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Based on record review and interviews, Hospital A failed to comply with 489.24 (e) (1)-(2) for 1 of 1 patient (Patient #1) in that the ED staff at Hospital A's Emergency Department (ED) did not contact Hospital B (Mental Health Hospital) to secure an available bed for the transfer of (Patient #1) who was deemed suicidal and who required inpatient mental health treatment. Hospital A subsequently discharged (Patient #1) to Police custody without ensuring (Patient #1's) mental health needs were met.

Findings Included:

Review of Hospital A's ED medical record for (Patient #1) dated 11/08/14 revealed the following:

(Patient #1's) ambulance run sheet dated 11/08/14 reflected, "Arrived to find patient sitting upright on the floor of the living room...patient was slurring her words and appeared intoxicated...husband was concerned the patient had taken too much of her medications...had a hematoma above her left eye...bruise on the center of her forehead that appeared older...bruise around her right eye...bruising on left ribs...patient would not give a clear answer on how the bruising to her ribs had occurred...denied attempt to injure herself, placed in police custody and taken to hospital...patient was APOWWD (apprehension by police officer without warrant)."

The physician note dated 11/08/14 timed at 0113 reflected, "Patient is a 61 year old female who comes to the ED complaining of AMS (altered mental status)...history of attempted suicide with pills...per police...patient stated she wanted to kill herself...bruising in various states of healing...slurred speech...CT of head...urine drug screen...barbiturates, urine positive...benzodiazepines, urine positive...0256 rechecked patient relayed to police that there are no beds available at... (behavioral health)...according to SW (social worker), okay to release patient into police custody now that she is medically screened...discharge the condition of the patient at this time is stable...closed head injury, facial contusion, suicidal ideation. "

The progress note (social work) dated 11/08/14 timed at 0135 reflected, "Husband states he made statement to patient that if patient kept taking all the pills she would kill herself...patient made statement that she wanted to die according to husband...patient taking Klonopin...had injured ankle with boot on...according to husband this is not patient's first time abusing her medications...argumentative, impulsive, low frustration tolerance and AMS (altered mental status)...substance use prescriptive drugs...poor judgment, family conflict, decreased motivation...easily frustrated...patient desires inpatient treatment...plan patient under police custody...patient if medically cleared will be taken by police...no beds at the...(behavioral health)."

Hospital A's policy entitled, "Medical Screening Examinations and Patient Transfers" with an effective date of 10/2013 reflected, "All transfers of patients between hospital and other hospitals shall conform to all requirements of state and federal laws, rules and regulations relating to such transfers...physician responsibilities...prior to transfer, the transferring physician shall secure a receiving physician and a receiving hospital that are appropriate to the medical needs of the patient and that will accept responsibility for patient's medical treatment and hospital care..."

Hospital B's medical record for (Patient #1) dated 11/08/14 revealed the following:

The document entitled, "Notification of Emergency Detention" dated 11/08/14 timed at 0122 reflected, "(Patient #1) had been overdosing on prescriptions...husband called because female was falling all over the house...made a comment she wanted to die...for the above reason, I present this notification to seek temporary admission to (Hospital A) inpatient mental health facility or hospital facility for the detention of (Patient #1)."

The document entitled, "Notification of Emergency Detention" dated 11/08/14 timed at 0324 reflected, "(Patient #1) has been self-medicating on prescription drugs...husband called because he fears (Patient #1) would try to kill herself...made threats to kill herself...had slurred speech and appears to be under the influence...for the above reason I present this notification to seek temporary admission to Hospital B's inpatient mental health facility or hospital facility for the detention of (Patient #1)..."

The RN (Registered Nurse) admission Assessment dated 11/08/14 at 0802 reflected, "Patient transferred from a medical facility...APOWW after being discharged from Hospital A...no Doctor to Doctor or Nurse to Nurse was done...discharging hospital (Hospital A) was asked to fax a copy of all medical records pertaining to patient's stay...patient came with paper work of discharge instructions regarding contusion, head injury and suicidal feelings."

On 12/02/14 at 1445 Personnel #7 (Hospital A) was asked if she reviewed (Patient #1's) medical record. Personnel #7 stated she could not find any further information which addressed the hospital provided and/or ensured (Patient #1's) psychiatric needs were addressed after it was identified no psychiatric beds were available in the hospital's behavioral health unit. Personnel #7 verified the patient should have been transferred to a psychiatric facility and the appropriate transfer paperwork be completed. Personnel #7 verified the patient was returned to the custody of the police.

On 12/02/14 at 2205 Personnel #9 (Hospital A) was interviewed by telephone. Personnel #9 stated (Patient #1) was brought in by APOWW (apprehension by police officer without warrant). Personnel #9 stated she did not contact the hospital transfer center regarding a transfer to a psychiatric hospital for inpatient psychiatric care. Personnel #9 stated no memorandum of transfer was completed. Personnel #9 stated she spoke with the police and (Patient #1) was returned to police custody as the hospital had no behavioral beds. Personnel #9 stated the ED completes a MOT (memorandum of transfer) when sending a patient from the ED to Hospital A's (behavioral unit). The surveyor asked Personnel #9 how (Patient #1's) case was different than the hospital finding a psychiatric hospital for (Patient #1) and completing doctor to doctor and transfer information. Personnel #9 stated the police took the patient but she was unaware of where. Personnel #9 did not offer any further information.

On 12/04/14 at 1445 Non Hospital Personnel #3 was interviewed by telephone. Non Hospital Personnel #3 stated (Patient #1) was brought into Hospital A for medical injuries and concerns that (Patient #1) overdosed on pills and was verbalizing self-harm. Non Hospital Personnel #3 verified (Patient #1) was placed on APOWW status and was seen by the physician. Non Hospital Personnel #3 stated Personnel #9 (Hospital A) spoke with her regarding (Patient #1) and said the hospital did not have any beds in the psychiatric department. Non Hospital Personnel #3 stated she asked the male nurse at the desk if the psychiatric unit had any beds, which he said they did not.

Non Hospital Personnel #3 stated at that time (Patient #1) was assisted into the police car by hospital staff as (Patient #1) had a boot on her foot. Non Hospital Personnel #3 stated she thought it was strange (Patient #1) was discharged back to police custody. Non Hospital Personnel #3 stated Personnel #9 (Hospital A) asked her what the police were going to do with (Patient #1). Non Hospital Personnel #3 stated she informed Personal #9 (Hospital A) she guessed the only option would be to take (Patient #1) somewhere else. Non Hospital Personnel #3 stated she had to complete a second APOWW and transported (Patient #1) to Hospital B where (Patient #1) was admitted. Non Hospital Personnel #3 stated Hospital B was provided (Patient #1's) discharge paperwork and verified no transfer and/or paperwork was initiated and/or completed by Hospital A.

Based on observation and interview, the hospital failed to post EMTALA signs in a place or places likely to be noticed by all individuals entering 1 of 1 ED (emergency department) as well as those waiting for examination and treatment in that, no signs were posted for the ambulance entrance, the triage area and treatment area in the ED.

Findings Included:

On 12/02/14 at 1100 observation rounds were conducted in the ED with Personnel #5. There were no EMTALA signs in the ambulance entrance, triage room, the treatment rooms, or other waiting areas of the ED. Personnel #5 stated the only EMTALA sign was located in the main emergency room waiting area. Personnel #5 stated there were not any EMTALA signs in the ambulance entrance, treatment rooms and/or triage room.

Based on record review and interviews, Hospital A failed to provide an appropriate transfer for 1 of 1 patient (Patient #1) in that the ED staff at Hospital A's Emergency Department (ED) did not contact Hospital B (Mental Health Hospital) to secure an available bed for (Patient #1) who was deemed suicidal and who required inpatient mental health treatment. Hospital A subsequently discharged (Patient #1) to Police custody without ensuring (Patient #1's) mental health needs were met.

Findings Included:

Review of Hospital A's ED medical record for (Patient #1) dated 11/08/14 revealed the following:

(Patient #1's) ambulance run sheet dated 11/08/14 reflected, "Arrived to find patient sitting upright on the floor of the living room...patient was slurring her words and appeared intoxicated...husband was concerned the patient had taken too much of her medications...had a hematoma above her left eye...bruise on the center of her forehead that appeared older...bruise around her right eye...bruising on left ribs...patient would not give a clear answer on how the bruising to her ribs had occurred...denied attempt to injure herself, placed in police custody and taken to hospital...patient was APOWWD (apprehension by police officer without warrant)."

The physician note dated 11/08/14 timed at 0113 reflected, "Patient is a 61 year old female who comes to the ED complaining of AMS (altered mental status)...history of attempted suicide with pills...per police...patient stated she wanted to kill herself...bruising in various states of healing...slurred speech...CT of head...urine drug screen...barbiturates, urine positive...benzodiazepines, urine positive...0256 rechecked patient relayed to police that there are no beds available at...(behavioral health)...according to SW (social worker), okay to release patient into police custody now that she is medically screened...discharge the condition of the patient at this time is stable...closed head injury, facial contusion, suicidal ideation. "

The progress note (social work) dated 11/08/14 timed at 0135 reflected, "Husband states he made statement to patient that if patient kept taking all the pills she would kill herself...patient made statement that she wanted to die according to husband...patient taking Klonopin...had injured ankle with boot on...according to husband this is not patient's first time abusing her medications...argumentative, impulsive, low frustration tolerance and AMS (altered mental status)...substance use prescriptive drugs...poor judgment, family conflict, decreased motivation...easily frustrated...patient desires inpatient treatment...plan patient under police custody...patient if medically cleared will be taken by police...no beds at the...(behavioral health)."

Hospital A's policy entitled, "Medical Screening Examinations and Patient Transfers" with an effective date of 10/2013 reflected, "All transfers of patients between hospital and other hospitals shall conform to all requirements of state and federal laws, rules and regulations relating to such transfers...physician responsibilities...prior to transfer, the transferring physician shall secure a receiving physician and a receiving hospital that are appropriate to the medical needs of the patient and that will accept responsibility for patient's medical treatment and hospital care..."

Hospital B's medical record for (Patient #1) dated 11/08/14 revealed the following:

The document entitled, "Notification of Emergency Detention" dated 11/08/14 timed at 0122 reflected, "(Patient #1) had been overdosing on prescriptions...husband called because female was falling all over the house...made a comment she wanted to die...for the above reason, I present this notification to seek temporary admission to (Hospital A) inpatient mental health facility or hospital facility for the detention of (Patient #1)."

The document entitled, "Notification of Emergency Detention" dated 11/08/14 timed at 0324 reflected, "(Patient #1) has been self-medicating on prescription drugs...husband called because he fears (Patient #1) would try to kill herself...made threats to kill herself...had slurred speech and appears to be under the influence...for the above reason I present this notification to seek temporary admission to Hospital B's inpatient mental health facility or hospital facility for the detention of (Patient #1)..."

The RN (Registered Nurse) admission Assessment dated 11/08/14 at 0802 reflected, "Patient transferred from a medical facility...APOWW after being discharged from Hospital A...no Doctor to Doctor or Nurse to Nurse was done...discharging hospital (Hospital A) was asked to fax a copy of all medical records pertaining to patient's stay...patient came with paper work of discharge instructions regarding contusion, head injury and suicidal feelings."

On 12/02/14 at 1445 Personnel #7 (Hospital A) was asked if she reviewed (Patient #1's) medical record. Personnel #7 stated she could not find any further information which addressed the hospital provided and/or ensured (Patient #1's) psychiatric needs were addressed after it was identified no psychiatric beds were available in the hospital's behavioral health unit. Personnel #7 verified the patient should have been transferred to a psychiatric facility and the appropriate transfer paperwork be completed. Personnel #7 verified the patient was returned to the custody of the police.

On 12/02/14 at 2205 Personnel #9 (Hospital A) was interviewed by telephone. Personnel #9 stated (Patient #1) was brought in by APOWW (apprehension by police officer without warrant). Personnel #9 stated she did not contact the hospital transfer center regarding a transfer to a psychiatric hospital for inpatient psychiatric care. Personnel #9 stated no memorandum of transfer was completed. Personnel #9 stated she spoke with the police and (Patient #1) was returned to police custody as the hospital had no behavioral beds. Personnel #9 stated the ED completes a MOT (memorandum of transfer) when sending a patient from the ED to Hospital A's (behavioral unit). The surveyor asked Personnel #9 how (Patient #1's) case was different than the hospital finding a psychiatric hospital for (Patient #1) and completing doctor to doctor and transfer information. Personnel #9 stated the police took the patient but she was unaware of where. Personnel #9 did not offer any further information.

On 12/04/14 at 1445 Non Hospital Personnel #3 was interviewed by telephone. Non Hospital Personnel #3 stated (Patient #1) was brought into Hospital A for medical injuries and concerns that (Patient #1) overdosed on pills and was verbalizing self-harm. Non Hospital Personnel #3 verified (Patient #1) was placed on APOWW status and was seen by the physician. Non Hospital Personnel #3 stated Personnel #9 (Hospital A) spoke with her regarding (Patient #1) and said the hospital did not have any beds in the psychiatric department. Non Hospital Personnel #3 stated she asked the male nurse at the desk if the psychiatric unit had any beds, which he said they did not.

Non Hospital Personnel #3 stated at that time (Patient #1) was assisted into the police car by hospital staff as (Patient #1) had a boot on her foot. Non Hospital Personnel #3 stated she thought it was strange (Patient #1) was discharged back to police custody. Non Hospital Personnel #3 stated Personnel #9 (Hospital A) asked her what the police were going to do with (Patient #1). Non Hospital Personnel #3 stated she informed Personal #9 (Hospital A) she guessed the only option would be to take (Patient #1) somewhere else. Non Hospital Personnel #3 stated she had to complete a second APOWW and transported (Patient #1) to Hospital B where (Patient #1) was admitted. Non Hospital Personnel #3 stated Hospital B was provided (Patient #1's) discharge paperwork and verified no transfer and/or paperwork was initiated and/or completed by Hospital A.