HospitalInspections.org

Based on a review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) log, medical records, video recording, policy and procedures, and interviews, it was determined that the facility failed to include one (P#1) of 21 sampled patient on the facility's EMTALA log. In addition the facility failed to ensure that a medical screening examination (MSE) was provided for three (P#1, P#7, P#17) of 21 sampled patients.

Findings:

Cross refer to A-2405 as it relates to the facility's failure to maintain a central log for P#1 who came accompanied by a trained mental health worker and law enforcement with a signed 1013 on 3/20/24.

Cross refer to A-2406, as it relates to the facility's failure to ensure that three (P#1, P#7, P#17) received an appropriate Medical Screening Examination (MSE).

Based on a review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) log, medical records, video recording, policy and procedures, and interviews, it was determined that the facility failed to include one (P#1) of 21 sampled patient on the facility's EMTALA log when P#1 arrived at the facility accompanied by a trained mental health worker and law enforcement with a signed 1013 (involuntary hold paperwork) on 3/20/24.

Findings were:

A review of the facility's EMTALA log for 3/20/24 failed to reveal an entry for P#1.

A review of police incident details revealed that P#1 was transported from a Community Mental Health Center (CMHC) on 1013 to the facility. Transport was initiated on 3/20/24 at 4:51 p.m.

A review of video recordings of the facility lobby took place on 4/1/24 at 3:10 p.m. with the facility's Director of Performance Improvement and Risk Management. The following was observed:
Recording of 3/20/24 at 6:26 p.m. three people observed walking into the lobby; they were identified as the county police officer, Co-responder AA, and Patient #1. Co-responder AA had some papers with her; went to the check-in window, spoke with receptionist (EE), and appeared to sign the sign in sheet. P #1 and Co-responder AA sat in the lobby.
At 6:33 p.m., Intake Counselor JJ was seen in the lobby talking with Co-responder AA; then walked to the back.
At 6:35 p.m. Intake RN GG came out to the lobby, looked at the papers and spoke with Co-responder AA. The officer went outside. P #1 and Co-responder AA remained seated in the lobby.
At 6:38 p.m. RN GG walked out of view of the camera.
At 6:51 p.m., the officer came back into the lobby. Co-responder AA walked to the check-in window.
At 7:17 p.m. the Officer, Co responder AA, and P #1 exited the lobby.
At 7:18 p.m. an outside camera view showed their vehicle driving off.

Review of the facility's policy #: PC.007, revised 10/2022, titled "Assessment and Referral Services-EMTALA" revealed it was the policy of the facility to assess, stabilize and/or appropriately transfer individuals who come to the facility with an emergency medical condition (EMC). Further review of the policy revealed: 7. all persons presenting as walk-ins and or transfers. All persons presenting to the facility's Admissions department will be entered into the EMTALA log.

A phone interview with Co-Responder AA took place on 4/01/24 at 12:05 p.m. Co-Responder AA stated that she worked with the County Police Department as a Team Lead Co-Responder. Co-Responder AA explained that her role was as trained personnel in mental health crisis. Co-Responder AA signed P #1 onto the sign in sheet once they arrived at the facility.

During an interview with the facility's Director of Intake and Admissions (Director) (CC) on 4/1/24 at 12:57 p.m. in a private office, Director CC stated that he had been at the facility since 2016. Director CC explained the 1013 protocol at the facility. Director CC said once a patient with a 1013 arrived, the person at the front desk first notified the Intake Nurse that there was a 1013 that just arrived. Director CC said the 1013 patient bypassed the normal process that involved some waiting in the lobby, and they took the 1013 patient straight to the Intake area in the back where they completed all the paperwork, including putting the patient on the EMTALA log.

During an interview with Front Desk Receptionist (Receptionist) EE on 4/1/24 at 4:40 p.m. in a private office, Receptionist EE recalled P#1 and the evening he arrived with the two escorts. Receptionist EE said she did the routine health questionnaire (Covid questions) for the patient and notified intake staff that a 1013 patient had just arrived. Receptionist EE recalled that the intake nurse (RN GG) came out and spoke with Co-responder AA. Intake Counselor (JJ) then came out and spoke with Co-responder AA. Receptionist EE said Intake Counselor JJ told her that they (the facility) had not received paperwork for P#1. Receptionist EE said she saw the officer, Co-responder AA and P #1 walk out of the lobby. Receptionist EE said she received training on EMTALA and explained that all patients who came to the facility and asked for treatment were provided an assessment. She explained her job was to have all patients sign in and call intake anytime a patient came to the lobby. Receptionist EE said she did not know the details around P #1 or why the nurse did not want to see him.

Based on a review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) log, medical records, video recording, policy and procedures, and interviews, it was determined that the facility failed to ensure that an appropriate medical screening examination was provided to individuals presenting to the hospital for emergency services for three (P#1, P#7, P#17) of 21 sampled patients. Specifically, P#1, P#7 and P#17 arrived at the facility for emergency psychiatric services and the facility failed to provide a screening assessment.

Findings were:

A review of the facility's EMTALA log for 3/20/24 failed to reveal an entry for P#1.

A review of police incident details revealed that P#1 was transported from a Community Mental Health Center (CMHC) on 1013 (involuntary commitment order) to the facility. Transport was initiated on 3/20/24 at 4:51 p.m.

A review of video recordings of the facility lobby took place on 4/1/24 at 3:10 p.m. with the facility's Director of Performance Improvement and Risk Management. The following was observed: Recording of 3/20/24 at 6:26 p.m. three people observed walking into the lobby; they were identified as the county police officer, Co-responder AA, and Patient #1. Co-responder AA had some papers with her; went to the check-in window, spoke with receptionist (EE), and appeared to sign the sign in sheet. P #1 and Co-responder AA sat in the lobby.
At 6:33 p.m., Intake Counselor JJ was seen in the lobby talking with Co-responder AA; then walked to the back.
At 6:35 p.m. Intake RN GG came out to the lobby, looked at the papers and spoke with Co-responder AA. The officer went outside. P #1 and Co-responder AA remained seated in the lobby.
At 6:38 p.m. RN GG walked out of view of the camera.
At 6:51 p.m. the officer came back into the lobby. Co-responder AA walked to the check-in window.
At 7:17 p.m. the Officer, Co responder AA, and P #1 exited the lobby.
At 7:18 p.m. an outside camera view showed their vehicle driving off.

The facility failed to produce any further documentation of P#1's visit.

Review of P#1's medical record obtained from the Community Mental Health Center (CMHC) revealed P#1 was a 17-year-old male with a history of Bipolar disorder with Psychotic Features (mental state associated with episodes of mood swings ranging from depressive lows to manic highs characterized by the presence of either delusions or hallucinations or both); Schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly), ADHD (attention deficit hyperactivity disorder), ODD (oppositional defiant disorder: a disorder marked by defiant and disobedient behavior to authority figures) who presented to the local CMHC on 3/20/24 at 3:30 p.m. for a follow-up and medication management appointment. Record notes indicated P #1's last visit had been over a month prior and P#1 was arrested for family battery during an altercation with his father. P #1 was taking the following medications at the time of the CMHC visit:
Invega Sustenna 234 mg IM (injection) every month for psychosis
Metformin 500 mg for metabolic syndrome prevention (an increase in blood glucose)
Cogentin 1 mg twice a day for prevention of uncontrolled muscle movements.
Vistaril 25 mg at noon and 50mg twice a day for anxiety
Hydroxyzine Pamoate 50 mg for anxiety

Continued review of P #1's CMHC medical record revealed that the family reported that P#1's behavior had not improved, and he continued to display aggressive behavior towards family and paranoia (a mental disorder characterized by extreme fear and distrust of others). During a standard interview with the CMHC provider (MD II), P #1 appeared to be engaged compared to his last office visit, P #1 denied hallucinations but appeared to be responding to internal stimuli (voices). MD II notes stated that P #1 became agitated in the CMHC office when his father asked him why he was so paranoid. P #1 accused his dad of coming to his room and planting devices. According to MD II, things got out of control; both P #1 and his father were difficult to redirect. P #1 was adamant that he would not agree to commit voluntarily to an inpatient facility for treatment. MD II made the decision to place P #1 on a 1013 (involuntary hold) hold due to acute psychosis, poor insight, threats toward parents, and a need for higher level of care.

Review of the facility's policy #: PC.007, revised 10/2022, titled "Assessment and Referral Services-EMTALA" revealed it was the policy of the facility to assess, stabilize and/or appropriately transfer individuals who come to the facility with an emergency medical condition (EMC). The policy stated that Qualified Medical Professionals (QMP's) will provide an appropriate Medical Screening Examination for any individual who comes to the facility and requests an examination to determine whether the person had an emergency medical condition. The policy further revealed that an individual who is determined to have an EMC would be stabilized within the fullest capability of the facility, or transferred pursuant to this facility's policy and procedure to another facility which can appropriately meet the person's needs. PROCEDURE:
1. Definitions
For purposes of this Policy, the following definitions shall apply:
1.1. "Comes to..." The facility " means, with respect to an individual requesting examination or treatment that the individual is on the hospital property. For purposes of this section, "property" means the entire hospital campus.
1.2. "Emergency Medical Condition", a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
1.2.1. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
1.2.2. Serious impairment to bodily functions; or
1.2.3. Serious dysfunction of any bodily organ or part
1.3. "Qualified Medical Professional" are defined by job description as the Intake Director, Intake Counselors, Nurse Managers, Nursing Supervisors, Registered Nurses, and Physicians. Intake staff is trained to perform pulse and blood pressure assessments, complete the medical and psychiatric screening form, and determine the existence of an emergent medical condition related to psychiatric/substance abuse issues. Nurses and Physicians are trained to determine the existence of an emergency medical condition related to psychiatric/substance abuse or medical issues. Changes in any of the above items as related to provisions of clinical services, including additional categories of facility clinical employees shall be reviewed and approved before implementation.

2. Screening Examination
An appropriate screening examination should be provided to the individual by Qualified Medical Professional (QMP) for determination as to whether or not an emergency medical condition exists. The screening examination shall not be delayed in order to inquire as to whether or not the individual has sufficient financial resources to pay for treatment, including the availability of insurance coverage.

Continued review of the policy revealed that:
6. The facility must accept the transfer of someone from another hospital ED where:
6.1. The person has an emergency psychiatric condition.
6.2. The transferring facility cannot fully stabilize or treat the emergency psychiatric condition.
6.3. The facility has the specialized capability to stabilize and treat the emergency psychiatric condition, and
6.4. The facility has the capacity (i.e. beds, equipment, and staff) to treat the person. It must make the decision about accepting the transfer without regard to the patient's ability to pay and thus should not request, obtain, or consider financial information until after the decision to accept the patient is made.
7. All persons presenting as walk-ins and or transfers. All persons presenting to the facility will be entered into the EMTALA Log.

Review of policy No.: PC.008, title "Patient Comprehensive Triage & Assessment", last reviewed 1/2017 revealed that all patients admitted to the facility were assessed/triaged and evaluated. Results of assessments are reviewed and integrated by the multidisciplinary treatment team to prioritize identified problems within the Master Treatment Plan. Procedures:
1.0 Triage/Assessment
Patients are generally seen in the order that they arrive and triaged/assessed for any emergent situations. Patients are requested to complete their initial paperwork including the assessment information sheet and demographic sheets prior to being escorted from the lobby area to an assessment room. Patients' clinical presentation and mental status are periodically reassessed during the initial triage/assessment. Assessment staff gives the patient an estimate of the amount of time and assessment process may take and offers food, beverage, etc.
2.0 Assessment and Referral
Assessment is the process of determining the treatment needs of a patient and coordinating referral within the facility's Health System or alternate provider. An inquiry call form is completed by the Assessment Coordinator and/or nursing personnel on each inquiry. The disposition of the individual is documented on the TRIMS and/or referral sheet and maintained in a confidential file in the Assessment Office or in storage. Basic medical information is obtained to ascertain the physical health of the individual to determine if any exclusionary medical conditions exist prior to admission.

A phone interview with Co-Responder AA took place on 4/01/24 at 12:05 p.m. Co-Responder AA stated that she worked with the County Police Department as a Team Lead Co-Responder. Co-Responder AA explained that her role was as trained personnel in mental health crisis. Co-Responder AA said the County police employed trained mental health staff who escorted police officers responding to calls that involved patients with mental health issues. Co-Responder AA recalled that she accompanied a police officer on 3/20/24 responding to CMHC that involved P#1. Co-Responder AA said that the clinic physician had placed P#1 on a 1013 and requested that he (P#1) be transported to the facility. Co-Responder AA recalled that when they arrived at the CMHC, the 1013 form was complete and P #1 got in the police vehicle without incident. Co-Responder AA said she and the police officer transported P #1 to the facility. Co-Responder AA signed P #1 into the patient log once they arrived at the facility. Registered Nurse (RN) GG came to meet them in the lobby and after reviewing the 1013 form, RN GG told her that they (the facility) would not accept the patient (P #1) and a second staff member came out and confirmed that they did not accept P #1. Co-Responder AA said P #1 was calm and collected the entire time and she decided to take him home after she communicated with P #1's parent. Co-responder AA confirmed that the Officer that escorted her and P #1 to the facility was off the week of the survey investigation.

During an interview with the facility's Medical Director (MD) BB on 4/1/24 at 12:30 p.m. in a private office, MD BB explained that he was the Medical Director of the facility and had oversight of admissions as well. MD BB stated that when a patient arrived as a 1013, the facility's established protocol was to send the patient directly to the admission area for an assessment. MD BB said patients on a 1013 still had an assessment but there was no need for the patient to go through the normal intake process because a qualified professional already declared the patient 1013. MD BB explained the facility admitted all 1013 patients and there were no exceptions. MD BB said if the facility had no beds available, they (the facility) were to find the patient a place to stay at the facility while they were working with other facilities to find him/her a bed somewhere else. MD BB said the facility sometimes accepted patients even when they did not have a bed; and they sometimes moved patients to different units in an attempt to accommodate a patient in crisis. MD BB stated, "you do what you have to do when 1013 arrived". MD BB said the first step was always to take the patient in and contact the families later for medication consent but keeping the patient here for his/her safety was the very first step whether it was a minor. MD BB said all staff, at least in the Intake Department, were aware of this practice. MD BB said if anyone turned down a 1013 patient, that would constitute a violation of their policy and that should never happen because staff received training on patients presenting in the lobby for treatment.

During an interview with the facility's Director of Intake and Admissions (Director) (CC) on 4/1/24 at 12:57 p.m. in a private office, Director CC stated that he had been at the facility since 2016. Director CC explained the 1013 protocol at the facility. Director CC said once a patient with a 1013 arrived, the person at the front desk first notified the Intake Nurse that there was a 1013 that just arrived. Director CC said the 1013 patient bypassed the normal process that involved some waiting in the lobby, and they took the 1013 patient straight to the Intake area in the back where they completed all the paperwork, including putting the patient on the EMTALA log. Director CC said once the patient was in the back, the Intake Counselor did the assessment, called the doctor to give report on the patient and give the doctor the result of the assessment. Director CC explained that the doctor was the only person who could decide to admit the patient, even a patient on a 1013. Director CC explained that once a patient was declared a 1013 at another facility, the patient had no choice but to be admitted. He said even in the case of a minor, they still admitted the patient and contacted family/guardian's once they got the patient on the unit for safety. Director CC said only the doctor had the authority to change the patient's status from 1013 to voluntary. Director CC said that a 1013 patient must be admitted, even if there was no bed available; he said they could always accommodate the patient on a couch somewhere, get him (the patient) stable while they looked for placement somewhere else. Director CC said they did that in the past. Director CC said that all staff recently completed an EMTALA refresher, and they talked about once a patient crossed the gate, he was on their property and such patient became their patient. Director CC further stated that he was certain they had a bed available when P #1 came in on 3/20/24.

A phone interview with the CMHC Program Manager (Manager) (DD) took place on 4/1/24 at 3:00 p.m. Manager DD said she was a Licensed Clinical Social Worker (LCSW) at the CMHC where P #1 came for a routine follow up visit on 3/20/24. Manager DD recalled that during the visit on 3/20/24, P #1 decompensated while arguing with his parents. Manager DD said P #1 became loud, angry, and could not be verbally redirected. Manager DD said P #1 was making threats and the provider (MD II) decided to put P #1 on a 1013. Manager DD said at the CMHC, when a patient has a 1013, the CMHC called the local police for transport to the receiving facility. Manager DD recalled calling the facility on 3/20/24 around 4:14 p.m. seeking placement for P#1. She recalled speaking to RN GG. Manager DD recalled that she gave RN GG the 1013 status of P#1 as well as the current assessment. Manager DD said RN GG told her to bring P #1 to the facility. Manager DD said Doctor II completed the 1013 form for P#1 and she called the police department for transportation. Manager DD said one officer and Co-responder AA came to pick up the patient. Manager DD said P #1 got into the police vehicle without a problem. Manager DD said later that night he received communication that the facility did not accept the patient.

During an interview with Front Desk Receptionist (Receptionist) EE on 4/1/24 at 4:40 p.m. in a private office, Receptionist EE recalled P#1 and the evening he arrived with the two escorts. Receptionist EE said she did the routine health questionnaire (Covid questions) for the patient and notified intake staff that a 1013 patient had just arrived. Receptionist EE recalled that the intake nurse (RN GG) came out and spoke with Co-responder AA. Intake Counselor (JJ) then came out and spoke with Co-responder AA. Receptionist EE said Intake Counselor JJ told her that they (the facility) had not received paperwork for P#1. Receptionist EE said she saw the officer, Co-responder AA and P #1 walk out of the lobby. Receptionist EE said she received training on EMTALA and explained that all patients who came to the facility and asked for treatment were provided an assessment. She explained her job was to have all patients sign in and call intake anytime a patient came to the lobby. Receptionist EE said she did not know the details around P #1 or why the nurse did not want to see him.

A phone interview with CMHC Director (Director) (FF) took place on 4/2/24 at 10:00 a.m. Director FF said she was the Director of the CMHC where P #1 was routinely seen for follow up appointments. Director FF said on 3/20/24, P #1 came with his father for a routine visit. Director FF said during the visit, P #1 decompensated, became very loud, and argued with his father. Director FF said P #1 made verbal threats; became psychotic (a state that the person loses a sense of reality) with loud cursing in the office. Director FF said P #1 could not be redirected and the doctor signed a 1013 for his safety. Director FF said once the doctor gave the 1013 order, Manager DD called the facility for placement. Director FF said facility staff told Manager DD to bring the patient. Director FF said once they got the okay from the facility, they called the police who arrived with an Officer and a Mental Health Counselor. Director FF said P #1 calmed down once the police arrived and they took him without incident to the facility. Director FF said later that evening, Co-Responder AA called to report that the facility did not accept P #1. Director FF said she asked why but she never got a clear answer as to why the facility turned the patient down.

During an interview with Intake Nurse (RN) (GG) on 4/2/24 at 10:21 a.m. in a private office. RN GG said she worked in the Intake Department and had been a nurse for 25 years. RN GG said when patients presented either voluntarily or involuntarily (1013), she assessed them in the back. RN GG explained her assessment consisted of the level of care the patients needed and she transmitted her findings to the facility's doctor who then decided to admit the patients or referred them to outpatient services. RN GG recalled P #1 was transferred from an outpatient clinic. RN GG acknowledged that received a call from a clinic about P#1 and the person asked her for her name. She said after she gave the caller her first name, then the caller asked for her last name. RN GG said that was curious to her that someone asked her for her first and her last name. RN GG said the caller told her about P#1 and 1013. RN GG said approximately one hour later, P#1 arrived and did not have a packet. RN GG explained that when the facility accepted a 1013 patient, they completed a packet for the patient before his/her arrival. RN GG recalled that she could not find any paperwork for P#1. RN GG said Co-Responder AA showed her a 1013 and her name was on the form as the accepting nurse. RN GG said she went to talk to Intake Counselor JJ about the patient. RN GG said they had a system called Concord where transferring facilities sent all patient information before a patient arrived if they (facility) had accepted the patient. RN GG said P #1's name did not appear on the system. Intake RN GG explained that she was aware of the EMTALA obligations to give an assessment to anybody who presented to the facility and requested services. Intake RN GG said she received annual training that included EMTALA.

An interview with the facility's Director of Nursing (DON) HH took place on 4/2/24 at 11:10 a.m. in a private office. DON HH said she had been a nurse for ten years and at the facility for a month in her role. DON HH said she was not aware of the P#1, but staff were aware that any person who presented at the facility, anywhere on campus who needed an assessment medical or mental should receive such assessment until a doctor could decide the person's disposition. DON HH explained that even in the case of serious medical emergencies such as labor or a heart attack they must take the patient, do their best, and arrange for transfer. Director HH said regardless of the circumstances, they must provide a Medical Screening Exam (MSE) and stabilize the patient at a minimum. She said we can't just say we don't deliver babies here; we do our best and call 911. DON HH said the same applied for a patient on a 1013, they must provide the MSE and let the doctor know of the 1013 and the details of the intake. DON HH said the only reason to refer a 1013 was if the patient was not medically cleared and needed immediate medical treatment and they were still required to make transportation arrangements. DON HH said the facility had a provider on-call 24/7 for the Intake RN to reach out to and it was inexcusable to turn a 1013 patient down. Director HH said the completion of a packet for a 1013 patient was part of the process but the most important part of the 1013 protocol was to accommodate the patient and take care of paperwork later. DON HH said RN GG had not followed the facility's policy regarding EMTALA. DON HH said that staff just completed a "Skilled Fair" training and such training addressed EMTALA law.

A phone interview with the CMHC Psychiatrist (MD) II took place on 4/2/24 at 11:49 a.m. MD II stated P #1 had been receiving outpatient services for some time but at another location. MD II said P #1 was just released from jail and came to her office for a routine follow up appointment. MD II explained that while in the office, P#1 became irritable, paranoid, and difficult to redirect. MD II said she decided P #1 was a significant risk to himself and others. M II said she tried to explain to P#1 that he needed inpatient treatment. MD II said P #1 flatly refused to voluntarily go to the hospital and she put the patient on a 1013 because P #1 needed higher level of care in a different environment than at home.

An interview took place with Intake Counselor JJ on 4/2/24 at 2:30 p.m. in a private office. Intake Counselor JJ recalled that she arrived at work around 6 p.m. the evening that P#1; did not know anything about P #1's case.
Intake Counselor JJ said RN GG told her about a phone call she received earlier from someone asking for her but did not tell her why. Intake Counselor JJ said when the front desk called and told them there was a 1013, she went and told Co-Responder AA that she just came in and did not know anything about P #1. Intake Counselor JJ said she asked the escorts of P #1 about the paperwork; Co-responder AA showed her the 1013 form with RN GG's name on the form as the accepting staff member. Intake Counselor JJ recalled that the 1013 was the only paperwork accompanying P#1. Intake Counselor JJ said she then went to the back to check the system they used for all accepting patients (Concord), and she told Co-transporter AA that she would need to check the bed status as well. The transferring CMHC also needed to be for some details because all she got was a 1013 form. Intake Counselor JJ said she called the front desk, and the receptionist told her the staff left with the patient (P #1). Intake Counselor JJ said she was working at the facility for two years and she understood they operated like a hospital, and they could not turn down people who came in the lobby for help. She said they were supposed to give an assessment to everyone.

A follow up interview with Director CC took place on 4/3/24 at 12:43 p.m. in a private office about two missing charts (P #7 and P #17). Director CC explained that sometimes patients arrive, and once staff start asking routine questions, the patient decides to leave. Director CC stated that patients had the right to refuse treatment and the facility could not hold a patient unless there was a signed 1013 or the patient appeared psychotic. Director CC went on to state that this happened frequently. He also explained that if a person left, the patient's name would be on the EMTALA log, but an account could not be created. Patients that arrive and then refuse treatment are documented as 'Refused Services'. Director CC acknowledged that P#7 and P#17 were documented as being referred to outpatient services and staff could not locate a medical record. Director CC stated that P#7 and P#17 should have an MSE on file because the doctor was the only person that could make referrals.

A follow up phone interview with MD BB took place on 4/3/24 at 2:00 p.m. regarding P #7 and P #17 who did not have an assessment but only outpatient referral. MD BB explained there was always an intake assessment done before a patient was to receive a referral for outpatient services. MD BB said there should always be a full assessment; such assessment could be completed by the nurse, Counselor, or the Director of Admissions but there must be an assessment before a patient can be referred to outpatient services.

Review of 20 additional medical records revealed that two patients, P #7, and P #17 were included on the facility's sign in log and noted as having outpatient referrals. No other records or documentation on P#7 or P#17 were located.

A review of the facility's EMTALA log revealed that P #7 arrived at the facility on 1/31/24. Upon request of P#7's medical record, the facility failed to produce a medical record. A note was provided that indicated P#7 was referred to outpatient services with no evidence of an MSE.

A review of the facility's EMTALA log revealed that P #17 arrived at the facility on 11/10/23. Upon request of P#17's medical record, the facility failed to produce a medical record. A note was provided that indicated P#17 was referred to outpatient services with no evidence of an MSE.