HospitalInspections.org

Based on medical record review, review of facility policy, review of an agreement to provide crisis services, review of Medical Staff Rules and Regulations, observation, and interview, the facility failed to conspicuously post signs, failed to maintain a complete Emergency Room Log for six patients (#7, #9, #10, #13, #18, #19) of twenty sampled patients, and failed to provide appropriate transfers for three patients (#5, #7, # 18) of four patients reviewed.

The findings included:

Please refer to A-2402 for failure to conspicuously post signs.
Please refer to A-2405 for failure to maintain a complete Emergency Room Log.
Please refer to A-2407 for failure to provide stabilizing treatment.
Please refer to A-2409 for failing to provide appropriate transfer.

Based on observation and interview, the facility failed to conspicuously post signs with respect to the right to examination and treatment for emergency medical conditions and women in labor.

The findings included:

Observation of the facility's Emergency Room (ER) on November 1, 2013, at 2:53 p.m., revealed the required signage (Required signs inform patients of the right to receive an appropriate medical screening examination, necessary stabilizing treatment, and if necessary an appropriate transfer if the patient has a medical emergency, regardless of ability to pay, and if the facility does/does not participate in the Medicaid program.) posted over the registration desk in English and Spanish; the signage was located following observation in four locations from the double-door entry to the registration desk.

Observation of the double-door ambulance entry to the ER with the ER Manager on November 1, 2013, at 3:00 p.m., revealed no posted signs.

Interview with the ER Manager on November 1, 2013, at 3:00 p.m., at the ambulance entry to the ER, revealed the required signs had been posted on the wall to the right of the ambulance entry's double-doors in the past, and confirmed the facility failed to conspicuously post the required signs.

Based on review of the facility's Emergency Room Logs, medical record review, review of a Sign-in Sheet, and interview, the facility failed to maintain a complete central log for six patients (#7, #9, #10, #13, #18, #19) of twenty sampled patients.

The findings included:

Review of an Emergency Room (ER) Central Log dated September 24, 2013, revealed Patient #7 presented to the ER with diagnoses including Delusional Disorder. Continued review revealed no documentation regarding the disposition or condition of the patient.

Medical record review of a Transfer Form dated September 24, 2013, revealed the patient was tranferred to a psychiatric hospital.

Telephone interview with the Risk Manager on November 6, 2013, at 3:50 p.m., confirmed the facility failed to maintain a complete central log for Patient #7 on September 24, 2013.

Review of an ER Central Log for (Patient #9) dated September 14, 2013, revealed a medical record number, account number, date of birth, gender, and included, "...Disposition Date 09/14/13 (3:41 p.m.)..." Continued review revealed no documentation regarding a provider's name, triage time, diagnosis, disposition, or condition on disposition.

Review of an ER Sign-in Sheet dated September 14, 2013, provided by the Supervisor of Medical Records on November 5, 2013, revealed, "...(Patient #9)...Reason for Visit: used epipen (treatment for an allergic reaction) by accident...Date and Time of injury: 2:55 PM 9/14/13..."

Interview with the Supervisor of Medical Records on November 5, 2013, at 10:00 a.m., in the medical records department, revealed the facility had no medical record for Patient #9 dated September 14, 2013, and the patient left without being seen.

Interview with the Emergency Department Medical Director on November 5, 2013, at 10:35 a.m., in his office, revealed nurses were responsible to document when a patient left without being seen and confirmed the facility failed to maintain a central log for Patient #9 on September 14, 2013.

Review of an ER Central Log dated September 11, 2013, revealed Patient #10 presented to the ER. Continued review revealed no documentation regarding diagnosis, disposition or condition of the patient.

Medical record review of a nurse's note dated September 11, 2013, at 2:43 a.m., revealed, "...Discharge to home..."

Interview with Licensed Practical Nurse (LPN #1) on November 1, 2013, at 1:25 p.m., in the medical records department, revealed LPN #1's responsibilities included auditing the ER's Central Logs for accuracy and completion. Continued interview confirmed the facility failed to maintain a complete central log for Patient #10 on September 11, 2013.

Review of an ER Central Log dated July 19, 2013, revealed Patient #13 presented to the ER at 1:31 p.m., with diagnoses including Atypical Chest Pain. Continued review revealed no documentation regarding disposition or condition of the patient.

Medical record review of a History and Physical dated July 19, 2013, at 1:32 p.m., revealed, "...presents to ED (Emergency Department) c/o (complaint of) CP (chest pain)...nausea...chills..."

Medical record review of a physician's progress note dated July 19, 2013, at 3:32 p.m., revealed, "Paged...(Patient's Cardiologist)..."

Medical record review of a physician's progress note dated July 19, 2013, at 4:09 p.m., revealed, "...agree with the discharge instructions and disposition..."

Medical record review of a nurse's note dated July 19, 2013, at 4:59 p.m., revealed, "Discharge home."

Interview with LPN #1 on November 1, 2013, at 1:25 p.m., in the medical records department, confirmed the facility failed to maintain a complete central log for Patient #13 on July 19, 2013.

Review of an ER Central Log dated August 14, 2013, revealed Patient #18 presented to the ER with diagnoses including Suicidal Thoughts. Continued review revealed no documentation regarding disposition or condition of the patient.

Medical record review of a nurse's note dated August 14, 2013, at 10:43 a.m., revealed, "Disposition status is discharge. Discharged to: (psychiatric hospital)..."

Interview with LPN #1 on November 1, 2013, at 1:25 p.m., in the medical records department, confirmed the facility failed to maintain a complete Central Log for Patient #18 on August 14, 2013.

Review of an ER Central Log dated August 22, 2013, revealed Patient #19 presented to the ER. Continued review revealed the patient refused treatment and no documentation regarding a diagnosis.

Medical record review of an Emergency Room record dated August 22, 2013, revealed, "...Allergies Bee/Wasp Stings...Chief Complaint...Bee Sting..."

Medical record review of a nurse's note dated August 22, 2013, at 5:27 p.m., revealed, "Disposition status is against medical advice...Patient left. Pt (patient) stated, 'I feel better, I was just very anxious about being stung without my epi kit (emergency treatment of allergic reactions). But it's been an hr (hour) and I am fine, breathing ok.'...physically left department..."

Medical record review of a Withdrawal of Request of Medical Examination and Treatment form dated August 22, 2013, revealed the patient's signature and included, "...I understand it is possible that I may have a serious medical condition which could worsen, resulting in harm, injury...death..."

Telephone interview with the Risk Manager on November 6, 2013, at 3:50 p.m., confirmed the facility failed to maintain an accurate Central Log for Patient #19 on August 22, 2013.

Based on review of facility policy, review of an ambulance service trip report, medical record review, and interview, the facility failed to provide stabilizing treatment for one patient (#2) of twenty sampled patients.

The findings included:

Review of facility Policy Number: LDR.AD.023 most recently revised on August 27, 2009, revealed, "Definitions...The Federal Emergency Medical Treatment and Active Labor Act that requires hospitals to provide emergency screening medical examinations, stabilization to all patients presenting to the hospital requesting such services...Emergency Medical Condition: A medical condition with sufficient severity (including severe pain...) such that the absence of immediate medical attention could place the individual's health at risk...Stabilize: No material deterioration of the condition is likely, within reasonable medical probability...with respect to an emergency medical condition...Policy...Each Emergency Department will follow their normal triage and evaluation/treatment policy and procedures...and initially stabilize the patient within the Emergency Department's capabilities..."

Medical record review revealed the patient (#2) presented to the facility's (Hospital #1) Emergency Department on October 12, 2013.

Review of an Emergency Medical Service (EMS) Patient Trip Ticket dated October 12, 2013, revealed the patient was transported to the facility's Emergency Room, and included, "c/o (complained of)...Fall Hip Pain '10' R (right) arm skin tears R back around ribs '10' R shoulder...Pt (patient) stated...R arm and hip hurting...no pain in neck or back...A O X 3 (alert and oriented times three)...monitored with no change in pain and vitals...at destination Pt stated...neck was still sore..." Medical record review of an EMS Receiving Facility Information Sheet dated October 12, 2013, at 3:35 p.m., revealed, "...Chief Complaint: Fall R (right) arm skin tear, R wrist sore Bilateral Hip pain R Rib pain Medical History...R Hip Broke..."

Medical record review of an Emergency Room (ER) record dated October 12, 2013, revealed, "...Triage...(3:45 p.m.)...fall at home with injury to R hip and R elbow area...Vital Signs Blood Pressure 178/76 Pulse 103 PulseOx 93% Room air Respiration 16/min (minute) Temperature 97.8 Pain 6/10..."

Medical record review of the Medical Doctor's (M.D. #1) History of Present Illness dated October 12, 2013, at 3:53 p.m., revealed, "...fell down...hurting...right posterior chest wall. Says it hurts to touch or to breath (breathe) but not bad enough to have any pain medicine...No other injury...neck pain, or any other orthopedic pain...Hospital records reviewed...Nose atraumatic...Face/mandible nontender...no racoon's eyes...tender right posterior chest wall on palpation without crepitus, ecchymosis, or deformity...Pelvis stable/nontender...Upper extremities nontender except an abrasion on the right elbow without bony tenderness noted. Upper extremities: Full range of motion...Lower extremities: Full range of motion. Spine: Neck: supple, FROM (full range of motion), nontender..."

Medical record review of a chest and rib x-ray report dated October 12, 2013, at 3:59 p.m., revealed, "...Impression: No acute cardiopulmonary process. No evidence of displaced rib fracture."

Medical record review of a nurse's note dated October 12, 2013, at 4:00 p.m., revealed, "...Oriented to person, place, and time...pain noted over the mid thoracic spine...right elbow...single laceration with a total length of skin tear, approx. (approximately) 3.5 inches...was extensively cleaned ...dressing applied..."

Medical record review of Med (Medication) Orders dated October 12, 2013, at 4:04 p.m., revealed, "Acetaminophen...650 mg oral once stat (immediately)...(4:26 p.m.) Medication was just given...Indication: For Mild Pain."

Medical record review of a nurse's note dated October 12, 2013, at 4:26 p.m., revealed, "...Pain 4/10."

Medical record review of a physician's progress note dated October 12, 2013, at 4:48 p.m., revealed, "...Ribs...Chest...I have reviewed the radiologist's report for this film."

Medical record review of M.D. #1's documentation dated October 12, 2013, at 4:49 p.m., revealed, "...Primary Diagnosis 1. Contusion of chest 2. Abrasion, elbow area 3. Fall."

Medical record review of M.D. #1's note dated October 12, 2013, at 4:51 p.m., revealed, "Disposition decision is discharge..."

Medical record review of a nurse's note dated October 12, 2013, at 5:17 p.m., revealed, "...Pain 6/10...Disposition status is discharge...to home...with family..."

Medical record review of a nurse's note dated October 12, 2013, at 5:18 p.m., revealed, "Patient physically left department..."


Medical record review revealed the patient presented to Hospital #2's ER on October 12, 2013, at 6:11 p.m.

Medical record review of a Triage and Nursing History dated October 12, 2013, at 6:18 p.m., revealed, "...Onset of symptoms was 3 hrs. (hours) ago...History is supplied by the patient's relative...Pt fell on (patient's) front steps...has right rib pain, right arm pain, lower back pain, and pain in the right side of (patient's) head...was seen at (Hospital #1's) ER...were told...XR's (x-rays) were 'negative.' The patient was still in 'intense' pain and was brought directly here from (Hospital #1) by (patient's) family..."

Medical record review of a History of Present Illness dated October 12, 2013, at 6:56 p.m., revealed, "...Pt's (patient's) son says pt has c/o L (left) neck pain, R rib pain, R sided head pain, R elbow pain, bilat (bilateral) hip pain, and central back pain s/p (status post) fall...abrasion on...R elbow. Pt was seen at (Hospital #1) and told...x-rays were fine so (patient) was D/C (discharged). Pt is still experiencing severe pain so...family brought...here..."

Medical record review of CT (Computerized Tomography) reports dated October 12, 2013, revealed, "...Abdomen and Pelvis...Impression...Fractures of the left pubic rami with associated left pelvic hematoma...Cervical Spine...Nondisplaced fracture left anterior arch and lateral mass of C1."

Medical record review of the ER record dated October 12, 2013, at 8:38 p.m., revealed, "...Primary Diagnosis...Left Pubic Rami Fractures...Left Hip Hematoma...Nondisplaced Fracture of Left Anterior Arch and Lateral Mass of C1."

Medical record review of a Discharge Summary dated October 12, 2013, revealed, "...Discussed transfer with (physician at Hospital #3), who accepted transfer...Disposition decision is transfer..."

Medical record review of a nurse's note dated October 12, 2013, at 9:38 p.m., revealed, "...Pain 0/10..." Medical record review of a nurse's note dated October 12, 2013, at 9:39 p.m., revealed, "Patient was transferred via ambulance..."

Medical record review revealed the patient presented to Hospital #3's ER on October 12, 2013, at 10:59 p.m.

Medical record review of an ER record dated October 13, 2013, at 3:33 a.m., revealed, "...also complaining of R wrist pain..."

Medical record review of an x-ray report dated October 13, 2013, revealed, "...Impression: Images are degraded by patient motion and severe bony demineralization. Intra-articular angulated buckle fracture distal radius..."

Medical record review of a Discharge Summary dated October 15, 2013, revealed, "...Discharge Diagnoses...C1 nondisplaced fracture...Left pubic rami fractures with pelvic hematoma...Right radius fracture...Compression fracture of the mid thoracic vertebrae..." The family took the patient straight to a second hospital after discharge. The second hospital diagnosed a C1 fracture, a pelvic fracture and elbow injury (effusion possible fracture) and transferred patient to a trauma center.

Telephone interview with M.D. #1 on November 5, 2013, at 3:00 p.m., revealed he treated the patient based on the patient's clinical presentation and radiological findings. He stated, "...cannot account for subsequent fractures after discharging patient..."

C/O: #32691

Based on facility policy review, review of an agreement to provide crisis services, review of Medical Staff Rules and Regulations, medical record review, and interview, the facility failed to provide an appropriate transfer for three patients (#5, #7, #18) of four patients reviewed.

The findings included:

Based on review of facility Policy Number:LDR.AD.023, most recently reviewed August 27, 2009, revealed, "...Transfer of Emergency Patients...Emergency Medical Condition: A medical condition with sufficient severity (including...psychiatric disturbances...) such that the absence of immediate medical attention could place the individual's health at risk...Determination of an existing EMC (emergency medical condition) and the need to transfer the patient is the responsibility of the sending ED (Emergency Department) physician or the physician physically attending to the patient at the time of tranfer...If the receiving facility has the needed specialist/facilities available, then the patient may be transferred...The sending physician makes the decision regarding mode of transporting the patient. The mode of transport will be communicated to the receiving ED physician...If the (Corporation) facilities do not have the specialist/facilities needed for the patient's condition, or there are pre-existing transfer agreements...then the transfer of the patient will occur as per normal EMTALA (Emergency Medical Treatment and Labor Act) transfer agreements and policies...The sending physician and facility as per EMTALA protocol and policy will complete the hospital's standard transfer form...no matter where the patient is transferred..."

Review of an Amended Agreement to Provide Crisis Services Between (facility-Hospital #1) and (Hospital #2) dated June 20, 2000, revealed, "...automatically renewed annually...During the hours of 5:00 p.m. until 8:00 a.m. weekdays, and on weekends and holidays, (Facility) agrees to (through its Emergency Department staff) be the initial point of contact for any individual being presented for consideration of psychiatric hospitalization or in a state of psychiatric crisis. If the individual presenting for psychiatric assessment is a Tenncare enrollee, a (an) active (Hospital #2) client, or is uninsured, the Mobile Crisis Team shall be contacted to provide an assessment for that individual...If the payor source directs services to be obtained by (Hospital #2), then the Attending Physician can contact the Mobile Crisis Team for assessment...Each hospital, under the direction of the attending physician, is responsible for notifying the Mobile Crisis Team if they determine that an individual might be a candidate for emergency commitment...The hospital staff will provide a relevant and accurate information to the Mobile Crisis Team clinician upon initiating a request for an emergency psychiatric evaluation...Upon arrival, the Mobile Crisis Team clinician will then evaluate the individual, provide a copy of the clinical assessment, notify attending physician of suggested treatment...and facilitate patient referral process...A Mobile Crisis Team clinician will notifiy the psychiatric facility of the agreed need for admission...Documentation of this assessment will also be provided for hospital records...The Mobile Crisis Team clinician may determine that the patient would most effectively benefit from outpatient treatment...If the attending physician supports this decision, the Mobile Crisis Team clinician will assist in facilitating the psychiatric outpatient referral process. If the attending physician is not in agreement, and determines voluntary admission and/or emergency commitment is appropriate he/she may facilitate admission independent of the Mobile Crisis Team. Hence, the Mobile clinician will not facilitate placement in this situation..."

Review of Medical Staff Rules and Regulations most recently revised May 26, 2013, revealed, "...Medical Records may be converted to electronic format...any medical records which has been so converted shall be considered the official, permanent medical record for all purposes...All entries in the medical record must be signed, dated, and timed..."

Medical record (electronic) review revealed Patient #5 presented to the facility's Emergency Room (ER) on October 6, 2013.

Medical record review of a nurse's note dated October 6, 2013, at 12:36 p.m., revealed, "...Chief Complaint...Psychiatric evaluation...Mode of arrival...Transported by law enforcement...was found by (police department) walking down middle of road, confused..."

Medical record of a History of Present Illness (HPI) dated October 6, 2013, at 12:44 p.m., revealed, "...Main symptom: depression...symptoms are constant...CONCERN FOR PSYCHOTIC BREAK."

Medical record review of a Certificate of Need for Emergency Involuntary Admission signed by Doctor of Osteopathy (DO) #1 and dated October 6, 2013, at 3:00 p.m., revealed, "...on Sept. 6, 2013...I certify that this person is subject to involuntary care..." Continued review revealed the section of the form regarding mode of transportation was blank.

Medical record review of a physician's progress note dated October 6, 2013, at 3:03 p.m., revealed, "D/W (discussed with) MC (Mobile Crisis)...WILL TRY TO DIRECT ADMIT PT."

Medical record review of an External Transfer Form dated October, 2013, revealed, "...Physician's Documentation...Diagnosis: Psychosis...Reason for Transfer...Psychiatric Admission..." Continued review revealed the section of the form titled "Benefits of Transfer" was blank and dated October 6, 2013, at 3:30 p.m.

Medical record review of a physician's note dated October 6, 2013, at 6:07 p.m., revealed, "...Transfer to psychiatric evaluation facility...Discussed transfer with psychiatrist, who accepted transfer...EMTALA forms were reviewed and signed...Reason for transfer discussed with patient...stable for transport..."

Medical record review of an External Tranfer Form dated October, 2013, revealed, "...Nursing Documentation...Mode of Transport Sheriff...Report called by Mobile Crisis representative...Patient Consent to Transfer Committed...Date/Time 10-7-13 (8:00 a.m.)." Continued review revealed no documentation regarding the identity of a Mobile Crisis representative.

Medical record review of an External Transfer Form (Physician Documentation) dated October, 2013, revealed, "...Hospital Acceptance (Hospital #2)...Time 10/7/2013 12:45 (p.m.)..."

Medical record review revealed no documentation regarding a Mobile Crisis evaluation.

Interview with the Supervisor of Medical Records on November 5, 2013, at 1:28 p.m., in the medical records department, revealed the patient's record did not include Mobile Crisis documentation.

Telephone interview with the Office Coordinator for Mobile Crisis on November 5, 2013, at 1:32 p.m., revealed no documentation was available to verify the patient was evaluated by Mobile Crisis on October 6, 2013.

Medical record review of a History and Physical (Hospital #2) dated October 7, 2013, revealed, "...cleared medically in (facility's) ER...sent to the Geropsych Unit for further evaluation and management. It was noted in the ER that...blood pressure in the ER was 131/90...Plan: Admit to hospital in the Geropscyh Unit..."

Medical record review of a Discharge Summary (Hospital #2) dated October 14, 2013, revealed, "...sent on an involuntary basis from the emergency room at (facility)...was allowed to sign...in voluntarily since (patient) was basically oriented and nonpsychotic...Condition on discharge...not commitable..."

Interview with the ER Manager on November 5, 2013, at 2:00 p.m., in the medical records department, revealed staff had been taught to accurately complete the External Transfer Form. She stated, "...If Mobile Crisis is involved our staff may or may not know (the) Mobile Crisis representative involved. Mobile Crisis makes arrangements for psych transfers..."

Telephone interview with the ER Manager on November 7, 2013, at 10:13 a.m., confirmed the facility failed to follow facility policy and confirmed the facility failed to provide an appropriate transfer for Patient #5 on October 7, 2013.


Medical record (electronic) review revealed Patient #7 presented to the facility's ER on September 24, 2013.

Medical record review of a nurse's note dated September 24, 2013, at 1:12 p.m., revealed, "...Chief Complaint...Hallucinations."

Medical record review of a Triage and Nursing History dated September 24, 2013, at 1:17 p.m., revealed, "...Suicide Risk Screening: Patient HAS had thoughts of harming self...has organized or serious suicide intent..."

Medical record review of a History of Present Illness dated September 24, 2013, at 1:20 p.m., revealed, "...hallucinations over the past few days. Pt thinks...brothers (brother's) friends are trying to hurt (patient)...Pt says...is paranoid and...wants to kill (self)...and if had a gun...would..."

Medical record review of an undated Discharge Summary revealed, "...Primary Diagnosis...Delusional disorder...Has SI (suicidal ideation) without attempt. Will consult mobile crisis. Dispo (disposition) per their recommendation..."

Medical record review of a Certificate of Need for Emergency Involuntary Admission provided by Hospital #2 on November 5, 2013, and dated September 24, 2013, at 3:30 p.m., revealed, "...I certify that this person is subject to involuntary care..." Continued review revealed the following three statements had an "x" in the boxes preceding each statement:

"May be transported to an admitting psychiatric facility...by an
available friend, neighbor...
OR
May be transported to an admitting psychiatric facility...by
ambulance or secondary transportation agent designated by
the sheriff
OR
Must be transported to an admitting facility...by sheriff/
law enforcement..."

Medical record review of an External Transfer Form dated September 24, 2013, revealed, "...Report called to/pt accepted by (blank)...Name/Title Date/Time (blank) Report called by Mobile Crisis Representative (name deleted)...COMMITTED...Date/Time 9/24/13 (8:00 p.m.)."

Medical record review revealed no documentation regarding a Mobile Crisis consultation/evaluation.

Interview with the Supervisor of Medical Records on November 5, 2013, at 12:15 p.m., revealed the patient's medical record did not include Mobile Crisis documentation.

Medical record review of (Hospital #2) Mobile Crisis Team Face-to-Face Intervention Note provided by Hospital #2 on November 5, 2013, and dated September 24, 2013, revealed, "...seeing people, believes people want to kill (patient); thinks people are watching (patient)...No control of behavior No awareness of conseq (consequences)...Wishes (patient) were dead..." Continued review revealed the patient had a history of suicide attempts and included, "...won't contract (for safety)...Inpatient Referral Committment..."

Interview with the ER Manager on November 5, 2013, at 2:00 p.m., in the medical record department, revealed staff had been taught to accurately complete the External Transfer Form. She stated, "...Mobile Crisis makes arrangements for psych transfers..."

Telephone interview with the ER Manager on November 7, 2013, at 10:13 a.m., revealed the facility had failed to follow facility policy and confirmed the facility failed to provide an appropriate transfer for Patient #7 on September 24, 2013.


Medical record (electronic) review revealed Patient #18 presented to the facility's ER on August 13, 2013.

Medical record review of a nurse's note dated August 13, 2013, at 11:29 p.m., revealed, "...Chief Complaint...Psychiatric Evaluation...Transported by law enforcement...has organized or serious suicide attempt...Chronic problem..."

Medical record review of a History of Present Illness dated August 14, 2013, at 12:12 a.m., revealed, "...Tonight...Pt called the police...wanted to hurt...self with a gun...feeling suicidal for the past couple of months...has tried to hurt...self before..."

Medical record review of a Certificate of Need for Emergency Involuntary Admission signed by DO #2 and dated August 14, 2013, revealed the document was not timed and did not specify the mode of transportation. Continued review revealed, "...Check all that apply...I am a (check one)...(box-location to enter required information) licensed physician...(box) licensed psychologist designated as a health service provider..." Continued review revealed the physician had not checked either box. Please complete the following...I have consulted with the mental health crisis team and have determined that all available less drastic alternatives...are unsuitable...I spoke with..." Continued review revealed the physician had not completed the identity or title of the mental health crisis team representative with whom DO #2 had consulted.

Medical record review revealed no documentation regarding a mental health crisis evaluation.

Interview with the Supervisor of Medical Records on November 5, 2013, at 12:15 p.m., revealed the patient's medical record did not include mental health crisis documentation.

Medical record review of a Disposition signed by DO #2 dated August 14, 2013, at 1:47 a.m., revealed, "...I have also personally directed, reviewed, and agree with the discharge instructions and disposition."

Medical record review of an External Transfer Form dated August 14, 2013, revealed, "...Diagnosis: Suicidal Ideation...No Emergency Medical Condition Identified...This patient has been examined and an EMC has not been identified...Hospital Acceptance...(Hospital #2)...10:20 (a.m.)...Mode of Transport Police...Report called by Mobile Crisis representative..." Continued review revealed no identification of a Mobile Crisis representative, DO #2's signature at 5:45 a.m., and included, "...COMMITTED...10:40 (a.m.)."

Medical record review of a nurse's note dated August 14, 2013, at 10:43 a.m., revealed, "Discharged to...(Hospital #2)...in custody of law enforcement..."

Medical record review of a (Hospital #2) Mobile Crisis Team Face-to-Face Intervention Note provided by Hospital #2 on November 5, 2013, and dated August 14, 2013, revealed, "...hear people talking...Paranoia (checked)...suicidal...plan shoot self...guns available...Inpatient Referral...yes (checked)...Voluntary (checked)..."

Medical record review of a Mobile Crisis Follow-up Note provided by Hospital #2 on November 5, 2013, and dated August 14, 2013, at 12:20 p.m., revealed, "...Face-to-Face Completed...8/14/13 @ (at) 4:15 am (a.m.)...ER notified (10:20 am)..."

Telephone interview with the ER Manager on November 7, 2013, at 10:13 a.m., revealed the facility failed to follow facility policy and confirmed the facility failed to provide an appropriate transfer for Patient #18 on August 14, 2013.