Patient presented with psychiatric issues, including hallucinations and agitation. The family expressed concern about the patient being a threat to self or others and law enforcement was called for a possible state commitment. The patient had a history of oxycodone abuse in the past. The ED physician administered 10 mg of Haldol and planned on doing blood and urine screens, but when police indicated that the patient was willing to go for voluntary care at a hospital approximately 50 miles away, the physician did not do the tests and discharged the patient by private auto. Discharge instructions were allegedly provided, but not scanned into the EMR or signed by the patient to acknowledge receipt. No transfer documentation was completed and no advanced acceptance was obtained from the destination hospital. CMS cited the facility for inappropriate transfer (TAG A2409).
Two days following the visit, the ED physician modified the record to remove comments about hallucinations and agitation.
Comments:
Psychiatric issues are full-on EMTALA emergencies, especially when confirmed with hallucinations and agitation. Administration of a drug is additional indication that the patient requires full workup and proper transfer by medical vehicle.
From a risk management perspective, this case could have turned out very badly. In a similar case I was involved in, the patient agreed to go with his wife for voluntary commitment, but never showed up. The wife was found murdered. Several other EMTALA cases I have worked on involved patients killing themselves when allowed to be transported without formal security because they seemed cooperative.
Although not specifically cited in this case, prior CMS citations have found EMTALA violations for inadequate medical screening examinations where a full medical exam was not performed to rule out trauma, medical conditions, and toxic conditions prior to a mental health diagnosis. The fact that the physician intended to do a drug screen and failed to do it when he was aware of possible drug abuse would typically result in a citation.
Additional criticism was directed to the lack of times on most medical records to show the exact time the MSE was performed and the fact that discharge instructions were not part of the record.
The hospital was also cited for lack of EMTALA signs. (Tag A2402)
A2409-WI-2013-4-30