Table 2.

Case Study

In response to news media reports of psychiatric patients boarding for 38 days in an ED,23 CMS launched an EMTALA investigation against a hospital in the Southeast.24 After reviewing hospital records, investigators identified 36 EMTALA violations involving failure to provide appropriate screening examination, failure to provide appropriate stabilizing treatment, and failure to arrange appropriate transfer for patients with emergency psychiatric conditions.19 Per the OIG, “In these incidents, individuals presented to the hospital’s ED with unstable psychiatric emergency medical conditions. Instead of being examined and treated by an on-call psychiatrist, and despite empty beds in its psychiatric unit to which the patients could have been admitted for stabilizing treatment, the patients were involuntarily committed and kept in the ED for between 6 and 38 days each.”19 This facility is an important health care access center for patients in the region, as it is the only hospital operating in its county and the major referral center for eight counties.25 The hospital is located in the Appalachian foothills and serves a predominantly white population, with 15% living below the poverty level.26 It is the flagship of the largest private not-for-profit health care system in the state and the largest employer in the county and has been in operation for more than 100 years.25 While the patients in the investigation received medical screening examinations by an emergency physician, the facility was cited for failing to obtain psychiatric screening examinations. The report indicates that the on-call psychiatrist was not following the medical staff rules and regulation regarding urgent consultations (a 2-hour requirement). Additionally, although the on-call psychiatrist was prescribing treatment modalities to the ED provider when requested, CMS noted that they were not providing stabilizing treatment on a daily basis to the patients in the ED. Proposed corrective actions included reeducation of staff about requirements for psychiatrists to 1) see all involuntary hold patients in the ED upon commitment and 2) assume responsibility for the psychiatric care of involuntarily committed patients to provide stabilizing treatment until the patient is admitted for appropriate psychiatric care or transferred to another facility accepting involuntary commitment patients or discharged to an alternative safe environment. Additionally, policies were updated to require medical staff psychiatric providers to see the patients being held for capacity reasons in the ED each day until an appropriate admission, transfer, or discharge is arranged.

Regarding stabilization, the facility was noted to have an inpatient behavioral health unit licensed for 38 beds with capacity for additional patients while many of the psychiatric patients were boarding in the ED awaiting transfer to a state mental health facility. Although the hospital’s inpatient psychiatric facility had by policy and practice previously only accepted voluntary admissions, and only 28 of their 38 licensed beds were routinely staffed, CMS determined that the hospital had capability (available on-call psychiatric and psychiatric services) and capacity (available inpatient psychiatric beds on a behavioral health unit) to provide the psychiatry treatment and milieu needed for patients. CMS deemed the transfers inappropriate given that the sending facility had the capability to provide the same level of care as the receiving facility. In response to the EMTALA citations, the hospital proposed corrective actions including revising hospital policies to allow for admission of both voluntary and involuntary patients to the hospitals’ inpatient psychiatric unit and increasing the number of staffed beds in the unit to 34.27 On June 23, 2017, the hospital entered into a $1,295,000 civil monetary penalty settlement agreement with OIG related to violations of the EMTALA law for this case.19

CMS = Centers for Medicare & Medicaid Services; EMTALA = Emergency Medical Treatment and Labor Act; OIG = Office of the Inspector General