HospitalInspections.org

During an EMTALA investigation of complaint #42945 conducted 12/11/17 to 1/8/18, Tristar Centennial Medical Center was found to be out of compliance with Requirements for the Responsibilities of Medicare Participating Hospitals in Emergency Cases 42 CRF Part 489.20 and 489.24.

Based on review of facility policies, review of Medical Staff By-laws, review of Medical Staff Rules and Regulations, medical record review, review of Psychiatric On-Call schedules, and interviews, the facility failed to:

1. Ensure on call psychiatrists who were available and on call for duty performed an adequate examination and provided necessary treatment and/or services for all patient who presented to the ED with psychiatric signs and symptoms for 29 of 31 (Patient's #1, 2, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) patient records reviewed who presented to the ED seeking treatment for psychiatric conditions.
Refer to A-2404

2. Ensure an appropriate medical screening examination was performed within the capability of Hospital #1's Emergency Department (ED) and ensure patients presenting with psychiatric disorders were assessed by the hospital on call psychiatrists in order to determine if an emergency psychiatric conditions existed for 29 of 31 (Patient's #1, 2, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) patients who presented to the ED seeking treatment for psychiatric conditions.
Refer to A-2406

3. Ensure on-call psychiatrists performed an adequate assessment to determine the necessary treatment to stabilize signs/symptoms of psychiatric conditions for 28 of 31 (Patient's #1, 2, 4, 5, 6, 7, 8, 10,11, 12, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25, 26 and 27) patients who presented to the Emergency Department (ED) seeking treatment.
Refer to A-2407

4. Ensure patients with identified emergency psychaitric conditions were transferred to Hospital #1's inpatient psychiatric unit which had the capacity and capability to treat the patients. The hospital failed to minimize the risks to the patients' health by allowing patients with psychaitric conditions to remain in Hospital #1's Emergency Department (ED) for lengthy periods of time without treatment while waiting to be transferred to an outside hospital. The failure of the hospital to admit and treat patients with psychaitric conditions resulted in the inappropriate transfer of 19 of 27 (Patient's 1, 2, 4, 5, 6, 8, 11, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 19, 20, 21, 22, 25 and 26) patients who presented to Hospital #1's ED seeking treatment for a psychaitric condition.
Refer to A-2409

Based on facility policies, Medical Staff Bylaws, Medical Staff Rules and Regulations, Medical Staff on-call schedules, medical record reviews and interviews, the facility failed to ensure on call psychiatrists who were available and on call for duty performed an adequate examination and provided necessary treatment and/or services for all patient who presented to the ED with psychiatric signs and symptoms for 29 of 31 (Patient's #1, 2, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) patient records reviewed who presented to the ED seeking treatment for psychiatric issues.

The findings included:

1. Review of facility policy, "EMTALA [Emergency Medical Treatment and Labor Act]- Definitions and General Requirements" last reviewed 03/2013, revealed, " ...On-Call List refers to the list that the hospital is required to maintain that defines those physicians who are on the hospital's medical staff or who have privileges at the hospital ...and are available to provide treatment necessary after the initial examination to stabilized individuals with EMCs [Emergency Medical Condition] ...The purpose of the on-call list is to ensure that the DED [Dedicated Emergency Department] is prospectively aware of which physicians, including specialist and sub-specialist, are available to provide treatment necessary to stabilize individuals with EMCs. Only physicians that are available to physically come to the ER [Emergency Room] may be included on the on-call list. A physician available via telemedicine does not satisfy the on-call requirements under EMTALA ...PROCEDURE ...A. General Requirements ...2. If the hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer ...7. Maintain a list physicians on call after the initial examination to provide further examination and/or treatment necessary to stabilize an individual ...D. On-Call Obligations 1. Each hospital that has a Medicare provider participation agreement (including both the transferring and receiving hospitals and specialty hospitals) is required to maintain a list of physician specialists who are available for additional evaluation and stabilizing treatment of individuals with EMCs ...5. On-call physician specialists have a responsibility to provide specialty care services as needed to an individual who comes to the emergency department either as an initial presentation or upon transfer from another facility."

2. Review of the Medical Staff Bylaws adopted and approved December 10, 2015, revealed "...1.B. PURPOSES AND RESPONSIBILITIES ...(12) to monitor and enforce compliance with these Bylaws, the Credentials Policy, the Organization Manual, the Medical Staff Rules and Regulations, other Medical Staff policies, and Hospital policies; and..."

3. Review of facility Medical Staff Rules and Regulations, approved by the Medical Executive Committee on 6/14/16 and the Board of Trustees on 6/24/16 revealed, "... EMERGENCY SERVICES/MEDICAL SCREENING/TRANSFERS: A. Emergency Services:
1. Members of the Medical Staff shall accept responsibility for Emergency Service care in accordance with the Medical Staff Bylaws, Emergency Department policies and procedures and applicable state and federal law. Physicians scheduled for on-call coverage are fully accountable for their availability and responsiveness ..."

4. Review of Hospital #1's Medical Staff on-call Logs, for the specialty of psychiatry, revealed a Psychiatrist on-call each day for the months of January 2015 through October 2017 when 28 of 31 patients were in the ED.

5. Medical record review revealed Patient #1 presented to the ED at Hospital #1's campus on 7/12/17 at 3:33 PM via ambulance for complaints of "suicidal thoughts and a plan, Pt [patient] reports 'my world is coming undone.'" The patient was uninsured.

Review of the ED notes for Patient #1 revealed on 7/12/17 at "1651[4:51 PM] CAPS: [Community Assistance Program-Behavioral Health Assessment provided by Psychiatric Registered Nurses or Masters in Psychiatric/counseling, located on-site at Psychiatric Hospital #3] assessment completed and reviewed with [ED physician #1]; patient not medically cleared at this time, BAL [blood alcohol level] pending (UDS [urine drug screen] negative), hx [history] of alcoholism and recent relapse (reports last drink this AM), endorses SI [suicidal ideation] (no plan), hx of depression (not taking antidepressant), no HI [homicidal ideation], no symptoms of psychosis ...7/12/17 at 1725 [5:25 PM] Addendum: Pt medically cleared, call Ctr [center] notified [name] for MCRT [Mobile Crisis Response Team] tracking, reviewed clearance form, fax to MCRT ...7/13/17 at 0441 [4:41 AM], discussed with [name] at [Hospital #2]. Patient will be 61 on the waiting list ...7/13/17 at 0614 [6:14 AM] Pt reports 'feel like I'm withdrawing' ...will give meds per order ...7/13/17 at 2306 [11:06 PM] ...[Hospital #2] said the patient's waiting list number has not changed ..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #1 on 7/12/17 at 5:50 PM which documented, "...has a mental illness or serious emotional disturbance ...active symptoms of psychiatric disorder as noted: suicidal ideation with a plan of jumping off a bridge ...AND, poses an immediate substantial likelihood of serious harm ...In my opinion, the patient is at continued risk of self-harm if not placed under involuntary commitment ...Condition is likely to deteriorate further without treatment ..."

Review of ED physician #1's note dated 7/12/17 at 5:55 PM revealed the ED physician had initiated a Medical Screening Examination (MSE) on Patient #1 which included a History of Present Illness (HPI), a medical and psychiatric history, review of systems (ROS) and physical exam. ED Physician #1 documented, "49-year-old male with a past medical history of alcohol abuse and depression who presents complaining of suicidal ideation. The patient states for the past 4 days he's been having suicidal thoughts of jumping off a bridge ..."

The patient's care was transferred to ED Physician #2 on 7/13/17 at 4:19 AM. ED physician #2's note documented the patient was awaiting a mobile crisis evaluation.

ED Physician #3's note dated 7/13/17 at 7:32 AM documented, "awaiting placement at [name of Hospital #2]"

ED Physician #1's note dated 7/14/17 at 4:17 PM documented the patient's care had been transferred to ED physician #4.

ED Physician #4's note dated 7/15/17 at 12:10 AM documented, "This is a 50-year-old male. He is in the emergency department pending psychiatric placement as he [has] been evaluated by mobile crisis. He has not had any acute episodes during my management of the patient's care."

ED Physician #5's note dated 7/15/17 at 6:39 AM documented, "Patient has been stable throughout my ED shift. Patient is still desiring inpatient placement. Care will be passed off oncoming providers ..."

ED Physician #4's note dated 7/16/17 at 12:32 AM documented Patient #1 was stable.

ED Physician #6's note dated 7/16/17 at 5:49 PM documented, "Patient has been stable in the emergency department. He was accepted at [named hospital #2] ..."

Patient #1 was transferred to Hospital #2 on 7/16/17 at 7:59 PM, 100 hours after presenting to the Hospital #1's ED seeking treatment and stabilization for a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #1's psychiatric condition while the patient remained in Hospital #1's ED for 100 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why Patient #1 was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

6. Medical record review revealed Patient #2 presented to the ED at Hospital #1's campus on 7/13/17 at 12:47 AM via ambulance with chief complaint of, "57-year-old gentleman who present to emergency room with complaints of lower behavior. States he's been in Afghanistan until a week ago were [where] he was the chief weapons officer of a flight of stealth bombers and that he is in Nashville to receive the Congressional Medal of Honor at Centennial Park. Patient also complains of rectal bleeding for 5 days. He was seen at [Hospital #4] complaining of rectal bleeding approximately 12 hours ago. He had negative fecal occult blood and normal H&H [hemoglobin hematocrit] ... Patient missed alcohol. He says "I'm really messed up." But he denies suicidal or homicidal ideation. It is very difficult to obtain a street [history] from the patient secondary to fact that his is delusional and tangential [erratic] but he denies any pain at this time ..." The patient had out of state Medicaid insurance.

Review of ED Physician #2's note date 7/13/17 at 12:59 AM revealed a MSE which included a History of Present Illness (HPI), a medical and psychiatric history, review of systems (ROS) and physical exam was initiated. A Certificate of Need for Emergency Involuntary Admission (6404) was signed at 1:00 AM. ED physician #2 documented, "Patient presents with evidence of mania and delusions. I believe he is incapable of taking care of himself and is likely come significant harm if not institutionalized for stabilization. He was placed under involuntary hold 6404 and will require evaluation by mobile crisis ..."

Review of the CAPS evaluation performed on 7/13/17 at 3:53 AM revealed the evaluator discussed the patient's status with Hospital #1's on-call Psychiatrist. The hospital's on-call Psychiatrist stated to have Mobile Crisis evaluate the patient for possible treatment. There was no documentation the hospital's on-call Psychiatrist evaluated the patient.

Review of the Mobile Crisis Response Team notes dated 7/13/17 at 5:20 AM revealed Mobile Crisis referred the patient to be admitted for inpatient psychiatric treatment due to psychosis. The ED Notes documented the patient was placed on the waiting list to be admitted to Hospital #2 on 7/13/17.

ED physician #4's note dated 7/15/17 at 12:04 AM documented, "Patient is agitated here numerous times and requires multiple redirection. Patient still psychotic saying he has a G5 jet ready to pick up the Surgeon General to evaluate him. The patient was given Geodon [Antipsychotic medication for treatment of Schizophrenia and Bi-Polar disorder] and Ativan [Benzodiazepine/sedative for treatment of anxiety] as needed for his agitation and psychosis ..."

ED Physician #5's note dated 7/15/17 at 6:37 AM documented, "Patient has been observed throughout the emergency department stay during my shift. He has been medically stable. He is still acutely psychotic and will need placement ..."

ED Physician #7's note dated 7/16/17 at 4:23 PM documented, "Reassessed this patient during my shift multiple times. He is tried to escape from the ER multiple times, including an episode where he tried to get inside of an ambulance and drive off he was pulled from the ambulance, secondary to this and combativeness with staff in general inability to conform to safety precautions we have placed him in seclusion, think this is for the patient's safety as well as everyone else in the emergency department. I reassessed him 4 hours later and will continue disorder [this order] ..."

ED Physician #6's note dated 7/17/17 at 1:46 AM documented, " ...He placed the patient on an involuntary seclusion order at noon because the patient attempted to lift [leave] emergency department and was creating a risk to himself and staff. I evaluated him shortly after 4 PM and he was redirectable and cooperative and we withdrew the seclusion order. He was given some IM [Intramuscular] Geodon and we continued to monitor him in the emergency department until care was passed over to [name of ED physician #2] for continued management until he is transferred to [Hospital #2]."

Patient #2 was transferred to Hospital #2 on 7/17/17 at 9:45 AM, 105 hours after presenting to the Hospital #1's ED for seeking treatment and stabilization for a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #2's psychiatric condition while the patient remained in Hospital #1's ED for 105 hours awaiting to an inpatient psychiatric facility.

There was no documentation why Patient #1 was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

7. Medical record review revealed Patient #4 presented to the ED at Hospital #1's campus on 7/13/17 at 1:34 AM via ambulance with chief complaint of being found at the bus station bleeding from cutting his arm with a box cutter.
The patient was uninsured.

Review of ED Physician #2's note dated 7/13/17 at 1:36 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. Review of ED physician #2's note dated 7/13/17 at 1:36 AM revealed the patient was a , "36-year-old gentleman presents to emergency department after reportedly stabbing himself in the left thumb with a box cutter. Patient reports a long-standing psychiatric history for which he has been followed in Jackson, TN. He states that he has 'messed up to the head' and 'That what is going in this world is not real.' Patient is very agitated and uncooperative and is unwilling to provide further history ..."

Review of Nurses Behavioral Health Related notes dated 7/13/17 at 1:51 PM revealed, "Pt continues to be agitated. Security notified of inappropriate action ...7/14/17 at 5:00 AM ...Pt was pacing from bed to doorway for several minutes ..."

The CAPS evaluator note dated 7/13/17 at 5:04 AM documented, "This patient will need to be evaluated by the psychiatrist prior to any discharge to an unsupervised setting. Notified [name] at Behavioral Health Call Center of need for Mobile Crisis evaluation. Medical clearance sent ..."

A nurses note dated 7/13/17 at 7:13 AM documented, "Mobile Crisis recommends inpatient treatment. Mobile Crisis spoke with Transfer Center, pt referral to [Hospital #2] ..."

A nurses note dated 7/13/17 at 6:56 PM documented the patient had been approved for transfer by the attending Physician at Hospital #2 and was currently #43 on the wait list for a bed.

Patient #4 was transferred to Hospital #2 on 7/17/17 at 8:10 AM, 102 hours after presenting to Hospital #1's ED for treatment and stabilization for a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment of Patient #4's psychiatric condition when the patient remained in Hospital #1's ED for 102 hours awaiting for to an inpatient psychiatric facility.

There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3)for inpatient treatment.

8. Medical record review revealed Patient #5 presented to the ED at Hospital #1's campus on 7/13/17 at 11:15 PM via ambulance with chief complaint of Suicidal Ideation, wanting to jump off a bridge and hurt himself. The patient was uninsured.

Review of ED Physician#15's note dated 7/13/17 at 11:23 PM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician#15's documented, "37-year-old male with history of Schizoaffective disorder here tonight for depression and suicidal ideation. Patient was just seen in a hospital in Georgia yesterday for similar symptomatology. However patient was not having any thoughts of suicidal ideation. He allegedly bought a bus [ticket] to come here. Suicidal ideation began on his travel here. Patient plans on jumping off a bridge to hurt himself. Because of his suicidal thoughts patient contacted EMS [Emergency Medical Services] to bring him here ..."

A CAPS intake was initiated on 7/13/17 at 11:25 PM. On 7/14/17 at 6:00 AM the patient was placed on the waiting list to be transferred to Hospital #2. He was #61 on the waiting list.

Patient #5 was transferred to Hospital #2 on 7/18/17 at 11:10 AM, 107 hours after presenting to Hospital #1's ED for treatment and stabilization of a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #5's psychiatric condition while the patient remained in Hospital #1's ED for 107 hours awaiting for transfer to an inpatient psychiatric facility.

There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

9. Medical record review revealed Patient #6 presented to the ED at Hospital #1's campus on 7/16/17 at 7:47 AM via ambulance for complaints of "...confused, disoriented, found walking through traffic on 440 ..." The patient was uninsured.

Medical record review of ED Physician #7's note dated 7/16/17 at 8:08 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED physician #7 on 7/16/17 at 11:00 AM documented, "Reported history of behaviors clinically indicative of a psychiatric disorder, prior history of psychiatric hospitalizations, substance abuse, behavior that puts patient at risk for self-harm, appears delusional, feel unsafe to leave ...Condition is likely to deteriorate further without treatment ..."

Review of the Behavioral Health CAPS Assessment performed on 7/16/17 at 10:35 AM revealed, "...recommendations for the patient's disposition was discussed with provider (Hospital #1's on-call Psychiatrist #1) and the on-call Psychiatrist, "referred to Call Center/MCRT for disposition..."

The Emergency Department notes dated 7/16/17 at 11:16 AM documented, "Patient seen by CAPS, she presented bizarre but denied suicidal, homicidal at the time of assessment. Patient was not able to give demographic, social or any pertinent information ..."

Review of the ED Physician #6's notes dated 7/17/17 at 7:51 PM revealed, "Patient was cooperative throughout my stay except at one point she tried to leave the ED she was redirected back to her room by security and I gave her oral Haldol [an antipsychotic] and Valium [an anxiolytic and sedative used to treat anxiety, muscle spasms and seizures] which she took and was cooperative from that point on ..."

Patient #6 was transferred to Hospital #2 on 7/20/17 at 3:48 AM , 91 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #6's psychiatric condition while the patient remained in Hospital #1's ED for 91 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient psychiatric treatment.

10. Medical record review revealed Patient #7 presented to the ED at Hospital #1's campus on 10/11/17 at 3:06 PM via walk in with chief complaint of Suicidal Ideation and wanting detox (detoxification). The patient was uninsured.

Medical record review of ED Nurse Practitioner (NP) #2's note dated 10/11/17 at 3:15 PM revealed Patient #7 was provided a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. NP #2's note dated 10/11/17 at 3:15 PM documented, "Patient to ER for detox. Reports that he has been regularly using IV [intravenous] heroin and opiates. States last use was approximately 2-3 days ago and last use of opiates was approximately 2 days ago. Reports that he is tired of doing drugs and he's been having suicidal ideation. Wants help stopping. Does not have a plan. Denies any HI..."

Review of the CAPS behavior health assessment dated 10/11/17 at 4:39 PM revealed the patient was not referred to the psychiatrist on-call.

Review of the Emergency Room Notes dated 10/11/17 at 5:11 PM documented, "[Hospital #3] does not have a detox bed at this time. Pt will be given to the Call Center to call Mobile Crisis ..." The patient was seen by Mobile Crisis on 10/11/17 at 8:15 PM with recommendations for inpatient further evaluation and treatment due to suicidal ideation.

ED Physician #8 dated 10/13/17 at 5:00 AM documented, "...received sign out from [ED physician #5]. 6404 [Certificate of Need for Emergency Involuntary Admission] completed. Patient is medically cleared ...Patient is awaiting transfer to [Hospital #2] for further psychiatric care ..."

ED Physician #6's note dated 10/14/17 at 6:28 AM documented, "Patient has been fairly stable throughout my shift. He was given Ativan [a sedative used to relieve anxiety] by mouth but continued to pace and said that he was unable to sleep. He asked for 5 or 6 Tylenol PMs [Tylenol containing Benadryl, an antihistamine] which were not given to him however I did give him 50 mg [milligrams] of hydroxyzine [antihistamine ] which helped him to relax through the rest of my shift. He is still #40 on the list for [Hospital #2] and he has arty [already] been here for 111 hours ..."

ED Physician #4's note dated 10/16/17 at 4:09 AM documented, "The patient became agitated during his ER stay. He did require 10 mg of Geodon intramuscularly for his agitation. The patient is now stable ..."

Patient #7 was transferred to Hospital #2 on 10/18/17 at 7:59 AM, 160 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #7's psychiatric condition while the patient remained in Hospital #1's ED for 160 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

11. Medical record review revealed Patient #8 presented to the ED at Hospital #1's campus on 8/24/17 at 9:17 PM via ambulance for complaints of decreased mental alertness. The patient had TN Care/Blue Care insurance (Medicaid).

Review of ED physician #2's note dated 8/24/17 at 7:19 PM revealed a MSE which included a HPI, a medical and psychiatric history, ROS and physical exam was initiated. ED Physician #2's note on 8/24/17 at 7:19 PM documented, "28-year-old female who was just discharged earlier this afternoon from [hospital #1] to a rehabilitation facility for benzodiazepine and opioid dependence presents to the emergency room this evening via EMS with chief complaint of unwilling to speak not acting right. Was initially admitted to the hospital after a questionable near drowning thought to be secondary to a seizure secondary to benzodiazepine withdrawal ...She was discharged earlier this afternoon and went to the [name of outpatient drug rehab facility] for her drug dependence however after a few hours there she started acting bizarrely wandering the halls and then reached the point where when would no long respond or talk..."

Review of the Emergency Department Notes dated 8/25/17 at 4:45 AM revealed, "...CAPS CONSULT WAS COMPLETED, DISPOSITION DISCUSSED WITH [ED physician #2]. HE WOULD WRITE 6401 [6404]... DUE TO PT'S INSURANCE PT REQUIRES A CALL CENTER REFERRAL FOR MCRT ASSESSMENT..."

ED physician #2 dated 8/25/17 at 5:23 AM documented, "Patient is once again refusing to speak or interact. She will require evaluation by mobile crisis."

Review of the CAPS assessment dated 8/25/17 at 5:38 AM revealed the psychiatrist recommended Electroconvulsive Therapy (ECT). An attempt to assess the patient via Telemed was unsuccessful due to the patient's refusal to communicate.

Patient #8 was discharged to Hospital #8 on 8/27/17 at 12:14 PM.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment of Patient #8's psychiatric condition while the patient remained in Hospital #1's ED for 62 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

12. Medical record review revealed Patient #10 presented to the ED at Hospital #1's campus on 1/5/17 at 10:21 AM via ambulance with chief complaint of psychosis. The patient was discharged from Hospital #3 on 1/4/17 and returned to group home. The group home sent him to the ED on 1/5/17 due to talking to himself, confusion and incorrect responses. The patient was uninsured.

Medical record review of ED NP #2's note dated 1/5/17 at 10:47 AM revealed a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam was initiated. NP #2's note documented, "...Patient to ER for CAPS eval [evaluation]. Was dcd [discharged] home from [Hospital #3] yesterday and sent to group home. Group home sends patient back this AM for eval due to Psychosis. Patient talking to himself and confused, incorrect responses to questioning. Appears to be responding to internal stimuli. Patient denies SI or HI ...Patient follows directions and is pleasant, but talking to himself and giving bizarre answers to questions..."

Review of a nurse's note dated 1/5/17 at 10:43 AM revealed, " ...Pt [patient] sent from [Named group home] for psych [psychiatric] eval [evaluation]...Pt was d.c. [discharged] home from [Hospital #3] yesterday and sent to group home...pt has extensive psych history ...pt is dillusional [delusional], and talking to person not seen..." Further review of the nurse's notes revealed, "...[1/5/17 at 11:09 AM] ...security notified as patient is confrontational and passive aggressive...[1/6/17 at 8:32 PM]...he was talking to himself. When I asked who he was speaking to, he stated that he was speaking to his ex-wife ...[1/7/17 at 12:14 AM]...pt is awake talking to himself ..."

A CAPS assessment was initiated on 1/5/17 at 11:35 AM. CAPS recommendation was to readmit for psychiatric care. CAPS documented that there were no beds available at Hospital #3 and the call center would be referred to find placement. Further record review revealed the patient was on the "pending board" for Hospital #3 due to full capacity as of 1/7/17. The patient had also been referred to Hospital #2 and was on the waiting list.

A Certificate of Need for Emergency Involuntary Admission (6404) was signed on 1/9/17 10:31 AM.

Patient #10 was transferred to Hospital #2 on 1/9/17 at 1:32 PM, 99 hours after presenting to the ED for treatment and stabilization of a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #10's psychiatric condition while the patient remained in Hospital #1's ED for 99 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

13. Medical record review revealed Patient #11 presented to the ED at Hospital #1's campus on 5/30/17/17 at 12:32 AM via ambulance with chief complaint of hallucinations. The patient had TN Care/Blue Cross insurance (Medicaid).

Medical record review of ED physician #2's note dated 5/30/17 at 1:05 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician #2's note dated 5/30/17 at 1:05 AM documented, "21-year-old female with a history of schizophrenia and bipolar disorder and recent hospitalization who presents to the emergency room complaining of increasing hallucinations that are distressing to her. She denies suicidal ideation. No homicidal ideation. She states that she has a lot of stressors at home and has a stressful relationship with her mother who is her conservator ..."

Review of the CAPS assessment performed on 5/30/17 at 1:05 AM revealed recommendations for patient disposition was discussed with the on-call psychiatrist but there was no documentation of the psychiatrist recommendations.

A physician's order, from ED physician #2, dated 5/30/17 at 5:45 AM, documented to give Depakote 500 milligrams (mg) by mouth (PO) daily (Anti-convulsant used to treat seizures and Bi-Polar disease), Haloperidol 5 mg PO twice a day (Antipsychotic), Cogentin 1 mg PO twice a day (Anti-tremor medication used to treat side effects of other drugs). Documentation revealed Patient #11 received Haloperidol 5 mg, Depakote 500 mg and Cogentin 1 mg at 6:20 AM and Haloperidol 5 mg and Cogentin 1 mg at 9:43 PM. There was no documentation Patient #11 received any medications prior to discharge from Hospital #1's ED on 6/3/17.

Review of the Emergency Notes revealed the patient was seen by Mobile Crisis on 5/30/17 at 10:00 AM.

ED physician #5's note dated 6/2/17 at 6:54 PM documented, "Patient has been medically stable throughout his [her] emergency department stay. He [She] has been accepted to [name of Hospital #2] at this date and time ..."

Patient #11 was transferred to Hospital #2 on 6/3/17 at 4:24 AM, 100 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #11's psychiatric condition while the patient was in Hospital #1's ED for 100 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

14. Medical record review revealed Patient #12 presented to the ED at Hospital #1's campus on 6/4/17 at 10:20 AM via ambulance with chief complaint of nursing home requesting a psychiatric evaluation and neck pain. The patient had Medicare Parts A & B insurance.

Medical record review of ED physician #9's note dated 6/4/17 at 11:12 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician #9's note dated 6/4/17 at 11:12 AM documented, "This is a 74-year-old male present from a skilled nursing facility. Per the facility's report he overnight called EMS many times due to having some neck pain. He does report a neck injury about a year ago. He denies any new injury. He states that he does not like living at the skilled nursing facility and they are "driving him crazy". He denies any suicidal or homicidal ideation ....Obtained more information from the nursing facility. He apparently has been combative and trying to strike at the staff. They were concerned for his safety as well as the safety of the staff members and he was sent here for psychiatric evaluation. He does have underlying Schizoaffective disorder as well as recently diagnosed dementia ..."

Review of the CAPS assessment completed on 6/4/17 at 12:39 PM revealed the assessment was discussed with the psychiatrist on call who recommended inpatient psychiatric hospitalization for stabilization and observation. Hospital #3 was unable to accept patient due to no bed availability.

ED physician #6's note dated 6/5/17 at 5:58 AM documented, " ...We continued to watch [patients name] during my shift. I restarted his home medications especially his blood pressure medicines that he takes in the evening and his nighttime medicines. We will continue to await psychiatric placement closer to home as the patient's daughter decline transport to [Hospital #6] because it was too far ..."

A nurse's note dated 6/5/17 at 6:44 PM documented, "Patient's daughter spoke with [ED physician #9] and does not want to go to [Hospital #6] as it is too far. She wants to wait for [Hospital #3] or nearby facility. Called and informed Transfer Center ..."

A nurse's note dated 6/6/17 at 1:31 PM documented, " ...family not aware they could not go to [Hospital #3] due to insurance. Only option in Davidson Co. is [Hospital #5] unknown when they will have a bed available ..."

Patient #12 was transferred to Hospital #6 on 6/6/17 at 8:45 PM, 58 hours after presenting to the ED for treatment and stabilization of a psychiatric problem.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #12's psychiatric condition while the patient remained in Hospital #1's ED for 58 hours waiting for transfer to an inpatient psychia

Based on review of facility policies, Medical Staff Bylaws, Medical Staff Rules and Regulations, Medical Staff On-Call schedules, medical record review and interviews, the facility failed to provide an appropriate medical screening examination within the capability of Hospital #1's Emergency Department (ED) and ensure patients presenting with psychiatric disorders were assessed by the hospital on call psychiatrists in order to determine if an emergency psychiatric conditions existed for 29 of 31 (Patient's #1, 2, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) patients who presented to the ED seeking treatment for psychiatric conditions.

The findings included:

1. Review of facility policy, "EMTALA - Definitions and General Requirements" last reviewed 3/2013, revealed, " ...On-Call List refers to the list that the hospital is required to maintain that defines those physicians who are on the hospital's medical staff or who have privileges at the hospital ...and are available to provide treatment necessary after the initial examination to stabilized individuals with EMCs ...The purpose of the on-call list is to ensure that the DED [Dedicated Emergency Department] is prospectively aware of which physicians, including specialist and sub-specialist, are available to provide treatment necessary to stabilize individuals with EMCs. Only physicians that are available to physically come to the ER may be included on the on-call list. A physician available via telemedicine does not satisfy the on-call requirements under EMTALA... PROCEDURE... A. General Requirements... 2. If the hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer ...7. Maintain a list physicians on call after the initial examination to provide further examination and/or treatment necessary to stabilize an individual... D. On-Call Obligations: 1. Each hospital that has a Medicare provider participation agreement (including both the transferring and receiving hospitals and specialty hospitals) is required to maintain a list of physician specialists who are available for additional evaluation and stabilizing treatment of individuals with EMCs... 5. On-call physician specialists have a responsibility to provide specialty care services as needed to an individual who comes to the emergency department either as an initial presentation or upon transfer from another facility."

2. Review of the Medical Staff Bylaws adopted and approved December 10, 2015, revealed "... 1.B. PURPOSES AND RESPONSIBILITIES... (12) to monitor and enforce compliance with these Bylaws, the Credentials Policy, the Organization Manual, the Medical Staff Rules and Regulations, other Medical Staff policies, and Hospital policies; and ..."

3. Review of facility Medical Staff Rules and Regulations, approved by the Medical Executive Committee on 6/14/16 and approved by the Board of Trustees on 6/24/16, revealed, " ... IV. EMERGENCY SERVICES/MEDICAL SCREENING/TRANSFERS: A. Emergency Services: 1. Members of the Medical Staff shall accept responsibility for Emergency Service care in accordance with the Medical Staff Bylaws, Emergency Department policies and procedures and applicable state and federal law. Physicians scheduled for on-call coverage are fully accountable for their availability and responsiveness..."

4. Review of the Medical Staff On-Call Logs, for the specialty of psychiatry, from January, 2015, through October, 2017, revealed a Psychiatrist was on-call each day during the time 29 of 31 patients were in the ED.

5. Medical record review revealed Patient #1 presented to the ED at Hospital #1's campus on 7/12/17 at 3:33 PM via ambulance for complaints of "suicidal thoughts and a plan, Pt reports 'my world is coming undone'." The patient was uninsured.

Review of the ED notes for Patient #1 revealed on 7/12/17 at "1651[4:51 PM] CAPS: [Community Assistance Program-Behavioral Health Assessment provided by Psychiatric Registered Nurses or Masters in Psychiatric/counseling, located on-site at Psychiatric Hospital #3] assessment completed and reviewed with [ED physician #1]; patient not medically cleared at this time, BAL [blood alcohol level] pending (UDS [urine drug screen] negative), hx [history] of alcoholism and recent relapse (reports last drink this AM), endorses SI [suicidal ideation] (no plan), hx of depression (not taking antidepressant), no HI [homicidal ideation], no symptoms of psychosis ...7/12/17 at 1725 [5:25 PM] Addendum: Pt medically cleared, call Ctr [center] notified [name] for MCRT [Mobile Crisis Response Team] tracking, reviewed clearance form, fax to MCRT ...7/13/17 at 0441 [4:41 AM], discussed with [name] at [Hospital #2]. Patient will be 61 on the waiting list ...7/13/17 at 0614 [6:14 AM] Pt reports 'feel like I'm withdrawing' ...will give meds per order ...7/13/17 at 2306 [11:06 PM] ...[Hospital #2] said the patient's waiting list number has not changed ..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #1 on 7/12/17 at 5:50 PM which documented, "...has a mental illness or serious emotional disturbance ...active symptoms of psychiatric disorder as noted: suicidal ideation with a plan of jumping off a bridge ...AND, poses an immediate substantial likelihood of serious harm ...In my opinion, the patient is at continued risk of self-harm if not placed under involuntary commitment ...Condition is likely to deteriorate further without treatment ..."

Review of ED physician #1's note dated 7/12/17 at 5:55 PM revealed the ED physician had initiated a Medical Screening Examination (MSE) on Patient #1 which included a History of Present Illness (HPI), a medical and psychiatric history, review of systems (ROS) and physical exam. ED Physician #1 documented, "49-year-old male with a past medical history of alcohol abuse and depression who presents complaining of suicidal ideation. The patient states for the past 4 days he's been having suicidal thoughts of jumping off a bridge ..."

The patient's care was transferred to ED Physician #2 on 7/13/17 at 4:19 AM. ED physician #2's note documented the patient was awaiting a mobile crisis evaluation.

ED Physician #3's note dated 7/13/17 at 7:32 AM documented, "awaiting placement at [name of Hospital #2]"

ED Physician #1's note dated 7/14/17 at 4:17 PM documented the patient's care had been transferred to ED physician #4.

ED Physician #4's note dated 7/15/17 at 12:10 AM documented, "This is a 50-year-old male. He is in the emergency department pending psychiatric placement as he [has] been evaluated by mobile crisis. He has not had any acute episodes during my management of the patient's care."

ED Physician #5's note dated 7/15/17 at 6:39 AM documented, "Patient has been stable throughout my ED shift. Patient is still desiring inpatient placement. Care will be passed off oncoming providers ..."

ED Physician #4's note dated 7/16/17 at 12:32 AM documented Patient #1 was stable.

ED Physician #6's note dated 7/16/17 at 5:49 PM documented, "Patient has been stable in the emergency department. He was accepted at [named hospital #2] ..."

Patient #1 was transferred to Hospital #2 on 7/16/17 at 7:59 PM, 100 hours after presenting to the Hospital #1's ED seeking treatment and stabilization for a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment of Patient #1's psychiatric condition while the patient remained in Hospital #1's ED for 100 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why Patient #1 was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

6. Medical record review revealed Patient #2 presented to the ED at Hospital #1's campus on 7/13/17 at 12:47 AM via ambulance with chief complaint of, "57-year-old gentleman who present to emergency room with complaints of lower behavior. States he's been in Afghanistan until a week ago were [where] he was the chief weapons officer of a flight of stealth bombers and that he is in Nashville to receive the Congressional Medal of Honor at Centennial Park. Patient also complains of rectal bleeding for 5 days. He was seen at [Hospital #4] complaining of rectal bleeding approximately 12 hours ago. He had negative fecal occult blood and normal H&H [hemoglobin hematocrit] ... Patient missed alcohol. He says "I'm really messed up." But he denies suicidal or homicidal ideation. It is very difficult to obtain a street [history] from the patient secondary to fact that his is delusional and tangential [erratic] but he denies any pain at this time ..." The patient had out of state Medicaid insurance.

Review of ED Physician #2's note date 7/13/17 at 12:59 AM revealed a MSE which included a History of Present Illness (HPI), a medical and psychiatric history, review of systems (ROS) and physical exam was initiated. A Certificate of Need for Emergency Involuntary Admission (6404) was signed at 1:00 AM. ED physician #2 documented, "Patient presents with evidence of mania and delusions. I believe he is incapable of taking care of himself and is likely come significant harm if not institutionalized for stabilization. He was placed under involuntary hold 6404 and will require evaluation by mobile crisis ..."

Review of the CAPS evaluation performed on 7/13/17 at 3:53 AM revealed the evaluator discussed the patient's status with Hospital #1's on-call Psychiatrist. The hospital's on-call Psychiatrist stated to have Mobile Crisis evaluate the patient for possible treatment. There was no documentation the hospital's on-call Psychiatrist evaluated the patient.

Review of the Mobile Crisis Response Team notes dated 7/13/17 at 5:20 AM revealed Mobile Crisis referred the patient to be admitted for inpatient psychiatric treatment due to psychosis. The ED Notes documented the patient was placed on the waiting list to be admitted to Hospital #2 on 7/13/17.

ED physician #4's note dated 7/15/17 at 12:04 AM documented, "Patient is agitated here numerous times and requires multiple redirection. Patient still psychotic saying he has a G5 jet ready to pick up the Surgeon General to evaluate him. The patient was given Geodon [Antipsychotic medication for treatment of Schizophrenia and Bi-Polar disorder] and Ativan [Benzodiazepine/sedative for treatment of anxiety] as needed for his agitation and psychosis ..."

ED Physician #5's note dated 7/15/17 at 6:37 AM documented, "Patient has been observed throughout the emergency department stay during my shift. He has been medically stable. He is still acutely psychotic and will need placement ..."

ED Physician #7's note dated 7/16/17 at 4:23 PM documented, "Reassessed this patient during my shift multiple times. He is tried to escape from the ER multiple times, including an episode where he tried to get inside of an ambulance and drive off he was pulled from the ambulance, secondary to this and combativeness with staff in general inability to conform to safety precautions we have placed him in seclusion, think this is for the patient's safety as well as everyone else in the emergency department. I reassessed him 4 hours later and will continue disorder [this order] ..."

ED Physician #6's note dated 7/17/17 at 1:46 AM documented, " ...He placed the patient on an involuntary seclusion order at noon because the patient attempted to lift [leave] emergency department and was creating a risk to himself and staff. I evaluated him shortly after 4 PM and he was redirectable and cooperative and we withdrew the seclusion order. He was given some IM [Intramuscular] Geodon and we continued to monitor him in the emergency department until care was passed over to [name of ED physician #2] for continued management until he is transferred to [Hospital #2]."

Patient #2 was transferred to Hospital #2 on 7/17/17 at 9:45 AM, 105 hours after presenting to the Hospital #1's ED for seeking treatment and stabilization for a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment of Patient #2 or stabilization treatment for Patient #2's psychiatric condition while the patient remained in Hospital #1's ED for 105 hours awaiting to an inpatient psychiatric facility.

There was no documentation why Patient #2 was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

7. Medical record review revealed Patient #4 presented to the ED at Hospital #1's campus on 7/13/17 at 1:34 AM via ambulance with chief complaint of being found at the bus station bleeding from cutting his arm with a box cutter.
The patient was uninsured.

Review of ED Physician #2's note dated 7/13/17 at 1:36 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. Review of ED physician #2's note dated 7/13/17 at 1:36 AM revealed the patient was a , "36-year-old gentleman presents to emergency department after reportedly stabbing himself in the left thumb with a box cutter. Patient reports a long-standing psychiatric history for which he has been followed in Jackson, TN. He states that he has 'messed up to the head' and 'That what is going in this world is not real.' Patient is very agitated and uncooperative and is unwilling to provide further history ..."

Review of Nurses Behavioral Health Related notes dated 7/13/17 at 1:51 PM revealed, "Pt continues to be agitated. Security notified of inappropriate action ...7/14/17 at 5:00 AM ...Pt was pacing from bed to doorway for several minutes ..."

The CAPS evaluator note dated 7/13/17 at 5:04 AM documented, "This patient will need to be evaluated by the psychiatrist prior to any discharge to an unsupervised setting. Notified [name] at Behavioral Health Call Center of need for Mobile Crisis evaluation. Medical clearance sent ..."

A nurses note dated 7/13/17 at 7:13 AM documented, "Mobile Crisis recommends inpatient treatment. Mobile Crisis spoke with Transfer Center, pt referral to [Hospital #2] ..."

A nurses note dated 7/13/17 at 6:56 PM documented the patient had been approved for transfer by the attending Physician at Hospital #2 and was currently #43 on the wait list for a bed.

Patient #4 was transferred to Hospital #2 on 7/17/17 at 8:10 AM, 102 hours after presenting to Hospital #1's ED for treatment and stabilization for a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment of Patient #4's psychiatric condition when the patient remained in Hospital #1's ED for 102 hours awaiting for to an inpatient psychiatric facility.

There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit for inpatient treatment.

8. Medical record review revealed Patient #5 presented to the ED at Hospital #1's campus on 7/13/17 at 11:15 PM via ambulance with chief complaint of Suicidal Ideation, wanting to jump off a bridge and hurt himself. The patient was uninsured.

Review of ED Physician#15's note dated 7/13/17 at 11:23 PM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician#15's documented, "37-year-old male with history of Schizoaffective disorder here tonight for depression and suicidal ideation. Patient was just seen in a hospital in Georgia yesterday for similar symptomatology. However patient was not having any thoughts of suicidal ideation. He allegedly bought a bus [ticket] to come here. Suicidal ideation began on his travel here. Patient plans on jumping off a bridge to hurt himself. Because of his suicidal thoughts patient contacted EMS [Emergency Medical Services] to bring him here ..."

A CAPS intake was initiated on 7/13/17 at 11:25 PM. On 7/14/17 at 6:00 AM the patient was placed on the waiting list to be transferred to Hospital #2. He was #61 on the waiting list.

Patient #5 was transferred to Hospital #2 on 7/18/17 at 11:10 AM, 107 hours after presenting to Hospital #1's ED for treatment and stabilization of a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #5's psychiatric condition while the patient remained in Hospital #1's ED for 107 hours awaiting for transfer to an inpatient psychiatric facility.

There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

9. Medical record review revealed Patient #6 presented to the ED at Hospital #1's campus on 7/16/17 at 7:47 AM via ambulance for complaints of " ...confused, disoriented, found walking through traffic on 440 ..." The patient was uninsured.

Medical record review of ED Physician #7's note dated 7/16/17 at 8:08 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED physician #7 on 7/16/17 at 11:00 AM documented, "Reported history of behaviors clinically indicative of a psychiatric disorder, prior history of psychiatric hospitalizations, substance abuse, behavior that puts patient at risk for self-harm, appears delusional, feel unsafe to leave ...Condition is likely to deteriorate further without treatment ..."

Review of the Behavioral Health CAPS Assessment performed on 7/16/17 at 10:35 AM revealed, "...recommendations for the patient's disposition was discussed with provider (Hospital #1's on-call Psychiatrist #1) and the on-call Psychiatrist, "referred to Call Center/MCRT for disposition..."

The Emergency Department notes dated 7/16/17 at 11:16 AM documented, "Patient seen by CAPS, she presented bizarre but denied suicidal, homicidal at the time of assessment. Patient was not able to give demographic, social or any pertinent information ..."

Review of the ED Physician #6's notes dated 7/17/17 at 7:51 PM revealed, "Patient was cooperative throughout my stay except at one point she tried to leave the ED she was redirected back to her room by security and I gave her oral Haldol [an antipsychotic] and Valium [an anxiolytic and sedative used to treat anxiety, muscle spasms and seizures] which she took and was cooperative from that point on ..."

Patient #6 was transferred to Hospital #2 on 7/20/17 at 3:48 AM , 91 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #6's psychiatric condition while the patient remained in Hospital #1's ED for 91 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient psychiatric treatment.

10. Medical record review revealed Patient #7 presented to the ED at Hospital #1's campus on 10/11/17 at 3:06 PM via walk in with chief complaint of Suicidal Ideation and wanting detox (detoxification). The patient was uninsured.

Medical record review of ED Nurse Practitioner (NP) #2's note dated 10/11/17 at 3:15 PM revealed Patient #7 was provided a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. NP #2's note dated 10/11/17 at 3:15 PM documented, "Patient to ER for detox. Reports that he has been regularly using IV [intravenous] heroin and opiates. States last use was approximately 2-3 days ago and last use of opiates was approximately 2 days ago. Reports that he is tired of doing drugs and he's been having suicidal ideation. Wants help stopping. Does not have a plan. Denies any HI..."

Review of the CAPS behavior health assessment dated 10/11/17 at 4:39 PM revealed the patient was not referred to the psychiatrist on-call.

Review of the Emergency Room Notes dated 10/11/17 at 5:11 PM documented, "[Hospital #3] does not have a detox bed at this time. Pt will be given to the Call Center to call Mobile Crisis ..." The patient was seen by Mobile Crisis on 10/11/17 at 8:15 PM with recommendations for inpatient further evaluation and treatment due to suicidal ideation.

ED Physician #8 dated 10/13/17 at 5:00 AM documented, "...received sign out from [ED physician #5]. 6404 [Certificate of Need for Emergency Involuntary Admission] completed. Patient is medically cleared ...Patient is awaiting transfer to [Hospital #2] for further psychiatric care ..."

ED Physician #6's note dated 10/14/17 at 6:28 AM documented, "Patient has been fairly stable throughout my shift. He was given Ativan [a sedative used to relieve anxiety] by mouth but continued to pace and said that he was unable to sleep. He asked for 5 or 6 Tylenol PMs [Tylenol containing Benadryl, an antihistamine] which were not given to him however I did give him 50 mg [milligrams] of hydroxyzine [antihistamine ] which helped him to relax through the rest of my shift. He is still #40 on the list for [Hospital #2] and he has arty [already] been here for 111 hours ..."

ED Physician #4's note dated 10/16/17 at 4:09 AM documented, "The patient became agitated during his ER stay. He did require 10 mg of Geodon intramuscularly for his agitation. The patient is now stable ..."

Patient #7 was transferred to Hospital #2 on 10/18/17 at 7:59 AM, 160 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment of Patient #7 or stabilizing treatment for Patient #7's psychiatric condition while the patient remained in Hospital #1's ED for 160 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

11. Medical record review revealed Patient #8 presented to the ED at Hospital #1's campus on 8/24/17 at 9:17 PM via ambulance for complaints of decreased mental alertness. The patient had TN Care/Blue Care insurance (Medicaid).

Review of ED physician #2's note dated 8/24/17 at 7:19 PM revealed a MSE which included a HPI, a medical and psychiatric history, ROS and physical exam was initiated. ED Physician #2's note on 8/24/17 at 7:19 PM documented, "28-year-old female who was just discharged earlier this afternoon from [hospital #1] to a rehabilitation facility for benzodiazepine and opioid dependence presents to the emergency room this evening via EMS with chief complaint of unwilling to speak not acting right. Was initially admitted to the hospital after a questionable near drowning thought to be secondary to a seizure secondary to benzodiazepine withdrawal ...She was discharged earlier this afternoon and went to the [name of outpatient drug rehab facility] for her drug dependence however after a few hours there she started acting bizarrely wandering the halls and then reached the point where when would no long respond or talk..."

Review of the Emergency Department Notes dated 8/25/17 at 4:45 AM revealed, "...CAPS CONSULT WAS COMPLETED, DISPOSITION DISCUSSED WITH [ED physician #2]. HE WOULD WRITE 6401 [6404]... DUE TO PT'S INSURANCE PT REQUIRES A CALL CENTER REFERRAL FOR MCRT ASSESSMENT..."

ED physician #2 dated 8/25/17 at 5:23 AM documented, "Patient is once again refusing to speak or interact. She will require evaluation by mobile crisis."

Review of the CAPS assessment dated 8/25/17 at 5:38 AM revealed the psychiatrist recommended Electroconvulsive Therapy (ECT). An attempt to assess the patient via Telemed was unsuccessful due to the patient's refusal to communicate.

Patient #8 was discharged to Hospital #8 on 8/27/17 at 12:14 PM.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment of Patient #8's psychiatric condition while the patient remained in Hospital #1's ED for 62 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

12. Medical record review revealed Patient #10 presented to the ED at Hospital #1's campus on 1/5/17 at 10:21 AM via ambulance with chief complaint of psychosis. The patient was discharged from Hospital #3 on 1/4/17 and returned to group home. The group home sent him to the ED on 1/5/17 due to talking to himself, confusion and incorrect responses. The patient was uninsured.

Medical record review of ED NP #2's note dated 1/5/17 at 10:47 AM revealed a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam was initiated. NP #2's note documented, "...Patient to ER for CAPS eval [evaluation]. Was dcd [discharged] home from [Hospital #3] yesterday and sent to group home. Group home sends patient back this AM for eval due to Psychosis. Patient talking to himself and confused, incorrect responses to questioning. Appears to be responding to internal stimuli. Patient denies SI or HI ...Patient follows directions and is pleasant, but talking to himself and giving bizarre answers to questions..."

Review of a nurse's note dated 1/5/17 at 10:43 AM revealed, " ...Pt [patient] sent from [Named group home] for psych [psychiatric] eval [evaluation]...Pt was d.c. [discharged] home from [Hospital #3] yesterday and sent to group home...pt has extensive psych history ...pt is dillusional [delusional], and talking to person not seen..." Further review of the nurse's notes revealed, "...[1/5/17 at 11:09 AM] ...security notified as patient is confrontational and passive aggressive...[1/6/17 at 8:32 PM]...he was talking to himself. When I asked who he was speaking to, he stated that he was speaking to his ex-wife ...[1/7/17 at 12:14 AM]...pt is awake talking to himself ..."

A CAPS assessment was initiated on 1/5/17 at 11:35 AM. CAPS recommendation was to readmit for psychiatric care. CAPS documented that there were no beds available at Hospital #3 and the call center would be referred to find placement. Further record review revealed the patient was on the "pending board" for Hospital #3 due to full capacity as of 1/7/17. The patient had also been referred to Hospital #2 and was on the waiting list.

A Certificate of Need for Emergency Involuntary Admission (6404) was signed on 1/9/17 10:31 AM.

Patient #10 was transferred to Hospital #2 on 1/9/17 at 1:32 PM, 99 hours after presenting to the ED for treatment and stabilization of a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #10's psychiatric condition while the patient remained in Hospital #1's ED for 99 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

13. Medical record review revealed Patient #11 presented to the ED at Hospital #1's campus on 5/30/17/17 at 12:32 AM via ambulance with chief complaint of hallucinations. The patient had TN Care/Blue Cross insurance (Medicaid).

Medical record review of ED physician #2's note dated 5/30/17 at 1:05 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician #2's note dated 5/30/17 at 1:05 AM documented, "21-year-old female with a history of schizophrenia and bipolar disorder and recent hospitalization who presents to the emergency room complaining of increasing hallucinations that are distressing to her. She denies suicidal ideation. No homicidal ideation. She states that she has a lot of stressors at home and has a stressful relationship with her mother who is her conservator ..."

Review of the CAPS assessment performed on 5/30/17 at 1:05 AM revealed recommendations for patient disposition was discussed with the on-call psychiatrist but there was no documentation of the psychiatrist recommendations.

A physician's order, from ED physician #2, dated 5/30/17 at 5:45 AM, documented to give Depakote 500 milligrams (mg) by mouth (PO) daily (Anti-convulsant used to treat seizures and Bi-Polar disease), Haloperidol 5 mg PO twice a day (Antipsychotic), Cogentin 1 mg PO twice a day (Anti-tremor medication used to treat side effects of other drugs). Documentation revealed Patient #11 received Haloperidol 5 mg, Depakote 500 mg and Cogentin 1 mg at 6:20 AM and Haloperidol 5 mg and Cogentin 1 mg at 9:43 PM. There was no documentation Patient #11 received any medications prior to discharge from Hospital #1's ED on 6/3/17.

Review of the Emergency Notes revealed the patient was seen by Mobile Crisis on 5/30/17 at 10:00 AM.

ED physician #5's note dated 6/2/17 at 6:54 PM documented, "Patient has been medically stable throughout his [her] emergency department stay. He [She] has been accepted to [name of Hospital #2] at this date and time ..."

Patient #11 was transferred to Hospital #2 on 6/3/17 at 4:24 AM, 100 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #11's psychiatric condition while the patient remained in Hospital #1's ED for 100 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

14. Medical record review revealed Patient #12 presented to the ED at Hospital #1's campus on 6/4/17 at 10:20 AM via ambulance with chief complaint of nursing home requesting a psychiatric evaluation and neck pain. The patient had Medicare Parts A & B insurance.

Medical record review of ED physician #9's note dated 6/4/17 at 11:12 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician #9's note dated 6/4/17 at 11:12 AM documented, "This is a 74-year-old male present from a skilled nursing facility. Per the facility's report he overnight called EMS many times due to having some neck pain. He does report a neck injury about a year ago. He denies any new injury. He states that he does not like living at the skilled nursing facility and they are "driving him crazy". He denies any suicidal or homicidal ideation ....Obtained more information from the nursing facility. He apparently has been combative and trying to strike at the staff. They were concerned for his safety as well as the safety of the staff members and he was sent here for psychiatric evaluation. He does have underlying Schizoaffective disorder as well as recently diagnosed dementia ..."

Review of the CAPS assessment completed on 6/4/17 at 12:39 PM revealed the assessment was discussed with the psychiatrist on call who recommended inpatient psychiatric hospitalization for stabilization and observation. Hospital #3 was unable to accept patient due to no bed availability.

ED physician #6's note dated 6/5/17 at 5:58 AM documented, " ...We continued to watch [patients name] during my shift. I restarted his home medications especially his blood pressure medicines that he takes in the evening and his nighttime medicines. We will continue to await psychiatric placement closer to home as the patient's daughter decline transport to [Hospital #6] because it was too far ..."

A nurse's note dated 6/5/17 at 6:44 PM documented, "Patient's daughter spoke with [ED physician #9] and does not want to go to [Hospital #6] as it is too far. She wants to wait for [Hospital #3] or nearby facility. Called and informed Transfer Center ..."

A nurse's note dated 6/6/17 at 1:31 PM documented, " ...family not aware they could not go to [Hospital #3] due to insurance. Only option in Davidson Co. is [Hospital #5] unknown when they will have a bed available ..."

Patient #12 was transferred to Hospital #6 on 6/6/17 at 8:45 PM, 58 hours after presenting to the ED for treatment and stabilization of a psychiatric problem.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #12's psychiatric condition while the patient remained in Hospital #1's ED for 58 hours waiting for placement or transfer to an inpatient psychiatric facility.

The

Based on facility policies, Medical Staff Bylaws, Medical Staff Rules and Regulations, Medical Staff on-Call schedules, medical record reviews and interviews, the facility failed to ensure on-call psychiatrists performed an adequate assessment to determine the necessary treatment to stabilize signs/symptoms of psychiatric conditions for 28 of 31 (Patient's #1, 2, 4, 5, 6, 7, 8, 10,11, 12, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25, 26 and 27) patients who presented to the Emergency Department (ED) seeking treatment.

The findings included:

1. Review of facility policy, "EMTALA - Definitions and General Requirements" last reviewed 03/2013, revealed, " ...On-Call List refers to the list that the hospital is required to maintain that defines those physicians who are on the hospital's medical staff or who have privileges at the hospital ...and are available to provide treatment necessary after the initial examination to stabilized individuals with EMCs [Emergency Medical Condition] ... PROCEDURE ...A. General Requirements...2. If the hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer ...7. Maintain a list physicians on call after the initial examination to provide further examination and/or treatment necessary to stabilize an individual ...D. On-Call Obligations 1. Each hospital that has a Medicare provider participation agreement (including both the transferring and receiving hospitals and specialty hospitals) is required to maintain a list of physician specialists who are available for additional evaluation and stabilizing treatment of individuals with EMCs ...5. On-call physician specialists have a responsibility to provide specialty care services as needed to an individual who comes to the emergency department either as an initial presentation or upon transfer from another facility ..."

2. Review of the Medical Staff Bylaws adopted and approved December 10, 2015, revealed "...1.B. PURPOSES AND RESPONSIBILITIES...(12) to monitor and enforce compliance with these Bylaws, the Credentials Policy, the Organization Manual, the Medical Staff Rules and Regulations, other Medical Staff policies, and Hospital policies; and..."

3. Review of facility Medical Staff Rules and Regulations, approved by the Medical Executive Committee on 6/14/16 and the Board of Trustees on 6/24/16 revealed, "... EMERGENCY SERVICES/MEDICAL SCREENING/TRANSFERS: A. Emergency Services:
1. Members of the Medical Staff shall accept responsibility for Emergency Service care in accordance with the Medical Staff Bylaws, Emergency Department policies and procedures and applicable state and federal law. Physicians scheduled for on-call coverage are fully accountable for their availability and responsiveness ..."

4. Review of Hospital #1's Medical Staff on-call Logs, for the specialty of psychiatry, revealed a Psychiatrist on-call each day for the months of January 2015 through October 2017 when 28 of 31 patients were in the ED.

5. Medical record review revealed Patient #1 presented to the ED at Hospital #1's campus on 7/12/17 at 3:33 PM via ambulance for complaints of "suicidal thoughts and a plan, Pt [patient] reports 'my world is coming undone.'" The patient was uninsured.

Review of the ED notes for Patient #1 revealed on 7/12/17 at "1651[4:51 PM] CAPS: [Community Assistance Program-Behavioral Health Assessment provided by Psychiatric Registered Nurses or Masters in Psychiatric/counseling, located on-site at Psychiatric Hospital #3] assessment completed and reviewed with [ED physician #1]; patient not medically cleared at this time, BAL [blood alcohol level] pending (UDS [urine drug screen] negative), hx [history] of alcoholism and recent relapse (reports last drink this AM), endorses SI [suicidal ideation] (no plan), hx of depression (not taking antidepressant), no HI [homicidal ideation], no symptoms of psychosis ...7/12/17 at 1725 [5:25 PM] Addendum: Pt medically cleared, call Ctr [center] notified [name] for MCRT [Mobile Crisis Response Team] tracking, reviewed clearance form, fax to MCRT ...7/13/17 at 0441 [4:41 AM], discussed with [name] at [Hospital #2]. Patient will be 61 on the waiting list ...7/13/17 at 0614 [6:14 AM] Pt reports 'feel like I'm withdrawing' ...will give meds per order ...7/13/17 at 2306 [11:06 PM] ...[Hospital #2] said the patient's waiting list number has not changed ..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #1 on 7/12/17 at 5:50 PM which documented, "...has a mental illness or serious emotional disturbance ...active symptoms of psychiatric disorder as noted: suicidal ideation with a plan of jumping off a bridge ...AND, poses an immediate substantial likelihood of serious harm ...In my opinion, the patient is at continued risk of self-harm if not placed under involuntary commitment ...Condition is likely to deteriorate further without treatment ..."

Review of ED physician #1's note dated 7/12/17 at 5:55 PM revealed the ED physician had initiated a Medical Screening Examination (MSE) on Patient #1 which included a History of Present Illness (HPI), a medical and psychiatric history, review of systems (ROS) and physical exam. ED Physician #1 documented, "49-year-old male with a past medical history of alcohol abuse and depression who presents complaining of suicidal ideation. The patient states for the past 4 days he's been having suicidal thoughts of jumping off a bridge ..."

The patient's care was transferred to ED Physician #2 on 7/13/17 at 4:19 AM. ED physician #2's note documented the patient was awaiting a mobile crisis evaluation.

ED Physician #3's note dated 7/13/17 at 7:32 AM documented, "awaiting placement at [name of Hospital #2]"

ED Physician #1's note dated 7/14/17 at 4:17 PM documented the patient's care had been transferred to ED physician #4.

ED Physician #4's note dated 7/15/17 at 12:10 AM documented, "This is a 50-year-old male. He is in the emergency department pending psychiatric placement as he [has] been evaluated by mobile crisis. He has not had any acute episodes during my management of the patient's care."

ED Physician #5's note dated 7/15/17 at 6:39 AM documented, "Patient has been stable throughout my ED shift. Patient is still desiring inpatient placement. Care will be passed off oncoming providers ..."

ED Physician #4's note dated 7/16/17 at 12:32 AM documented Patient #1 was stable.

ED Physician #6's note dated 7/16/17 at 5:49 PM documented, "Patient has been stable in the emergency department. He was accepted at [named hospital #2] ..."

Patient #1 was transferred to Hospital #2 on 7/16/17 at 7:59 PM, 100 hours after presenting to the Hospital #1's ED seeking treatment and stabilization for a psychiatric condition.

There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #1 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #1 was in Hospital #1's ED 100 hours awaiting placement/transfer to an inpatient psychiatric treatment facility.

6. Medical record review revealed Patient #2 presented to the ED at Hospital #1's campus on 7/13/17 at 12:47 AM via ambulance with chief complaint of, "57-year-old gentleman who present to emergency room with complaints of lower behavior. States he's been in Afghanistan until a week ago were [where] he was the chief weapons officer of a flight of stealth bombers and that he is in Nashville to receive the Congressional Medal of Honor at Centennial Park. Patient also complains of rectal bleeding for 5 days. He was seen at [Hospital #4] complaining of rectal bleeding approximately 12 hours ago. He had negative fecal occult blood and normal H&H [hemoglobin hematocrit] ... Patient missed alcohol. He says "I'm really messed up." But he denies suicidal or homicidal ideation. It is very difficult to obtain a street [history] from the patient secondary to fact that his is delusional and tangential [erratic] but he denies any pain at this time ..." The patient had out of state Medicaid insurance.

Review of ED Physician #2's note date 7/13/17 at 12:59 AM revealed a MSE which included a History of Present Illness (HPI), a medical and psychiatric history, review of systems (ROS) and physical exam was initiated. A Certificate of Need for Emergency Involuntary Admission (6404) was signed at 1:00 AM. ED physician #2 documented, "Patient presents with evidence of mania and delusions. I believe he is incapable of taking care of himself and is likely come significant harm if not institutionalized for stabilization. He was placed under involuntary hold 6404 and will require evaluation by mobile crisis ..."

Review of the CAPS evaluation performed on 7/13/17 at 3:53 AM revealed the evaluator discussed the patient's status with Hospital #1's on-call Psychiatrist. The hospital's on-call Psychiatrist stated to have Mobile Crisis evaluate the patient for possible treatment. There was no documentation the hospital's on-call Psychiatrist evaluated the patient.

Review of the Mobile Crisis Response Team notes dated 7/13/17 at 5:20 AM revealed Mobile Crisis referred the patient to be admitted for inpatient psychiatric treatment due to psychosis. The ED Notes documented the patient was placed on the waiting list to be admitted to Hospital #2 on 7/13/17.

ED physician #4's note dated 7/15/17 at 12:04 AM documented, "Patient is agitated here numerous times and requires multiple redirection. Patient still psychotic saying he has a G5 jet ready to pick up the Surgeon General to evaluate him. The patient was given Geodon [Antipsychotic medication for treatment of Schizophrenia and Bi-Polar disorder] and Ativan [Benzodiazepine/sedative for treatment of anxiety] as needed for his agitation and psychosis ..."

ED Physician #5's note dated 7/15/17 at 6:37 AM documented, "Patient has been observed throughout the emergency department stay during my shift. He has been medically stable. He is still acutely psychotic and will need placement ..."

ED Physician #7's note dated 7/16/17 at 4:23 PM documented, "Reassessed this patient during my shift multiple times. He is tried to escape from the ER multiple times, including an episode where he tried to get inside of an ambulance and drive off he was pulled from the ambulance, secondary to this and combativeness with staff in general inability to conform to safety precautions we have placed him in seclusion, think this is for the patient's safety as well as everyone else in the emergency department. I reassessed him 4 hours later and will continue disorder [this order] ..."

ED Physician #6's note dated 7/17/17 at 1:46 AM documented, " ...He placed the patient on an involuntary seclusion order at noon because the patient attempted to lift [leave] emergency department and was creating a risk to himself and staff. I evaluated him shortly after 4 PM and he was redirectable and cooperative and we withdrew the seclusion order. He was given some IM [Intramuscular] Geodon and we continued to monitor him in the emergency department until care was passed over to [name of ED physician #2] for continued management until he is transferred to [Hospital #2]."

Patient #2 was transferred to Hospital #2 on 7/17/17 at 9:45 AM, 105 hours after presenting to the Hospital #1's ED for seeking treatment and stabilization for a psychiatric condition.

There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #2 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #2 was in Hospital #1's ED 105 hours awaiting placement/transfer to an inpatient psychiatric treatment facility.

7. Medical record review revealed Patient #4 presented to the ED at Hospital #1's campus on 7/13/17 at 1:34 AM via ambulance with chief complaint of being found at the bus station bleeding from cutting his arm with a box cutter.
The patient was uninsured.

Review of ED Physician #2's note dated 7/13/17 at 1:36 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. Review of ED physician #2's note dated 7/13/17 at 1:36 AM revealed the patient was a , "36-year-old gentleman presents to emergency department after reportedly stabbing himself in the left thumb with a box cutter. Patient reports a long-standing psychiatric history for which he has been followed in Jackson, TN. He states that he has 'messed up to the head' and 'That what is going in this world is not real.' Patient is very agitated and uncooperative and is unwilling to provide further history ..."

Review of Nurses Behavioral Health Related notes dated 7/13/17 at 1:51 PM revealed, "Pt continues to be agitated. Security notified of inappropriate action ...7/14/17 at 5:00 AM ...Pt was pacing from bed to doorway for several minutes ..."

The CAPS evaluator note dated 7/13/17 at 5:04 AM documented, "This patient will need to be evaluated by the psychiatrist prior to any discharge to an unsupervised setting. Notified [name] at Behavioral Health Call Center of need for Mobile Crisis evaluation. Medical clearance sent ..."

A nurses note dated 7/13/17 at 7:13 AM documented, "Mobile Crisis recommends inpatient treatment. Mobile Crisis spoke with Transfer Center, pt referral to [Hospital #2] ..."

A nurses note dated 7/13/17 at 6:56 PM documented the patient had been approved for transfer by the attending Physician at Hospital #2 and was currently #43 on the wait list for a bed.

Patient #4 was transferred to Hospital #2 on 7/17/17 at 8:10 AM, 102 hours after presenting to Hospital #1's ED for treatment and stabilization for a psychiatric condition.

There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #4 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #4 was in Hospital #1's ED 102 hours awaiting placement/transfer to an inpatient psychiatric treatment facility.

8. Medical record review revealed Patient #5 presented to the ED at Hospital #1's campus on 7/13/17 at 11:15 PM via ambulance with chief complaint of Suicidal Ideation, wanting to jump off a bridge and hurt himself. The patient was uninsured.

Review of ED Physician#15's note dated 7/13/17 at 11:23 PM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician#15's documented, "37-year-old male with history of Schizoaffective disorder here tonight for depression and suicidal ideation. Patient was just seen in a hospital in Georgia yesterday for similar symptomatology. However patient was not having any thoughts of suicidal ideation. He allegedly bought a bus [ticket] to come here. Suicidal ideation began on his travel here. Patient plans on jumping off a bridge to hurt himself. Because of his suicidal thoughts patient contacted EMS [Emergency Medical Services] to bring him here ..."

A CAPS intake was initiated on 7/13/17 at 11:25 PM. On 7/14/17 at 6:00 AM the patient was placed on the waiting list to be transferred to Hospital #2. He was #61 on the waiting list.

Patient #5 was transferred to Hospital #2 on 7/18/17 at 11:10 AM, 107 hours after presenting to Hospital #1's ED for treatment and stabilization of a psychiatric condition.

There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #5 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #5 was in Hospital #1's ED 107 hours awaiting placement/transfer to an inpatient psychiatric treatment facility.

9. Medical record review revealed Patient #6 presented to the ED at Hospital #1's campus on 7/16/17 at 7:47 AM via ambulance for complaints of "...confused, disoriented, found walking through traffic on 440 ..." The patient was uninsured.

Medical record review of ED Physician #7's note dated 7/16/17 at 8:08 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED physician #7 on 7/16/17 at 11:00 AM documented, "Reported history of behaviors clinically indicative of a psychiatric disorder, prior history of psychiatric hospitalizations, substance abuse, behavior that puts patient at risk for self-harm, appears delusional, feel unsafe to leave ...Condition is likely to deteriorate further without treatment ..."

Review of the Behavioral Health CAPS Assessment performed on 7/16/17 at 10:35 AM revealed, "...recommendations for the patient's disposition was discussed with provider (Hospital #1's on-call Psychiatrist #1) and the on-call Psychiatrist, "referred to Call Center/MCRT for disposition..."

The Emergency Department notes dated 7/16/17 at 11:16 AM documented, "Patient seen by CAPS, she presented bizarre but denied suicidal, homicidal at the time of assessment. Patient was not able to give demographic, social or any pertinent information ..."

Review of the ED Physician #6's notes dated 7/17/17 at 7:51 PM revealed, "Patient was cooperative throughout my stay except at one point she tried to leave the ED she was redirected back to her room by security and I gave her oral Haldol [an antipsychotic] and Valium [an anxiolytic and sedative used to treat anxiety, muscle spasms and seizures] which she took and was cooperative from that point on ..."

Patient #6 was transferred to Hospital #2 on 7/20/17 at 3:48 AM , 91 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition.

There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #6 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #6 was in Hospital #1's ED 91 hours awaiting placement/transfer to an inpatient psychiatric treatment facility.

10. Medical record review revealed Patient #7 presented to the ED at Hospital #1's campus on 10/11/17 at 3:06 PM via walk in with chief complaint of Suicidal Ideation and wanting detox (detoxification). The patient was uninsured.

Medical record review of ED Nurse Practitioner (NP) #2's note dated 10/11/17 at 3:15 PM revealed Patient #7 was provided a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. NP #2's note dated 10/11/17 at 3:15 PM documented, "Patient to ER for detox. Reports that he has been regularly using IV [intravenous] heroin and opiates. States last use was approximately 2-3 days ago and last use of opiates was approximately 2 days ago. Reports that he is tired of doing drugs and he's been having suicidal ideation. Wants help stopping. Does not have a plan. Denies any HI..."

Review of the CAPS behavior health assessment dated 10/11/17 at 4:39 PM revealed the patient was not referred to the psychiatrist on-call.

Review of the Emergency Room Notes dated 10/11/17 at 5:11 PM documented, "[Hospital #3] does not have a detox bed at this time. Pt will be given to the Call Center to call Mobile Crisis ..." The patient was seen by Mobile Crisis on 10/11/17 at 8:15 PM with recommendations for inpatient further evaluation and treatment due to suicidal ideation.

ED Physician #8 dated 10/13/17 at 5:00 AM documented, "...received sign out from [ED physician #5]. 6404 [Certificate of Need for Emergency Involuntary Admission] completed. Patient is medically cleared ...Patient is awaiting transfer to [Hospital #2] for further psychiatric care ..."

ED Physician #6's note dated 10/14/17 at 6:28 AM documented, "Patient has been fairly stable throughout my shift. He was given Ativan [a sedative used to relieve anxiety] by mouth but continued to pace and said that he was unable to sleep. He asked for 5 or 6 Tylenol PMs [Tylenol containing Benadryl, an antihistamine] which were not given to him however I did give him 50 mg [milligrams] of hydroxyzine [antihistamine ] which helped him to relax through the rest of my shift. He is still #40 on the list for [Hospital #2] and he has arty [already] been here for 111 hours ..."

ED Physician #4's note dated 10/16/17 at 4:09 AM documented, "The patient became agitated during his ER stay. He did require 10 mg of Geodon intramuscularly for his agitation. The patient is now stable ..."

Patient #7 was transferred to Hospital #2 on 10/18/17 at 7:59 AM, 160 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition.

There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #7 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #7 was in Hospital #1's ED 160 hours awaiting placement/transfer to an inpatient psychiatric treatment facility.

11. Medical record review revealed Patient #8 presented to the ED at Hospital #1's campus on 8/24/17 at 9:17 PM via ambulance for complaints of decreased mental alertness. The patient had TN Care/Blue Care insurance (Medicaid).

Review of ED physician #2's note dated 8/24/17 at 7:19 PM revealed a MSE which included a HPI, a medical and psychiatric history, ROS and physical exam was initiated. ED Physician #2's note on 8/24/17 at 7:19 PM documented, "28-year-old female who was just discharged earlier this afternoon from [hospital #1] to a rehabilitation facility for benzodiazepine and opioid dependence presents to the emergency room this evening via EMS with chief complaint of unwilling to speak not acting right. Was initially admitted to the hospital after a questionable near drowning thought to be secondary to a seizure secondary to benzodiazepine withdrawal ...She was discharged earlier this afternoon and went to the [name of outpatient drug rehab facility] for her drug dependence however after a few hours there she started acting bizarrely wandering the halls and then reached the point where when would no long respond or talk..."

Review of the Emergency Department Notes dated 8/25/17 at 4:45 AM revealed, "...CAPS CONSULT WAS COMPLETED, DISPOSITION DISCUSSED WITH [ED physician #2]. HE WOULD WRITE 6401 [6404]... DUE TO PT'S INSURANCE PT REQUIRES A CALL CENTER REFERRAL FOR MCRT ASSESSMENT..."

ED physician #2 dated 8/25/17 at 5:23 AM documented, "Patient is once again refusing to speak or interact. She will require evaluation by mobile crisis."

Review of the CAPS assessment dated 8/25/17 at 5:38 AM revealed the psychiatrist recommended Electroconvulsive Therapy (ECT). An attempt to assess the patient via Telemed was unsuccessful due to the patient's refusal to communicate.

Patient #8 was discharged to Hospital #8 on 8/27/17 at 12:14 PM.

There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #8 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #8 was in Hospital #1's ED 62 hours awaiting placement/transfer to an inpatient psychiatric treatment facility.

12. Medical record review revealed Patient #10 presented to the ED at Hospital #1's campus on 1/5/17 at 10:21 AM via ambulance with chief complaint of psychosis. The patient was discharged from Hospital #3 on 1/4/17 and returned to group home. The group home sent him to the ED on 1/5/17 due to talking to himself, confusion and incorrect responses. The patient was uninsured.

Medical record review of ED NP #2's note dated 1/5/17 at 10:47 AM revealed a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam was initiated. NP #2's note documented, "...Patient to ER for CAPS eval [evaluation]. Was dcd [discharged] home from [Hospital #3] yesterday and sent to group home. Group home sends patient back this AM for eval due to Psychosis. Patient talking to himself and confused, incorrect responses to questioning. Appears to be responding to internal stimuli. Patient denies SI or HI ...Patient follows directions and is pleasant, but talking to himself and giving bizarre answers to questions..."

Review of a nurse's note dated 1/5/17 at 10:43 AM revealed, " ...Pt [patient] sent from [Named group home] for psych [psychiatric] eval [evaluation]...Pt was d.c. [discharged] home from [Hospital #3] yesterday and sent to group home...pt has extensive psych history ...pt is dillusional [delusional], and talking to person not seen..." Further review of the nurse's notes revealed, "...[1/5/17 at 11:09 AM] ...security notified as patient is confrontational and passive aggressive...[1/6/17 at 8:32 PM]...he was talking to himself. When I asked who he was speaking to, he stated that he was speaking to his ex-wife ...[1/7/17 at 12:14 AM]...pt is awake talking to himself ..."

A CAPS assessment was initiated on 1/5/17 at 11:35 AM. CAPS recommendation was to readmit for psychiatric care. CAPS documented that there were no beds available at Hospital #3 and the call center would be referred to find placement. Further record review revealed the patient was on the "pending board" for Hospital #3 due to full capacity as of 1/7/17. The patient had also been referred to Hospital #2 and was on the waiting list.

A Certificate of Need for Emergency Involuntary Admission (6404) was signed on 1/9/17 10:31 AM.

Patient #10 was transferred to Hospital #2 on 1/9/17 at 1:32 PM, 99 hours after presenting to the ED for treatment and stabilization of a psychiatric condition.

There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #10 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #10 was in Hospital #1's ED 99 hours awaiting placement/transfer to an inpatient psychiatric treatment facility.

13. Medical record review revealed Patient #11 presented to the ED at Hospital #1's campus on 5/30/17/17 at 12:32 AM via ambulance with chief complaint of hallucinations. The patient had TN Care/Blue Cross insurance (Medicaid).

Medical record review of ED physician #2's note dated 5/30/17 at 1:05 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician #2's note dated 5/30/17 at 1:05 AM documented, "21-year-old female with a history of schizophrenia and bipolar disorder and recent hospitalization who presents to the emergency room complaining of increasing hallucinations that are distressing to her. She denies suicidal ideation. No homicidal ideation. She states that she has a lot of stressors at home and has a stressful relationship with her mother who is her conservator ..."

Review of the CAPS assessment performed on 5/30/17 at 1:05 AM revealed recommendations for patient disposition was discussed with the on-call psychiatrist but there was no documentation of the psychiatrist recommendations.

A physician's order, from ED physician #2, dated 5/30/17 at 5:45 AM, documented to give Depakote 500 milligrams (mg) by mouth (PO) daily (Anti-convulsant used to treat seizures and Bi-Polar disease), Haloperidol 5 mg PO twice a day (Antipsychotic), Cogentin 1 mg PO twice a day (Anti-tremor medication used to treat side effects of other drugs). Documentation revealed Patient #11 received Haloperidol 5 mg, Depakote 500 mg and Cogentin 1 mg at 6:20 AM and Haloperidol 5 mg and Cogentin 1 mg at 9:43 PM. There was no documentation Patient #11 received any medications prior to discharge from Hospital #1's ED on 6/3/17.

Review of the Emergency Notes revealed the patient was seen by Mobile Crisis on 5/30/17 at 10:00 AM.

ED physician #5's note dated 6/2/17 at 6:54 PM documented, "Patient has been medically stable throughout his [her] emergency department stay. He [She] has been accepted to [name of Hospital #2] at this date and time ..."

Patient #11 was transferred to Hospital #2 on 6/3/17 at 4:24 AM, 100 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition.

There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #11 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #11 was in Hospital #1's ED 100 hours awaiting placement/transfer to an inpatient psychiatric treatment facility.

14. Medical record review revealed Patient #12 presented to the ED at Hospital #1's campus on 6/4/17 at 10:20 AM via ambulance with chief complaint of nursing home requesting a psychiatric evaluation and neck pain. The patient had Medicare Parts A & B insurance.

Medical record review of ED physician #9's note dated 6/4/17 at 11:12 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician #9's note dated 6/4/17 at 11:12 AM documented, "This is a 74-year-old male present from a skilled nursing facility. Per the facility's report he overnight called EMS many times due to having some neck pain. He does report a neck injury about a year ago. He denies any new injury. He states that he does not like living at the skilled nursing facility and they are "driving him crazy". He denies any suicidal or homicidal ideation ....Obtained more information from the nursing facility. He apparently has been combative and trying to strike at the staff. They were concerned for his safety as well as the safety of the staff members and he was sent here for psychiatric evaluation. He does have underlying Schizoaffective disorder as well as recently diagnosed dementia ..."

Review of the CAPS assessment completed on 6/4/17 at 12:39 PM revealed the assessment was discussed with the psychiatrist on call who recommended inpatient psychiatric hospitalization for stabilization and observation. Hospital #3 was unable to accept patient due to no bed availability.

ED physician #6's note dated 6/5/17 at 5:58 AM documented, " ...We continued to watch [patients name] during my shift. I restarted his home medications especially his blood pressure medicines that he takes in the evening and his nighttime medicines. We will continue to await psychiatric placement closer to home as the patient's daughter decline transport to [Hospital #6] because it was too far ..."

A nurse's note dated 6/5/17 at 6:44 PM documented, "Patient's daughter spoke with [ED physician #9] and does not want to go to [Hospital #6] as it is too far. She wants to wait for [Hospital #3] or nearby facility. Called and informed Transfer Center ..."

A nurse's note dated 6/6/17 at 1:31 PM documented, " ...family not aware they could not go to [Hospital #3] due to insurance. Only option in Davidson Co. is [Hospital #5] unknown when they will have a bed available ..."

Patient #12 was transferred to Hospital #6 on 6/6/17 at 8:45 PM, 58 hours after presenting to the ED for treatment and stabilization of a psychiatric problem.

There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #12 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #12 was in Hospital #1's ED 58 hours awaiting placement/transfer to an inpatient psychiatric treatment facility.

15. Medical record review revealed Patient #13 presented to the ED at Hospital #1's campus on 6/7/17 at 7:31 PM via walk-in with complaint of feeling depressed. The patient had stopped taking her psychiatric medications approximately 6 weeks previously, due to being pregnant. The patient was insured (Medicaid).

Review of a nurse's note dated 6/7/17 revealed Patient #13 was triaged at 7:38 PM. Further review of the nurse's triage note revealed, " ...Pt here with feelings of being depressed, feelings are more intense because she stopped taking her psych meds due to being pregnant. Stopped taking her meds approx [approximately] 6 weeks ago. 17 weeks pregnant ..."

Review of a nurse's note dated 6/7/17 at 8:35 PM revealed, " ...when asked if pt has suicidal thoughts, pt states "well I don't think I'll kill myself but I feel like life would be better if I wasn't around ..."

Medical record review of ED physician #2's note dated 6/7/17 at 8:43 PM revealed a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam was initiated. Review of ED Physician #2's note on 6/7/17 at 8:43 PM revealed, "4-year old [24] female with long-standing history of bipolar disorder presents saying that she is depressed and feeling worthless. She denies active suicidal or homicidal ideati

Based on review of facility policies, facility bylaws, rules and regulations, facility listing, medical record reviews and interviews, the facility failed to ensure patients with identified emergency psychaitric conditions were transferred to Hospital #1's inpatient psychiatric unit which had the capacity and capability to treat the patients. The hospital failed to minimize the risks to the patients' health by allowing patients with psychaitric conditions to remain in Hospital #1's Emergency Department (ED) for lengthy periods of time without treatment while waiting to be transferred to an outside hospital. The failure of the hospital to admit and treat patients with psychaitric conditions resulted in the inappropriate transfer of 19 of 27 (Patient's 1, 2, 4, 5, 6, 8, 11, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 19, 20, 21, 22, 25 and 26) patients who presented to Hospital #1's ED seeking treatment for a psychaitric condition.

The findings included:

1. Review of facility policy, "EMTALA - Definitions and General Requirements" last reviewed 03/2013, revealed, "..To Stabilize means, with respect to an EMC to either provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility or... Transfer Center means an entity to facilitate the transfer of emergency patients in need of a higher level of care from a transferring facility to an receiving facility via ground or air ambulance transportation. Such Transfer Center provides staffing to facilitate making arrangements for the transfer of such individuals, while the ED physicians or other physicians in there transferring facility retain decision-making responsibilities for determining to which receiving facility the individual is transferred and by what means,...The Transfer Center's main role is to facilitate the transfer between the transferring and receiving hospitals and to be a resource for data on the individual hospitals and their capability and capacity to receive transfer at any point in time...On-Call List refers to the list that the hospital is required to maintain that defines those physicians who are on the hospital's medical staff or who have privileges at the hospital ...and are available to provide treatment necessary after the initial examination to stabilized individuals with EMSs [Emergency Medical Condition] ...The purpose of the on-call list is to ensure that the DED [Dedicated Emergency Department] is prospectively aware of which physicians, including specialist and sub-specialist, are available to provide treatment necessary to stabilize individuals with EMSs. Only physicians that are available to physically come to the ER may be included on the on-call list. A physician available via telemedicine does not satisfy the on-call requirements under EMTALA ...PROCEDURE: ...A. General Requirements ...2. If the hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer ...7. Maintain a list physicians on call after the initial examination to provide further examination and/or treatment necessary to stabilize an individual ...D. On-Call Obligations 1. Each hospital that has a Medicare provider participation agreement (including both the transferring and receiving hospitals and specialty hospitals) is required to maintain a list of physician specialists who are available for additional evaluation and stabilizing treatment of individuals with EMCs ...5. On-call physician specialists have a responsibility to provide specialty care services as needed to an individual who comes to the emergency department either as an initial presentation or upon transfer from another facility."

2. Review of the Medical Staff Bylaws adopted and approved December 10, 2015, revealed " ...1. B. PURPOSES AND RESPONSIBILITIES ...(12) to monitor and enforce compliance with these Bylaws, the Credentials Policy, the Organization Manual, the Medical Staff Rules and Regulations, other Medical Staff policies, and Hospital policies; and ..."

3. Review of facility Medical Staff Rules and Regulations, approved by the Medical Executive Committee on 6/14/16 and the Board of Trustees on 6/24/16, IV. EMERGENCY SERVICES/MEDICAL SCREENING/TRANSFERS: A. Emergency Services:
1. Members of the Medical Staff shall accept responsibility for Emergency Service care in accordance with the Medical Staff Bylaws, Emergency Department policies and procedures and applicable state and federal law. Physicians scheduled for on-call coverage are fully accountable for their availability and responsiveness ..."

4. Review of a patient list presented to the surveyors by the Quality Improvement Manager on 12/28/17 at 8:00 AM, revealed the Transfer Center (Call Center) did not refer to (named Hospital #3) for admission. Two patients (Patients #9 and 10) were declined because there was no ADA [American Disabilities Act] room and lack of nursing staff. Twenty-two patients were not referred to the on-site psychiatric hospital (Hospital #3) for treatment. Those patients were: Patients #1, 2, 3, 4, 5, 6, 7, 8, 11, 13, 14-1, 14-2, 14-3, 14-4, 14-5, 15, 19, 21, 22, 25, 26 and 27.

5. Medical record review revealed Patient #1 presented to the ED at Hospital #1's campus on 7/12/17 at 3:33 PM via ambulance for complaints of "suicidal thoughts and a plan, Pt [patient] reports 'my world is coming undone.'" The patient was uninsured.

Review of the ED notes for Patient #1 revealed on 7/12/17 at "1651[4:51 PM] CAPS: [Community Assistance Program-Behavioral Health Assessment provided by Psychiatric Registered Nurses or Masters in Psychiatric/counseling, located on-site at Psychiatric Hospital #3] assessment completed and reviewed with [ED physician #1]; patient not medically cleared at this time, BAL [blood alcohol level] pending (UDS [urine drug screen] negative), hx [history] of alcoholism and recent relapse (reports last drink this AM), endorses SI [suicidal ideation] (no plan), hx of depression (not taking antidepressant), no HI [homicidal ideation], no symptoms of psychosis ...7/12/17 at 1725 [5:25 PM] Addendum: Pt medically cleared, call Ctr [center] notified [name] for MCRT [Mobile Crisis Response Team] tracking, reviewed clearance form, fax to MCRT ...7/13/17 at 0441 [4:41 AM], discussed with [name] at [Hospital #2]. Patient will be 61 on the waiting list ...7/13/17 at 0614 [6:14 AM] Pt reports 'feel like I'm withdrawing' ...will give meds per order ...7/13/17 at 2306 [11:06 PM] ...[Hospital #2] said the patient's waiting list number has not changed ..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #1 on 7/12/17 at 5:50 PM which documented, "...has a mental illness or serious emotional disturbance ...active symptoms of psychiatric disorder as noted: suicidal ideation with a plan of jumping off a bridge ...AND, poses an immediate substantial likelihood of serious harm ...In my opinion, the patient is at continued risk of self-harm if not placed under involuntary commitment ...Condition is likely to deteriorate further without treatment ..."

Review of ED physician #1's note dated 7/12/17 at 5:55 PM revealed the ED physician had initiated a Medical Screening Examination (MSE) on Patient #1 which included a History of Present Illness (HPI), a medical and psychiatric history, review of systems (ROS) and physical exam. ED Physician #1 documented, "49-year-old male with a past medical history of alcohol abuse and depression who presents complaining of suicidal ideation. The patient states for the past 4 days he's been having suicidal thoughts of jumping off a bridge ..."

The patient's care was transferred to ED Physician #2 on 7/13/17 at 4:19 AM. ED physician #2's note documented the patient was awaiting a mobile crisis evaluation.

ED Physician #3's note dated 7/13/17 at 7:32 AM documented, "awaiting placement at [name of Hospital #2]"

ED Physician #1's note dated 7/14/17 at 4:17 PM documented the patient's care had been transferred to ED physician #4.

ED Physician #4's note dated 7/15/17 at 12:10 AM documented, "This is a 50-year-old male. He is in the emergency department pending psychiatric placement as he [has] been evaluated by mobile crisis. He has not had any acute episodes during my management of the patient's care."

ED Physician #5's note dated 7/15/17 at 6:39 AM documented, "Patient has been stable throughout my ED shift. Patient is still desiring inpatient placement. Care will be passed off oncoming providers ..."

ED Physician #4's note dated 7/16/17 at 12:32 AM documented Patient #1 was stable.

ED Physician #6's note dated 7/16/17 at 5:49 PM documented, "Patient has been stable in the emergency department. He was accepted at [named hospital #2] ..."

Patient #1 was transferred to Hospital #2 on 7/16/17 at 7:59 PM, 100 hours after presenting to the Hospital #1's ED seeking treatment and stabilization for a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #1's psychiatric condition while the patient remained in Hospital #1's ED for 100 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why Patient #1 was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

6. Medical record review revealed Patient #2 presented to the ED at Hospital #1's campus on 7/13/17 at 12:47 AM via ambulance with chief complaint of, "57-year-old gentleman who present to emergency room with complaints of lower behavior. States he's been in Afghanistan until a week ago were [where] he was the chief weapons officer of a flight of stealth bombers and that he is in Nashville to receive the Congressional Medal of Honor at Centennial Park. Patient also complains of rectal bleeding for 5 days. He was seen at [Hospital #4] complaining of rectal bleeding approximately 12 hours ago. He had negative fecal occult blood and normal H&H [hemoglobin hematocrit] ... Patient missed alcohol. He says "I'm really messed up." But he denies suicidal or homicidal ideation. It is very difficult to obtain a street [history] from the patient secondary to fact that his is delusional and tangential [erratic] but he denies any pain at this time ..." The patient had out of state Medicaid insurance.

Review of ED Physician #2's note date 7/13/17 at 12:59 AM revealed a MSE which included a History of Present Illness (HPI), a medical and psychiatric history, review of systems (ROS) and physical exam was initiated. A Certificate of Need for Emergency Involuntary Admission (6404) was signed at 1:00 AM. ED physician #2 documented, "Patient presents with evidence of mania and delusions. I believe he is incapable of taking care of himself and is likely come significant harm if not institutionalized for stabilization. He was placed under involuntary hold 6404 and will require evaluation by mobile crisis ..."

Review of the CAPS evaluation performed on 7/13/17 at 3:53 AM revealed the evaluator discussed the patient's status with Hospital #1's on-call Psychiatrist. The hospital's on-call Psychiatrist stated to have Mobile Crisis evaluate the patient for possible treatment. There was no documentation the hospital's on-call Psychiatrist evaluated the patient.

Review of the Mobile Crisis Response Team notes dated 7/13/17 at 5:20 AM revealed Mobile Crisis referred the patient to be admitted for inpatient psychiatric treatment due to psychosis. The ED Notes documented the patient was placed on the waiting list to be admitted to Hospital #2 on 7/13/17.

ED physician #4's note dated 7/15/17 at 12:04 AM documented, "Patient is agitated here numerous times and requires multiple redirection. Patient still psychotic saying he has a G5 jet ready to pick up the Surgeon General to evaluate him. The patient was given Geodon [Antipsychotic medication for treatment of Schizophrenia and Bi-Polar disorder] and Ativan [Benzodiazepine/sedative for treatment of anxiety] as needed for his agitation and psychosis ..."

ED Physician #5's note dated 7/15/17 at 6:37 AM documented, "Patient has been observed throughout the emergency department stay during my shift. He has been medically stable. He is still acutely psychotic and will need placement ..."

ED Physician #7's note dated 7/16/17 at 4:23 PM documented, "Reassessed this patient during my shift multiple times. He is tried to escape from the ER multiple times, including an episode where he tried to get inside of an ambulance and drive off he was pulled from the ambulance, secondary to this and combativeness with staff in general inability to conform to safety precautions we have placed him in seclusion, think this is for the patient's safety as well as everyone else in the emergency department. I reassessed him 4 hours later and will continue disorder [this order] ..."

ED Physician #6's note dated 7/17/17 at 1:46 AM documented, " ...He placed the patient on an involuntary seclusion order at noon because the patient attempted to lift [leave] emergency department and was creating a risk to himself and staff. I evaluated him shortly after 4 PM and he was redirectable and cooperative and we withdrew the seclusion order. He was given some IM [Intramuscular] Geodon and we continued to monitor him in the emergency department until care was passed over to [name of ED physician #2] for continued management until he is transferred to [Hospital #2]."

Patient #2 was transferred to Hospital #2 on 7/17/17 at 9:45 AM, 105 hours after presenting to the Hospital #1's ED for seeking treatment and stabilization for a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #2's psychiatric condition while the patient remained in Hospital #1's ED for 105 hours awaiting to an inpatient psychiatric facility.

There was no documentation why Patient #1 was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

7. Medical record review revealed Patient #4 presented to the ED at Hospital #1's campus on 7/13/17 at 1:34 AM via ambulance with chief complaint of being found at the bus station bleeding from cutting his arm with a box cutter.
The patient was uninsured.

Review of ED Physician #2's note dated 7/13/17 at 1:36 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. Review of ED physician #2's note dated 7/13/17 at 1:36 AM revealed the patient was a , "36-year-old gentleman presents to emergency department after reportedly stabbing himself in the left thumb with a box cutter. Patient reports a long-standing psychiatric history for which he has been followed in Jackson, TN. He states that he has 'messed up to the head' and 'That what is going in this world is not real.' Patient is very agitated and uncooperative and is unwilling to provide further history ..."

Review of Nurses Behavioral Health Related notes dated 7/13/17 at 1:51 PM revealed, "Pt continues to be agitated. Security notified of inappropriate action ...7/14/17 at 5:00 AM ...Pt was pacing from bed to doorway for several minutes ..."

The CAPS evaluator note dated 7/13/17 at 5:04 AM documented, "This patient will need to be evaluated by the psychiatrist prior to any discharge to an unsupervised setting. Notified [name] at Behavioral Health Call Center of need for Mobile Crisis evaluation. Medical clearance sent ..."

A nurses note dated 7/13/17 at 7:13 AM documented, "Mobile Crisis recommends inpatient treatment. Mobile Crisis spoke with Transfer Center, pt referral to [Hospital #2] ..."

A nurses note dated 7/13/17 at 6:56 PM documented the patient had been approved for transfer by the attending Physician at Hospital #2 and was currently #43 on the wait list for a bed.

Patient #4 was transferred to Hospital #2 on 7/17/17 at 8:10 AM, 102 hours after presenting to Hospital #1's ED for treatment and stabilization for a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment of Patient #4's psychiatric condition when the patient remained in Hospital #1's ED for 102 hours awaiting for to an inpatient psychiatric facility.

There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3)for inpatient treatment.

8. Medical record review revealed Patient #5 presented to the ED at Hospital #1's campus on 7/13/17 at 11:15 PM via ambulance with chief complaint of Suicidal Ideation, wanting to jump off a bridge and hurt himself. The patient was uninsured.

Review of ED Physician#15's note dated 7/13/17 at 11:23 PM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician#15's documented, "37-year-old male with history of Schizoaffective disorder here tonight for depression and suicidal ideation. Patient was just seen in a hospital in Georgia yesterday for similar symptomatology. However patient was not having any thoughts of suicidal ideation. He allegedly bought a bus [ticket] to come here. Suicidal ideation began on his travel here. Patient plans on jumping off a bridge to hurt himself. Because of his suicidal thoughts patient contacted EMS [Emergency Medical Services] to bring him here ..."

A CAPS intake was initiated on 7/13/17 at 11:25 PM. On 7/14/17 at 6:00 AM the patient was placed on the waiting list to be transferred to Hospital #2. He was #61 on the waiting list.

Patient #5 was transferred to Hospital #2 on 7/18/17 at 11:10 AM, 107 hours after presenting to Hospital #1's ED for treatment and stabilization of a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #5's psychiatric condition while the patient remained in Hospital #1's ED for 107 hours awaiting for transfer to an inpatient psychiatric facility.

There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

9. Medical record review revealed Patient #6 presented to the ED at Hospital #1's campus on 7/16/17 at 7:47 AM via ambulance for complaints of "...confused, disoriented, found walking through traffic on 440 ..." The patient was uninsured.

Medical record review of ED Physician #7's note dated 7/16/17 at 8:08 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED physician #7 on 7/16/17 at 11:00 AM documented, "Reported history of behaviors clinically indicative of a psychiatric disorder, prior history of psychiatric hospitalizations, substance abuse, behavior that puts patient at risk for self-harm, appears delusional, feel unsafe to leave ...Condition is likely to deteriorate further without treatment ..."

Review of the Behavioral Health CAPS Assessment performed on 7/16/17 at 10:35 AM revealed, "...recommendations for the patient's disposition was discussed with provider (Hospital #1's on-call Psychiatrist #1) and the on-call Psychiatrist, "referred to Call Center/MCRT for disposition..."

The Emergency Department notes dated 7/16/17 at 11:16 AM documented, "Patient seen by CAPS, she presented bizarre but denied suicidal, homicidal at the time of assessment. Patient was not able to give demographic, social or any pertinent information ..."

Review of the ED Physician #6's notes dated 7/17/17 at 7:51 PM revealed, "Patient was cooperative throughout my stay except at one point she tried to leave the ED she was redirected back to her room by security and I gave her oral Haldol [an antipsychotic] and Valium [an anxiolytic and sedative used to treat anxiety, muscle spasms and seizures] which she took and was cooperative from that point on ..."

Patient #6 was transferred to Hospital #2 on 7/20/17 at 3:48 AM , 91 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #6's psychiatric condition while the patient remained in Hospital #1's ED for 91 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why the patient was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient psychiatric treatment.

10. Medical record review revealed Patient #8 presented to the ED at Hospital #1's campus on 8/24/17 at 9:17 PM via ambulance for complaints of decreased mental alertness. The patient had TN Care/Blue Care insurance (Medicaid).

Review of ED physician #2's note dated 8/24/17 at 7:19 PM revealed a MSE which included a HPI, a medical and psychiatric history, ROS and physical exam was initiated. ED Physician #2's note on 8/24/17 at 7:19 PM documented, "28-year-old female who was just discharged earlier this afternoon from [hospital #1] to a rehabilitation facility for benzodiazepine and opioid dependence presents to the emergency room this evening via EMS with chief complaint of unwilling to speak not acting right. Was initially admitted to the hospital after a questionable near drowning thought to be secondary to a seizure secondary to benzodiazepine withdrawal ...She was discharged earlier this afternoon and went to the [name of outpatient drug rehab facility] for her drug dependence however after a few hours there she started acting bizarrely wandering the halls and then reached the point where when would no long respond or talk..."

Review of the Emergency Department Notes dated 8/25/17 at 4:45 AM revealed, "...CAPS CONSULT WAS COMPLETED, DISPOSITION DISCUSSED WITH [ED physician #2]. HE WOULD WRITE 6401 [6404]... DUE TO PT'S INSURANCE PT REQUIRES A CALL CENTER REFERRAL FOR MCRT ASSESSMENT..."

ED physician #2 dated 8/25/17 at 5:23 AM documented, "Patient is once again refusing to speak or interact. She will require evaluation by mobile crisis."

Review of the CAPS assessment dated 8/25/17 at 5:38 AM revealed the psychiatrist recommended Electroconvulsive Therapy (ECT). An attempt to assess the patient via Telemed was unsuccessful due to the patient's refusal to communicate.

Patient #8 was discharged to Hospital #8 on 8/27/17 at 12:14 PM.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment of Patient #8's psychiatric condition while the patient remained in Hospital #1's ED for 62 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

11. Medical record review revealed Patient #11 presented to the ED at Hospital #1's campus on 5/30/17/17 at 12:32 AM via ambulance with chief complaint of hallucinations. The patient had TN Care/Blue Cross insurance (Medicaid).

Medical record review of ED physician #2's note dated 5/30/17 at 1:05 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician #2's note dated 5/30/17 at 1:05 AM documented, "21-year-old female with a history of schizophrenia and bipolar disorder and recent hospitalization who presents to the emergency room complaining of increasing hallucinations that are distressing to her. She denies suicidal ideation. No homicidal ideation. She states that she has a lot of stressors at home and has a stressful relationship with her mother who is her conservator ..."

Review of the CAPS assessment performed on 5/30/17 at 1:05 AM revealed recommendations for patient disposition was discussed with the on-call psychiatrist but there was no documentation of the psychiatrist recommendations.

A physician's order, from ED physician #2, dated 5/30/17 at 5:45 AM, documented to give Depakote 500 milligrams (mg) by mouth (PO) daily (Anti-convulsant used to treat seizures and Bi-Polar disease), Haloperidol 5 mg PO twice a day (Antipsychotic), Cogentin 1 mg PO twice a day (Anti-tremor medication used to treat side effects of other drugs). Documentation revealed Patient #11 received Haloperidol 5 mg, Depakote 500 mg and Cogentin 1 mg at 6:20 AM and Haloperidol 5 mg and Cogentin 1 mg at 9:43 PM. There was no documentation Patient #11 received any medications prior to discharge from Hospital #1's ED on 6/3/17.

Review of the Emergency Notes revealed the patient was seen by Mobile Crisis on 5/30/17 at 10:00 AM.

ED physician #5's note dated 6/2/17 at 6:54 PM documented, "Patient has been medically stable throughout his [her] emergency department stay. He [She] has been accepted to [name of Hospital #2] at this date and time ..."

Patient #11 was transferred to Hospital #2 on 6/3/17 at 4:24 AM, 100 hours after presenting to the ED seeking treatment and stabilization of a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #11's psychiatric condition while the patient was in Hospital #1's ED for 100 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

12. Medical record review revealed Patient #13 presented to the ED at Hospital #1's campus on 6/7/17 at 7:31 PM via walk-in with complaint of feeling depressed. The patient had stopped taking her psychiatric medications approximately 6 weeks previously, due to being pregnant. The patient was insured (Medicaid).

Review of a nurse's note dated 6/7/17 revealed Patient #13 was triaged at 7:38 PM. Further review of the nurse's triage note revealed, " ...Pt here with feelings of being depressed, feelings are more intense because she stopped taking her psych meds due to being pregnant. Stopped taking her meds approx [approximately] 6 weeks ago. 17 weeks pregnant ..."

Review of a nurse's note dated 6/7/17 at 8:35 PM revealed, " ...when asked if pt has suicidal thoughts, pt states "well I don't think I'll kill myself but I feel like life would be better if I wasn't around ..."

Medical record review of ED physician #2's note dated 6/7/17 at 8:43 PM revealed a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam was initiated. Review of ED Physician #2's note on 6/7/17 at 8:43 PM revealed, "4-year old [24] female with long-standing history of bipolar disorder presents saying that she is depressed and feeling worthless. She denies active suicidal or homicidal ideation. She is off all of her medications since she found out she was pregnant...6404 filled out. Awaiting evaluation by mobile crisis..."

Review of ED physician #16's note dated 6/8/17 at 6:18 AM revealed, "Mobile crisis has seen and recommends inpatient".

Review of the Emergency Notes on 6/8/17 at 2:44 PM revealed all private facilities had declined patient due to acuity. Hospital #2 was given referral. At 4:13 PM on 6/8/17 the patient was #31 on the waiting list for Hospital #2.

Review ED physician #16's note on 6/8/17 at 4:17 PM revealed the patient had been seen by mobile crisis and was waiting for psychiatric placement.

Patient #13 was transferred to Hospital #2 on 6/11/17 at 11:20 AM, 87 hours after presenting to the ED for treatment and stabilization of a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #13's psychiatric condition while the patient remained in Hospital #1's ED for 87 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

13. Medical record review revealed Patient #14-1 presented to the ED at Hospital #1's campus on 7/22/16 at 12:15 AM via ambulance with chief complaint of plans to overdose on cocaine, marijuana and alcohol, patient off seizure medications. The patient was uninsured.

Medical record review of ED physician #13's note dated 7/22/16 at 12:24 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED Physician #13's note dated 7/22/16 at 12:24 AM documented, "...reports he has suicidal thoughts and has a plan to overdose on cocaine, marijuana and drink too much alcohol. Has not been compliant with his medications ..." A Certificate of Need for Emergency Involuntary Admission (6404) was completed on 7/22/16 at 12:30 AM. On 7/22/16 at 10:04 AM the ED RN faxed the chart and 6404 to Hospital #2 as requested by Mobile Crisis. Patient was placed as #21 on the waiting list for Hospital #2.

Patient 14-2was transferred to Hospital #8 on 7/22/16 at 11:44 PM, 23 hours after presenting to the ED for treatment and stabilization of a psychiatric condition.

There was no documentation the on call psychiatrist had performed an assessment or stabilizing treatment for Patient #14-1's psychiatric condition while the patient was in Hospital #1's ED for 23 hours awaiting transfer to an inpatient psychiatric facility.

There was no documentation why the was not admitted to Hospital #1's onsite psychiatric unit (Hospital #3) for inpatient treatment.

14. Medical record review revealed Patient #14-2 presented to the ED at Hospital #1's campus on 10/6/16 at 11:06 PM via ambulance with chief complaint of suicidal ideation. The patient was uninsured.

Physician Assistant #4's note dated 10/7/16 at 1:33 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. Physician Assistant #4's note revealed the patient reported suicidal ideation today and he has a plan.

Review of the Emergency Notes revealed the following: 10/7/16 at 12:36 AM the patient was assessed by CAPS and identified suicidal ideations with alcohol dependency. At 4:24 AM the patients' blood alcohol level was 0.190 which was outside the parameters for Mobile Crisis team. At 9:30 AM, Mobile Crisis evaluated the patient and stated patient could go home and would discuss with ER MD. At 11:20 AM the ED MD stated the patient had to be placed and to let the Transfer Center know for placement. On 10/8/16 at 2:15 AM the patient was moved to a psych safe room in the ED. There was no documentation why the patient was moved. At 3:27 AM per the Transfer Center, the patient was to receive Telemedicine because he had been denied everywhere.

Telemedicine Physician #1's Psychiatric Evaluation Note from the Telemedicine referral dated 10/8/16 at 4:21 AM documented, " ...Risk factors: Homeless, lack of engagement in outpatient treatment, lack of primary support, history of prior suicide attempts, recent use of cocaine, ETOH [alcohol]. Plan: Based on above mentioned risk factors and on patient being unable to contract for safety on assessment today, it is recommended that patient be transferred to an inpatient facility for treatment of mood disorder and stabilization before being referred to a treatment facility for rehab ..."

Patient #14-2 was discharged to Hospital #2 on 10/8/16 at 12:24 AM for further evaluation of a psychiatric condition.

There was no documentation on-call psychiatrists had performed an adequate assessment of Patient #14-2 to determine the necessary treatment to stabilize the patient's psychiatric condition while Patient #14-2 was in Hospital #1's ED 46 hours awaiting placement/transfer to an inpatient psychiatric treatment facility.

15. Medical record review revealed Patient #14-3 presented to the ED at Hospital #1's campus on 10/28/16/16 at 11:58 PM via ambulance with chief complaint of drunk and suicidal. The patient was uninsured.

Medical record review of ED physician's assistant (PA) #4's note dated 10/29/16 at 12:24 AM revealed a MSE which included a HPI, a medical and psychiatric history, a ROS and physical exam was initiated. ED PA #4's note dated 10/29/16 at 12:24 AM documented, " ...Chief Complaint: Drunk and Suicidal again ...Pt chronically lives in the health and mental health system, he abuse drugs, drinks and has mental health history ...wants food and shelter ...Serum Alcohol level: 0.256