands on assessment. - Staff J, off-duty ED Physician, was trained to provide care, so he was not sure why Staff J did not provide the patient with an assessment when Staff J found the patient down on hospital grounds. - He received a telephone call from Staff J at approximately 10:40 PM ([DATE]) and Staff J reported to him that he found a patient down and the body was dead, very dead and had lividity. - Staff J reported that he was not moving the body because he believed it was a crime scene. - He believed that Staff J had performed an assessment on the patient since Staff J was the first to discover the patient down on the ground. - Even if the scene was a crime scene, he expected Staff J to render medical care/treatment while preserving the environment even if it was a crime scene. - After Staff J determined the environment was safe, he expected Staff J to proceed with performing a medical assessment since Staff J was a medical physician and was present on the scene, he expected Staff J to render care within the scope of his medical practice. During an interview on [DATE] at 2:26 PM, Staff E, Security Officer (SO), stated: - A call came over his radio that a person was down in the ED parking lot. - When he arrived to the ED parking lot, he observed a person face down on the ground and Staff J, off-duty ED Physician, was standing by his car, as he walked to the where the body was, Staff J also walked in the direction of the body. - He asked Staff J for a report and Staff J informed him that the body had not moved. - When he asked Staff J if he had approached the downed man prior to his arrival, Staff J replied no and Staff J did not provide him with an explanation as to why he (Staff J) had not approached the man prior to his arrival. - Together they approached the body, when they arrived next to the body, Staff J spoke to the man but there was no response or movement from him and Staff J never physically touched the man. - He went to the body, checked for a pulse in the man's neck, however, he did not feel/detect one, so he then checked for a pulse on the man's right wrist but he did not feel/detect one and reported his findings of no pulse to Staff J. - When an ED staff member rolled the person over from his stomach onto his back, the man did not respond and he visualized that the man's glasses and dentures were crooked and not in place and that the man had an abrasion across his nose without active bleeding. - He did not recall there being any indication that the man was involved in a crime or that it was a crime scene or why Staff J believed that it was a crime scene. - When ED staff suggested that the man needed CPR initiated and that the body needed to be moved inside to provide further care/treatment, Staff J stated NO and reported that the man had been deceased for approximately one hour, however, his (Staff E) observation did not correspond with the man being deceased for approximately an hour because he had patrolled the ED parking lot approximately 30 minutes prior to finding the man down on hospital property. During a telephone interview on [DATE] at 2:58 PM, Staff G, RN, Charge ED Nurse stated that: - She received a call requesting for a gurney to be brought outside because someone outside needed one. - When she arrived outside to where staff and the body was located, staff were discussing if they need to move the body inside to the ED. - Staff questioned if the patient was still alive and if life support needed to be initiated. - When Staff I, Paramedic/ED Technician rolled the patient over onto his back, Staff J, off-duty ED Physician, kept repeating to staff not to touch the body due to it being a crime scene. - Staff C, ED Physician, ED Medical Director, was called and stated that based on the report he received from Staff J, the person was deceased and not to start CPR. During an interview on [DATE] at 3:19 PM, Staff H, RN, ED Staff Nurse, stated that: - She answered the phone when Staff J, off-duty ED Physician, called to report that a man was found down in the ED parking lot. - Staff J requested for a Security Officer to come to the scene before he approached the body and for a gurney to be brought out where the body was found. - She notified security, then she and Staff I, Paramedic/ED Technician, retrieved a gurney and went to the ED parking lot and observed the patient face down in the grass. - Staff I went to the body, turned the patient over on his back and Staff J, told Staff I not to move the body due to it being a crime scene and because the patient was dead. - Staff I then checked the patient for a pulse and reported that he did not have one. - Staff J was standing away from the body and did not direct staff to initiate CPR on the patient. - The entire event/incident was confusing to her because Staff J kept repeating that it was a crime scene, the man was dead dead and that Staff J could pronounce the man deceased because he was the physician at the scene. - Staff I informed Staff J that to pronounce a person deceased there needed to be confirmation per electrocardiogram (EKG, a recording of the electrical activity of the heart) leads. - She heard a staff member request for the local police to be notified. - Staff J, had poor communication with nursing staff, he was very authoritative and difficult to work with. During an interview on [DATE] at 3:37 PM, Staff F, RN, House Supervisor, stated that: - She received a call from Staff E, SO, who reported to her that there was a dead body located in the ED parking lot. - After she received the report from Staff E, she went to the area reported, when she arrived there was pandemonium, so she went to Staff J, off-duty ED Physician, and asked him don't you need to bring this man into the ED, and Staff J replied he's dead. - When EMS and the local police arrived she questioned if it was a crime scene and staff informed her that Staff J instructed them not to touch the body because it was a crime scene. - When the local police arrived on the scene they took over. During an interview on [DATE] at 4:16 PM, Staff I, Paramedic/ED Technician, stated that: - Staff G, RN, ED Charge Nurse, requested for her to go the ED parking lot and check out the report of a body being found down on the ground. - As she walked out the ED entrance, she observed Staff J, off-duty ED Physician, and Staff E, SO, standing over a body that was down on the ground. - When she arrived at the location of the body, she asked Staff J what do we have and Staff J replied he did not know but was emphatic for her not to touch the body because he stated it was a crime scene, however, she rolled the body over onto his back. - When the body was rolled over, she noticed that the man's dentures were coming out of his mouth, the patient was extremely cyanotic (bluish/purple discoloration due to lack of oxygen in the blood), so she checked for a carotid pulse (carries blood to the head and neck) but it was absent, the man was not breathing so she checked his chin for rigor (stiffness that occurs after death), however, it was pliable (supple enough to bend freely). - She instructed Staff G, RN, ED Charge Nurse, that the body needed to be placed on the gurney and transported to the ED, however, Staff J informed staff that they were not moving the body because it was no different than finding someone at a fast food establishment, it was a crime scene and for staff not to touch the body. - As a paramedic, she had worked several crime scenes and still provided care/treatment required after the environment had been declared safe. - She experienced a lot of conflict because she was trained to provide emergency care/treatment while following physician's orders and when Staff J ordered her not to touch the body or to provide emergent care/treatment, it went against everything she knew needed to be done based on her education/training in providing emergency care/treatment when indicated. During an interview on [DATE] at 8:45 AM, Staff D, RN, Director of Emergency Services stated that: - She received a call from Staff G, RN, ED Charge Nurse, who reported that there was a dead body outside. - She asked Staff G if staff had taken a gurney outside, loaded the body on it, transported the body into the ED and Staff G informed her that the body had not been loaded onto the gurney because Staff J, off-duty ED Physician, refused to allow staff to touch the body because Staff J reported it was a crime scene. - She instructed Staff G to load the body onto the gurney, however, Staff J took the phone and informed her that it was his call, it was a crime scene and that the local police and coroner were notified because the body was dead dead. - She informed Staff G that this was not how this situation should have been handled. Based on interviews conducted with: - Staff A, Chief Executive Officer; - Staff C, ED Physician, ED Medical Director; - Staff D, RN, Director of Emergency Services - Staff E, Security Officer; - Staff G, RN, ED Charge Nurse; - Staff H, RN, ED Nurse, - Staff F, RN, House Supervisor; and - Staff I, Paramedic/ED Technician Staff reported that Staff J, off-duty ED Physician, used his authority as a medical physician to prevent hospital staff from providing care, treatment or to transfer the patient inside to the ED. Staff reported that Staff J informed them that he was in charge, he was a physician and it was his call therefore, staff did not feel that they had the authority not follow Staff J's orders when he ordered staff not to touch the body because it was a crime scene, not to initiate CPR on the body because the patient was dead dead. During a telephone interview on [DATE] at 11:42 AM, Staff O, on-duty ED Physician, stated that: - When she reported for duty there were approximately 25 patients waiting in the ED, so she immediately began to treat patients. - Sometime later in the shift she was informed by staff that a patient had been found down in the parking lot. - She was informed that Staff J, off-duty ED Physician, was on-site and was in charge of the situation. - Neither Staff J, off-duty ED Physician nor staff on the scene requested for her presence at the scene, therefore, she continued to see and care for patients in the ED. Review of the Autopsy Report dated [DATE] showed: - Findings: Severe coronary artery disease (CAD, narrowing of the arteries that limits blood flow to the heart that can lead to chest pain and/or a heart attack) with significant luminal (blood vessel) stenosis (abnormal narrowing of blood vessel) in the left anterior descending coronary artery. Severe coronary artery disease may result in sudden cardiac death due to arrhythmias, (a problem with the rate and/or rhythm of the heart). - Cause of Death: Atherosclerotic Heart Disease (obstruction of blood flow to the heart). - Manner of Death: Natural. The facility failed to ensure that Patient #1 received a MSE to rule out if he experienced EMC that required emergent care/treatment when he presented on the hospital's premises.

29047 Based on review of hospital policies, interviews and closed patient medical records, the hospital failed to provide an appropriate medical screening exam to determine the presence of an emergency for one (#6) patient; and failed to provide stabilizing treatment within the capability and capacity of the Emergency Department (ED) for one (#5) patient that presented with an emergency, out of a total of 20 patients selected for review from April through September, 2012. Findings included: 1. Review of hospital policy, EMTALA: Medical Screening Examination and Stabilization Policy dated 07/13/12, defined a patient as stable when the physician treating the emergency has determined that the EMC (emergency medical condition) that caused the individual to seek care in the ED is resolved. Review of hospital policy titled, Mental Health revised 01/07, showed that ED staff should contact the Behavioral Health Call Center (BHCC), operated under the guidance and supervision of the Health System's psychiatric hospital, for all patients who present to the ED demonstrating symptoms of a mental illness or substance abuse. The policy specified the BHCC will provide guidance and assistance to determine the appropriate level of care required, and receive intake information for the purpose of transfer, placement and follow up care. Review of Patient #5's closed medical record showed he presented to the ED on Sunday 7/1/12 at 12:06 PM stating he cut [his] groin on Friday. Documentation in the medical record indicated patient #5 signed the ED consent to treat form at 1:10 PM. ED registered nurse (RN) I documented her assessment of the patient on Monday 7/2/12 at 4:22 PM, over 24 hours after patient # 5 initially presented to the ED. RN I's late entry documentation indicated she assessed patient # 5 on 7/1/12 at 12:45 PM and that his behavior was appropriate. Upon physical examination of pt's testicles, this nurse observed two very swollen testicles, purplish in color with a tight yellow band secured at the base of the penis. ED physician J examined patient # 5 and documented (untimed entry) that the patient wanted castration for years, (has) never seen a Urologist. Further documentation revealed the patient had a history of Bipolar disorder (severe mood disorder), prior suicide attempts, that he denied current thoughts of suicide or homicide, and had a history of a gunshot wound to his abdomen resulting in the loss of his right kidney. ED physician J documented he had a long discussion with the patient and his family member. He does not want me to remove tourniquet, I advised follow up with his primary care physician and a psychiatric evaluation. Discussed risks of self-castration including infection, bleeding and death. ED physician J documented he contacted the on call urologist who recommended a psychiatric evaluation. ED physician J prescribed an oral antibiotic, a tetanus shot and application of a numbing gel-like medication (viscous Lidocaine) to the skin around the testicles, and provided discharge instructions for Epididymo-orchitis (a painful condition usually caused by either infection or swelling of both the testicles). Documentation in the medical record indicated Patient #5 departed the ED at 2:21 PM. The medical record did not contain evidence that patient # 5's emergency medical condition was stabilized prior to discharge. Review of a second closed medical record showed Patient #5 returned to the ED on 7/1/12 at 6:20 PM, approximately 4 ? hours after discharge complaining of severe pain and profuse bleeding. ED physician L examined the patient and documented his scrotum and testicles were gone and the patient was bleeding from a large open wound. The on-call trauma surgeon was notified and the patient was taken to the operating room for repair of his traumatic laceration. At 7:45 PM, RN I documented Patient #5 stated I told you I would take care of it honey, I had to do something because the ER (emergency room ) doc just sent me home without doing anything. I took my pocket knife at home and sharpened it really good and I just cut them off. Further documentation revealed that after surgery, the patient was taken to the intensive care unit for recovery and one-on-one psychiatric monitoring. An affidavit to support involuntary commitment was completed by a psychiatric nurse evaluator who specified that Patient #5 said men think if you're going to castrate me, you might as well kill me. Patient then states, 'I' m the same way, if I lose it I'd rather be dead. States he's been suicidal most of his life. Has had 2 suicide attempts including 1 gunshot to abdomen. Documentation in the medical record indicated Patient #5 was transferred by ambulance to a hospital with inpatient psychiatric care on Thursday 7/5/12 at 11:30 AM. During an interview on 10/04/12 at 2:43 PM, Urologist H confirmed that he was the urologist on-call to the ED on 07/01/12 and that he spoke with ED physician J about Patient #5's condition. Urologist H stated, Obviously this guy was suffering from a psychiatric condition. I advised him (ED physician J) to cut the ligature and immediately transfer to a psychiatric hospital. I told him I was not interested in performing surgery (castration) on a patient who was psychiatrically unstable (at the time of the first ED visit). During an interview on 10/03/12 at 8:22 PM, ED physician L (on duty when patient # 5 returned to the ED at 6:20 PM on 7/1/12) stated that Patient #5 had an emergency medical condition when he was discharged from the ED at 2:21 PM with his testicles still tied. Refer to tag A 2407 for further details. 2. Review of hospital policy, EMTALA: Medical Screening Examination and Stabilization Policy dated 07/15/08, showed a medical screening exam (MSE); -Is an ongoing process and must continue until the individual is stabilized or appropriately transferred; -Is appropriate to the individual's presenting signs and symptoms, that determines whether or not the individual has an emergency medical condition (EMC); -For individuals with psychiatric symptoms, the MSE should include both medical and psychiatric or behavioral components to determine that there is no EMC (e.g., alcohol or substance abuse, etc.); and that -The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicates a danger to self or others; and -For an individual with psychiatric conditions, the individual is considered to be stable for discharge when he or she is no longer considered to be a threat to self or others. Review of a closed medical record showed patient # 6 presented with law enforcement to the emergency department on 07/03/12 at 2:08 PM because she had threatened suicide. The medical record contained two affidavits signed by patient # 6's friends stating she had beat her head on the curb, threatened to commit suicide by jumping off a bridge and had jumped in front of a truck in an attempt to take her life. The ED nurse documented patient # 6 had bruises over her arms and legs. The ED physician examined patient # 6 and documented that she was depressed, angry, hostile, agitated, and tearful, had suicidal thoughts, and that she had a history of prior suicide attempts and psychiatric problems including bipolar disorder (a serious mood disorder). Further documentation by the ED physician indicated patient # 6 was physically abusive toward staff and police were notified and asked them to take patient to jail. Documentation indicated patient # 6 departed the ED at 2:49 PM. The medical record did not contain evidence that patient # 6 received a psychiatric evaluation or that she was no longer suicidal prior to discharge. Refer to tag A 2406 for further details. 27727

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27727 Based on record review and staff interview, the hospital failed to provide a medical screening examination sufficient to determine the presence of an emergency medical condition for one (#6) of 20 patients who presented to the hospital Emergency Department (ED) seeking care, out of a sample selected from April through September, 2012. Findings included: 1. Review of hospital policy titled, Mental Health revised 01/07, showed that ED staff should contact the Behavioral Health Call Center (BHCC), operated under the guidance and supervision of the Health System's psychiatric hospital for all patients who present to the ED demonstrating symptoms of a mental illness. The policy specified the BHCC will provide guidance and assistance to determine the appropriate level of care required, and receive intake information for the purpose of transfer, placement and follow up care. Review of documentation provided by the hospital's Chief Nursing Officer dated 10/3/12 specified that staff at [NAME] Regional Medical Center contact the mental health assessor team through the call center (the BHCC) if a patient needs psychiatric care or assessment, and we transfer if patient needs psychiatric care. Review of a closed medical record showed patient # 6 presented with law enforcement to the emergency department on 07/03/12 at 2:08 PM because she had threatened suicide. The medical record contained two affidavits signed by patient # 6's friends stating she had beat her head on the curb, threatened to commit suicide by jumping off a bridge and had jumped in front of a truck in an attempt to take her life. The ED nurse documented patient # 6 had bruises over her arms and legs. The ED physician examined patient # 6 and documented that she was depressed, angry, hostile, agitated, and tearful, had suicidal thoughts, and that she had a history of prior suicide attempts and psychiatric problems including bipolar disorder (a serious mood disorder). Further documentation by the ED physician indicated patient # 6 was physically abusive toward staff and police were notified and asked them to take patient to jail. Documentation indicated patient # 6 departed the ED at 2:49 PM. The medical record did not contain evidence that staff contacted the BHCC to arrange a psychiatric evaluation or transfer, or that patient # 6 was no longer suicidal prior to discharge. Review of a second closed medical record revealed law enforcement transported patient # 6 to another hospital ED on 7/3/12 at 3:25 PM for a psychiatric examination. During an interview on 10/03/12 at 10:26 AM, ED physician P stated that patient # 6 was well known to him and that she became abusive and uncooperative after his examination. ED physician P stated the police said they would put patient # 6 on a suicide watch. He stated that if the patient had been anyone else, he would have requested a psychiatric evaluation but because he knew her; he did not feel it was necessary. ED physician P stated that he did not feel the affidavits were credible because they (patient # 6 ' s friends) were both drugged up. He stated there was no way a psychiatric evaluation could be done in patient # 6's condition.

29047 Based on record review and interviews, the hospital failed to provide stabilizing treatment within its capacity and capability for one (#5) of 20 patients who presented to the hospital Emergency Department (ED) seeking care for an emergency medical condition, out of a sample selected from April through September, 2012. Findings included: 1. Review of hospital policy titled, Assessment and Reassessment, Vital Sign Policy for Emergency Department Patients revised 09/01/09, showed that it is the responsibility of the physician to determine stability for discharge. If the patient is deemed medically unstable, they may be admitted to the hospital until such time that an appropriate transfer for mental health evaluation and/or treatment may be achieved. Review of hospital policy titled, Mental Health revised 01/07, showed that the Health System's Behavioral Health Call Center (BHCC) should be contacted for all patients who present to the ED demonstrating symptoms of a mental illness or substance abuse. The policy specified the BHCC will provide guidance and assistance to determine the appropriate level of care required, and receive intake information for the purpose of transfer, placement and follow up care. 2. Review of Patient #5's closed medical record showed he presented to the ED on Sunday 7/1/12 at 12:06 PM stating he cut [his] groin on Friday. Documentation in the medical record indicated patient #5 signed the ED consent to treat form at 1:10 PM. ED registered nurse (RN) I documented her assessment of the patient on Monday 7/2/12 at 4:22 PM, over 24 hours after patient # 5 initially presented to the ED. RN I's late entry documentation indicated she assessed patient # 5 on 7/1/12 at 12:45 PM and that his behavior was appropriate. Upon physical examination of pt's testicles, this nurse observed two very swollen testicles, purplish in color with a tight yellow band secured at the base of the penis. ED physician J examined patient # 5 and documented (untimed entry) that the patient wanted castration for years, (has) never seen a Urologist. Further documentation revealed the patient had a history of Bipolar disorder (severe mood disorder), prior suicide attempts, that he denied current thoughts of suicide or homicide, and had a history of a gunshot wound to his abdomen resulting in the loss of his right kidney. ED physician J documented he had a long discussion with the patient and his family member. He does not want me to remove tourniquet, I advised follow up with his primary care physician and a psychiatric evaluation. Discussed risks of self-castration including infection, bleeding and death. ED physician J documented he contacted the on call urologist who recommended a psychiatric evaluation. ED physician J prescribed an oral antibiotic, a tetanus shot and application of a numbing gel-like medication (viscous Lidocaine) to the skin around the testicles, and provided discharge instructions for Epididymo-orchitis (a painful condition usually caused by either infection or swelling of both the testicles). Documentation in the medical record indicated Patient #5 departed the ED at 2:21 PM. Review of Patient #5's second closed medical record showed he returned to the ED on 7/1/12 at 6:20 PM, approximately 4 ? hours after discharge complaining of severe pain and profuse bleeding. ED physician L examined the patient and documented his scrotum and testicles were gone and the patient was bleeding from a large open wound. The on-call trauma surgeon was notified and the patient was taken to the operating room for repair of his traumatic laceration. At 7:45 PM, RN I documented Patient #5 stated I told you I would take care of it honey, I had to do something because the ER (emergency room ) doc just sent me home without doing anything. I took my pocket knife at home and sharpened it really good and I just cut them off. Further documentation revealed that after surgery, the patient was taken to the intensive care unit for recovery and one-on-one psychiatric monitoring. An affidavit to support involuntary commitment was completed by a psychiatric nurse evaluator who specified that Patient #5 said men think if you're going to castrate me, you might as well kill me. Patient then states, 'I' m the same way, if I lose it I'd rather be dead. States he's been suicidal most of his life. Has had 2 suicide attempts including 1 gunshot to abdomen. Documentation in the medical record indicated Patient #5 was transferred by ambulance to a hospital with inpatient psychiatric care on Thursday 7/5/12 at 11:30 AM. Review of the Hospital's on call list revealed a urologist was on call for the ED on Sunday 7/1/12. And through the Health System's BHCC, a mental health professional was available to perform a mental health examination when Patient #5 presented to the ED on 7/1/12 at 12:06 PM with a medical and psychiatric emergency. During an interview on 10/03/12 at 6:00 PM, ED physician J stated that he examined Patient #5 while his family member was in the room and confirmed that the patient had a ligature around his scrotum (testicle sac), and that the patient's scrotum was swollen and dark blue in color. ED physician J stated that patient # 5 hemmed and hawed around about why he was there then said he wanted to be castrated and that he was uncomfortable when a riding a horse and motorcycle. I asked to remove the tourniquet, but the patient refused. I asked why not and the patient responded contrary to what his goal was, what his experience was with castrating cattle. ED physician J stated he knew the patient was Bipolar but did not assess whether the patient took or was compliant with medications, whether he was seeing a psychiatrist, whether the patient's prior gunshot wound was self-inflicted, and could not recall what his prior attempt at suicide was and did not know if the patient had attempted suicide more than once. ED physician J stated that apart from his scrotum, he (patient # 5) was stable. When asked about psychiatric emergencies and the risk for self-harm, ED physician J confirmed that binding your testicles was a means of self-harm. I had a concern, unusual thing that he (patient # 5) did for an unusual reason. ED physician J stated that patient # 5 refused a psychiatric evaluation but he did not document this in the medical record. ED physician J stated he documented that he discussed the risk of infection, bleeding and death. ED physician J stated I felt the patient had a right to make the decision he was making. During an interview on 10/02/12 at 1:05 PM, Patient #5's family member stated that she took Patient #5 to the ED because he had banded his testicles which were swollen the size of grapefruits, oozing serous-sanguinous fluid (appears like diluted blood), and the skin at the base of the band was black. While Patient #5 checked in, the family member stated she parked the car and then went to his room in the ED. The ED physician came into the room, glanced at patient # 5's testicles and said, You should see a psychiatrist and a urologist, and left the room without performing a physical exam. The family member stated that the ED physician came back into the room and stated that the urologist said, I won't touch him, he needs a psychiatrist. The family member stated patient # 5 responded I will just have to take care of it myself. The family member said the nurse came into the room and put lidocaine (numbing medication) on patient # 5's tissue (skin around the band), gave the patient a prescription for an antibiotic, and both the patient and family member left. The family member stated the patient's parent and a sibling both committed suicide and that the patient sees a psychiatrist monthly, but the ED physician did not offer the patient a psychiatric evaluation. The family member said the ED physician didn't ask patient # 5 if he felt suicidal and didn't ask me either, he just said, This is crazy! This isn't an emergency, this is an ED. We don't do that (castrate) here. The family member stated that as they were leaving the ED patient # 5 told the ED physician that he would just take care of it himself, and that the ED physician said, Stop. I don't want you to do that. During an interview on 10/09/12 at 4:30 PM the ED Patient Care Technician (PCT) O stated that on 07/01/12, when Patient #5 came in the first time, ED physician J asked her to contact the urologist on-call. After the phone call (between ED physician J and Urologist H), ED physician J asked her to get the patient's family member so they could speak in private. PCT O stated she overheard ED physician J telling the family member that he (Patient #5) would greatly benefit from a psychiatrist and the family member nodded. The PCT O said that ED physician asked her to come and witness his conversation with Patient #5. PCT O said that ED physician J told patient # 5 We don't treat this particular situation (castration) here in the ED setting. You need to follow-up with a psychiatrist and PCP (Primary Care Physician). The patient seemed anxious and was walking around the room when he said to the ED physician, So, if someone comes in profusely bleeding, then you have no option but to take care of him, right? ED physician J said, That's right, but we're not going to talk about that. The patient asked if there was anything the doctor could do for his pain, so ED physician J ordered viscous (gel-like) Lidocaine to be applied to the patient's scrotum (testicle sac). PCT O said that after she left the room with the ED physician, I told (ED physician J) that sounded like a threat and he said, Yes, it did. ED physician J asked a nurse to apply the ordered medication to the patient's scrotum and PCT O was asked to witness the medication application. PCT O stated that during the medication application, Patient #5's testicles were inflamed, the size of a softball and very purple. During an interview on 10/02/12 at 3:30 PM, ED registered nurse (RN) I confirmed that she asked PCT O to witness while she applied viscous Lidocaine to Patient #5's testicles. RN I stated that the patient's testicles were swollen to the size of a grapefruit. RN I stated she asked ED physician J whether they were going to leave the patient's testicles banded and ED physician J said He has the right to refuse treatment but the patient did not sign a form indicating he was refusing against medical advice. RN I said that when patient # 5 returned to the ED later on 7/1/12 he was in a wheel chair and bloody from the waist down and that he told ED physician L he was in a mowing accident. During an interview on 10/03/12 at 8:22 AM, ED physician L (on duty on 7/1/12 when patient # 5 returned to the ED) stated that based on the information I was provided, I believe the guy (Patient #5) was suffering from an emergency medical condition when he was discharged with his testicles tied. ED physician L stated if he had examined patient # 5 when he first presented to the ED on 7/1/12, he would have been concerned about the patient's blood flow to his testicles, he would have attended to the patient's psychiatric needs, and would have refused to let the patient leave the ED, would have detained him if needed. During an interview on 10/04/12 at 2:43 PM, Urologist H confirmed that he was the urologist on-call to the ED on 07/01/12 and that he spoke with ED physician J about Patient #5's condition. Urologist H stated, Obviously this guy was suffering from a psychiatric condition. I advised him (ED physician J) to cut the ligature and immediately transfer to a psychiatric hospital. I told him I was not interested in performing surgery (castration) on a patient who was psychiatrically unstable (at the time of the first ED visit). During an interview on 10/04/12 at 3:53 PM, Surgeon M confirmed that he was the surgeon on-call on 07/01/12 and that the ED contacted him about a trauma case in the ED. After Surgeon M arrived at the ED, he took Patient #5, who had completely removed his testicles, to the operating room (OR) for surgical repair. Surgeon M admitted patient #5 to the Intensive Care Unit (ICU) for recovery and one-to-one observation (constant observation of the patient by a staff member) for the patient's safety. Surgeon M stated that I can't speak for (ED physician J) but I would have considered that he talk to someone, at least a psychiatrist. You can involuntarily commit someone if you think they are a harm to themselves . During an interview on 10/04/12 at 4:43 PM, House Supervisor N stated he was on duty when Patient #5 presented to the ED and said, He (Patient #5) was having psychiatric issues, I'm sure. During an interview on 10/02/12 at 7:40 PM, Triage Nurse K stated that Patient #5 was one of the last patients for ED physician J, because he left the ED early that day. If I would have known he (Patient #5) had banded his testicles I would have made him a triage level two (increased severity), and immediately gotten the doctor. Nurse K added that she would not have let the patient leave with his testicles banded, and felt Patient #5's condition warranted a psychiatric evaluation as he obviously had an urgent psychiatric matter. Nurse K stated that the ED can call the health system's psychiatric call center. The call center will send out a professional to complete a psychiatric evaluation. The psychiatric professional usually responds to the ED within one hour or less to evaluate the patient.