When a patient in need of psychiatric care arrives in the emergency department (ED), nurses play a vital role in ensuring safety and legal compliance. A recent court case highlights how critical your assessments and documentation are under EMTALA, especially during high-risk transfers.
Congress enacted the Emergency Medical Treatment and Active Labor Act (EMTALA) in 1986 to stop EDs from “dumping” patients who couldn’t pay by transferring them without treatment.
EMTALA requires EDs to assess whether a patient is having a medical emergency and stabilize them before any transfer.
If the ED determines the patient needs further treatment and admits them “in good faith,” EMTALA no longer applies.
If these requirements are met, a patient can’t allege a violation of EMTALA. Should a patient be injured during treatment, the only legal remedy would be under a state’s medical malpractice laws.
In the following case, a U.S. District Court in Utah evaluated how a medical center managed a patient who arrived at the ED and was later moved to its intensive care unit (ICU).
Background before the lawsuit
A man came to the medical center’s ED after a non-fatal suicide attempt. Staff initiated suicide precautions, observing him constantly, removing harmful objects, and checking for weapons.
They gave him IV fluids and Zofran to address his condition and contacted a poison control center.
After stabilization, staff admitted him to the ICU for close monitoring under “observation status,” not “inpatient.”
While in the ICU, he could eat and drink. A local counseling center performed a mental health evaluation, which recommended transferring him to a university neuropsychiatric institute located 140 miles away. Staff made the transfer arrangements once they deemed him medically stable, although not ready for discharge to home or outpatient care.
His family requested to drive him there. Several relatives accompanied him during the trip. On the way, he attempted suicide again, causing life-threatening injuries and permanent physical and mental damage.
Patient files a lawsuit
The patient sued the facility and its staff, alleging an EMTALA violation and professional negligence under state malpractice laws.
The defendants asked the court for summary judgment, seeking dismissal. The court denied the motion, citing factual uncertainty about whether the hospital admitted the patient as an inpatient or only held him under observation status.
The defendants then requested partial summary judgment on the EMTALA claim. They argued that because the patient was admitted as an inpatient and stabilized before the transfer, EMTALA no longer applied.
Court analysis and ruling
The court analyzed the patient’s admission status. It noted that while the patient received nursing services, IV fluids, and medications in the ICU, those treatments alone didn’t prove inpatient status.
The EMTALA Interpretive Guide clearly states that hospitals don’t consider patients in observation status as inpatients.
The court also addressed the question of stabilization. Staff stabilized the patient in the ED and ICU using suicide precautions and placed him where nurses could observe him constantly.
Under EMTALA rules, once the patient is “stabilized,” it’s essential to continue to ensure that the patient remains stable before a transfer.
The patient's second non-fatal suicide attempt during transfer suggested he wasn’t truly stable but had instead delayed acting on suicidal ideation.
Based on these findings, the court denied the defendants’ motion for partial summary judgment, allowing the case to proceed.
What ED nurses need to know about EMTALA
If you work in an ED, you must understand your EMTALA responsibilities. Comprehensive assessments become even more important when psychiatric conditions or suicide risk are present.
Document every assessment thoroughly and communicate your findings to the ED physician and healthcare team according to your facility’s policies. Also, document every communication, and monitor patients consistently. EMTALA doesn’t allow a “one-and-done” approach.
Often, your observation and documentation help determine whether a patient is stable enough for transfer, especially if the facility hasn’t admitted them as an inpatient.
Determining whether the patient is stable may be your only role as the treatment RN while the patient is in the ED. If, however, your state nurse practice act and facility policies and procedures authorize you to decide on transferring patients once they’re stabilized, you must do so in full compliance with EMTALA. Review EMTALA requirements in more detail here.
Final thoughts
Although EMTALA doesn’t provide legal action against you as an RN in assessing transfer readiness, your actions could still expose your employer to liability. If a patient suffers harm and your care falls below standard, you could also face a professional negligence lawsuit.
You might also face disciplinary action from your state nursing board if your assessment or care violates the state nurse practice act or board rules.
