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Based on documentation review, it was determined Patient #26's 8/3/10 presentation to the Hospital's ED was not recorded on the corresponding ED Log.

Findings included:

Please see Tag A 2406 for information related to Patient #26 and his/her 8/3/10 ED presentation.

Patient #26's name did not appear on the 8/3/10 ED Log.

Based on interviews and documentation review, it was determined:
1.) the Hospital failed to provide a MSE to Patient #26 on 8/3/10.
2.) the designation of personnel qualified to perform a MSE at the Hospital (in a policy approved by the governing body) did not include a group of physicians routinely providing MSEs.

Findings included:

1.) ED Charge Nurse #1 was interviewed in person at 2:30 PM on 8/9/10. She said on the afternoon of 8/3/10, ED Nurse Practitioner #1 told her (someone from) Mental Health Center #1 (a nearby mental health center) had just telephoned, indicating they (Mental Health Center #1 staff) were sending a patient to the ED for medical clearance and because the ED was very busy and already had 7 psychiatric patients; 5 of whom had been referred by Mental Health Center #1, she telephoned the Mental Health Center to see if the patient could be sent to (the ED of) Acute Care Hospital #2 instead. ED Charge Nurse #1 said the person she spoke with at the Mental Health Center indicated: the patient (Patient #26) was still at the Center; it looked like (the ED of) Acute Care Hospital #2 only had 2 of their (the Mental Health Center's) patients and; they would send Patient #26 to Acute Care Hospital #2.

ED Charge Nurse #1 said 15 to 20 minutes after her telephone conversation with the person at Mental Health Center #1, she was summoned to the Triage Area (ED area where patients presenting through the Ambulatory Entrance are screened to determine treatment priority) and informed a of psychiatric patient's arrival with police officers; under a Section 12a (Application that when properly completed mandates an involuntary hospitalization until a formal psychiatric evaluation is completed). ED Charge Nurse #1 reported asking the patient's name, learning the patient was Patient #26, indicating the Patient was suppose to go to Acute Care Hospital #2, and entering the (main) ED to see about a bed for the Patient and to telephone Mental Health Center #1.

ED Triage Nurse #1 was interviewed in person at 2:55 PM on 8/10/10. She said she was busy with a patient when she saw a patient accompanied by 2 police officers enter the ED Ambulatory Entrance, and heard an ED staff person say he/she was going to go get ED Charge Nurse #1. ED Triage Nurse #1 said the police officers had the patient sit in a chair near the Reception/Triage Area, and ED Charge Nurse #1 appeared and spoke with the patient and police officers. ED Triage Nurse #1 said during the patient/police officer/ED Charge Nurse #1 conversation; she heard the Charge Nurse say something like: I think this patient was suppose to go to ______ (the name of Acute Care Hospital #2) and that she was going to call ______ (the name of Mental Health Center #1).

ED Triage Nurse #1 said that when ED Charge Nurse #1 left the Reception/Triage Area; one of the police officers asked the other if Dispatch had said _______ (the name of Acute Care Hospital #2), and indicated he was going to go call Dispatch. ED Triage Nurse #1 said the other police officer and the patient remained in the Reception/Triage Area and she performed a triage assessment on another patient.

ED Charge Nurse #1 said when she returned to the Reception/Triage Area, Patient #26 and the police officers were gone, and a Tech (ED Technician) indicated the Patient had been taken to Acute Care Hospital #2.

ED Triage Nurse #1 said sometime after she heard the Police Officer's conversation about Dispatch; she noticed the Patient and Police Officers were gone, and she asked a Tech what had happened to them. ED Triage Nurse #1 said the Tech indicated the Patient and Police Officers had left/walked out.

There was no medical record associated with Patient #26's (above described) ED presentation.

Acute Care Hospital #2's Risk Manager was interviewed by telephone at 11:45 AM on 8/10/10. She said Patient #26 arrived in Acute Care Hospital #2's ED at 4:30 PM and received a MSE including medical and psychiatric evaluations. She also said the MSE did not reveal an emergency medical condition (EMC).

2.) The Hospital System's Medical Staff Bylaws indicated that in addition to the Medical Staff Bylaws, there shall be policies, procedures and rules and regulations applicable to all Medical Staff members and other individuals who have been granted clinical privileges or a scope of practice, and that: such Medical Staff policies, procedures and rules and regulations shall be considered an integral part of the Medical Staff Bylaws.

Documentation indicated the Hospital System's Administrative Policy titled "EMTALA Compliance for On-Call Physicians" was approved by the Hospital System's Board of Trustees on 6/9/04. The Policy indicated patients presenting to the ED must receive an appropriate MSE by a qualified medical provider (QMP) in order to determine if the patient has an EMC, and a QMP means: any licensed independent practitioner (LIP) with clinical privileges in the ED and qualified obstetrical nurses who may perform labor assessments on patients on the labor and delivery floor, or in the ED, under protocols and via telephone consultation with an obstetrical LIP on the medical staff.

The Hospital System's Medical Staff Bylaws and Rules and Regulations, Administrative Policy titled "EMTALA Compliance for On-Call Physicians" and/or other document approved by the governing body did not indicate LIPs with clinical privileges in Obstetrics could provide MSEs.

Based on documentation review, it was determined the only patient in a sample of 21 patients transferred from the Hospital's ED during the time period of 2/1-7/1/10 with an unstabilized EMC, was transferred without physician certification containing a summary of the risks and benefits upon which the transfer decision was based.

Findings included:

Patient #15 presented to the ED with complaint of left shoulder and posterior neck pain, headache, photosensitivity, blurred vision, difficulty moving his/her right arm, and right hand numbness, and was diagnosed with bilateral vertebral artery dissection (separation). Patient #15 was provided with medical treatment within the Hospital's capability and capacity, but could not be stabilized, and was transferred to a tertiary care hospital. Patient #15's Authorization To Transfer Form did not include a summary of the risks and benefits upon which the transfer decision was based.