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Based on review of EMTALA documents, logs and 20 patient records, it was revealed that the behavioral health unit which accepted individuals with emergency medical conditions from referring hospitals, failed to keep an effective log of those referrals.

A request for the behavioral health log for individuals with emergency medical conditions referred from other hospitals between the dates of 2/20/2016 and 3/1/2016 yielded a one-page log between the specific dates requested, indicating that the log had been made on the day of survey. Interview with the behavioral health unit manager at approximately 1330 revealed that referral information is written on individual records sent to the behavioral health unit, but are not kept in a log form. Based on this information, no effective log is found related to compliance with EMTALA regulation for referred behavioral health patients with emergency medical conditions.

Based on review of EMTALA related documents, logs and 20 patient records, it was revealed that, 1) the hospital failed to provide a medical screening examination for patient #1 who presented to the emergency department via police on February 29, 2016 and, 2) the hospital failed to specify who the governing body determined as qualified medical personnel (QMP) in the Bylaws and Rules and Regulations to perform a medical screening examination.

Patient #1 was transported via police to the emergency department (ED) of Suburban Hospital. Patient #1 was registered and an identification band was applied to her arm. Patient #1 later presented to hospital #2 . When questioned by staff at Hospital #2, patient #1 informed staff , that the arm band was cut from her arm, and she was taken to hospital #2. Review of Suburban Hospital's records related to this encounter indicated that patient #1 left before triage according to the nursing documentation .

Interview of the ED Director at approximately 0930 by the surveyor, revealed that Suburban Hospital's investigation noted that on the evening of patient #1's presentation, the ED was very busy, but not on diversion. Further, that the behavioral health area of the ED was at capacity, and that there was a code in which a physician was attempting to manage a very large and agitated behavioral health patient. Additionally, there was another agitated behavioral health patient who was believed to be dangerous.

Upon the arrival of patient #1, the triage nurse went to the ED behavioral health area and informed the physician of a new behavioral health patient, but did not clearly convey that patient #1 was already in the emergency department. Per the ED Director, the triage nurse could have placed patient #1 in a general ED bed, but did not, and did not access other supervisory consultation. Documentation provided with the complaint reported that patient #1's police escort stated they " were asked to bring the patient to (hospital#2)" and that " it was easier just not to argue " so the police took the patient to hospital #2.

The hospital investigation indicated that the triage nurse statement did not tell the police that they would not take patient #1.

Further survey revealed that behavioral health patient #4, who arrived at the ED with complaint of " Psych Eval " is also documented by the same RN as " left before triage " on 2/28/2016. Similarly to patient #1, no other documentation was found to explain this patient's departure shortly after arrival in the ED.

In addition, review of the Suburban Hospital's Bylaws, Rules and Regulations revealed no information as to who the governing body determined as qualified medical personnel (QMP) to conduct a medical screening examination.

Based on all information, the hospital failed to provide a medical screening examination per EMTALA regulation for patient #1, to determine an emergency medical condition, and failed to identify in the Bylaws, Rules and Regulations, who is QMP who may conduct a medical screening examination.

Based on a review of 3 open and 17 closed emergency department records, it is determined that 1) the hospital failed to demonstrate that it gave informed consent to patient #3 and #12 prior to transfer to another hospital; and 2) failed to certify the stability for transfer of patients #5, #8 and #12 and 3) failed to document the risks and benefits of the transfers of patients #8 and #12.

Patient #3 was a late middle-aged female who presented to the emergency department for a psychiatric evaluation for suicidal ideation. A medical screening exam was completed as well as a psychiatric evaluation. Patient #3 was determined to require inpatient treatment, and she accepted a voluntarily admission.
Patient #3 was to be transferred to the receiving hospital via ambulance. Further review of the record revealed an " Inter-hospital Transfer Form. " A portion of the form was labeled "Consent for Transfer" and revealed the risks and benefits of transfer which was filled in and signed by the physician, but the form was not signed by patient #3 who had capacity to do so.

The Hospital Policy "Patient Evaluation, Treatment or Transfer to Other Hospitals " states that "e. except in cases of involuntary psychiatric admission, obtain the written consent of the patient or the patient representative to the transfer, if possible ... "


Patient #18 is an adult male who presented to the emergency department via police after making threats to family members. Patient #1 received a medical screening exam and psychiatric evaluation. Based on the evaluation, patient #1 was made involuntary and was transferred to an accepting psychiatric facility. Review of the record revealed no physician certification prior to transfer regarding patient # 1's stability, and explanation of the risks and benefits related to the transfer.

Patient #12 is an adolescent female who presented to the emergency department following an overdose of non-steroidal pain relievers. Patient #1 received a medical screening exam and it was determined that patient #12 required inpatient care. Patient #1 was transferred to an accepting psychiatric facility. Review of the record revealed no physician certification of patient # 1's stability at transfer, no indication that the patient was aware of the risks and benefits of the transfer, and no signed consent for the transfer by patient #12's guardian.

Interview with the ED Director on 3/9/2016 revealed that the receiving hospitals will not accept a patient without a transfer form and that it was her belief that the forms were sent with the patients.

Based on all documentation and policy, the hospital failed to obtain appropriate consent, and failed to certify stability and provide information on the risks and benefits of transfers.