HospitalInspections.org

Based on review of the facility's computer query, Emergency Department Logs,Medical Staff Bylaws, Medical Staff Rules and Regulations, facility policies, medical records, Progress Note physician statement,on-call schedules, incident report, credential files, County Sheriff Office case report, and interviews with the hospital staff , and the County Sheriff Officer, it was determined that the facility failed to ensure compliance with CFR 489.24, for one (1) individual (Patient #11) of twenty (20) sampled patients.


Findings:

Cross refer to A2406 as it relates to failure to provide an appropriate Medical Screening Exam(MSE).

Cross refer to A2407 as it relates to failure to provide appropriate stabilizing treatment.

Cross refer to A2409 as it relates to failure to ensure that all transfers are appropriate.

Based on review of the facility's policies, computer query, and staff interviews, it was determined that the facility failed to maintain medical records and other records related to individuals transferred to or from the hospital when a request was made on the individuals behalf for an examination and treatment of a medical condition for one (1) individual (#11) of twenty (20) sampled patients presenting to the hospital's emergency department..

Findings:

Review of the facility's policy entitled General Policies - Emergency Department (ED) no policy number, last revised 01/2015, revealed medical records are maintained on all patients presented or presenting themselves for treatment.

On 10/06/2015, a computer query using the patient's name, date of birth, and date of event revealed there was no documented evidence that a medical record was generated for Patient (#11) who presented to the ED on 09/28/2015.


During an interview on 10/06/2015 at 1:25 p.m. in the Board Room, the ED Nurse Manager confirmed that on 09/28/2015 a female (patient #11) was brought to the ED entrance by two ladies. The Manager explained that the facility's Security Guards responded and that the female did not want to get out of the car. The Manager said that the local police department was then notified. The Manager stated the female finally got out of the car and entered the ED. The Manager said he/she asked the female if she had any medical problems or needed to be seen in the ED and that the female stated no. The Manager further explained that the female reported that she wanted to go to the Veterans' Administration Hospital. The Manager explained that the ED physician (#4) talked with Patient #11,the patient to refuse treatment and was requesting to go to the Veterans' Administration Hospital. The Manager said that after the physician spoke with Patient (#11), the patient said that she did not have a ride to the other facility. The Manager also stated that the local Sheriff Officer from the ____________County Sheriff Office offered to give the patient a ride to the Veterans' Administration Hospital. The Manager confirmed that a medical record should have been generated for Patient #11 on 9/28/2015.

An interview was conducted on 10/06/2015 at 1:40 p.m. with the ED physician (#4) who was present in the ED when patient #11 arrived on 9/28/2015. The physician said he/she did not document the findings because the female was not entered into the system.

A telephone interview was conducted on 10/07/2015 at 12:10 p.m. in the Board Room, with the Chief Security Guard. The Chief stated that he/she asked the Nurse Manager if there was any information regarding the female and was told there was no information because the patient was never entered into the system.

Based on review of the facility's policies, Central Log, and staff interview, it was determined that the facility failed maintain a central log on one (1) individual (#11) brought to the hospital's Emergency Department by 2 prudent laypersons seeking assistance and whether he or she refused treatment or was refused treatment, transferred, stabilized, and treated or discharged for one (1) (#11) of twenty (20) sampled patients entered into the Central Log.

Findings:

Review of the facility's policy entitled EMTALA (Emergency Medical Treatment and Labor Act): Central Log Policy, number 1307110, last revised 05/2015, revealed the hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination (MSE) could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged.

Review of the facility's Central Log from April 01, 2015 through October 6, 2015 revealed there was no documented evidence of patient (#11) being entered into the Central Log on 09/28/2015.

An interview was conducted on 10/06/2015 at 1:25 p.m. in the Board Room with the ED Nurse Manager. The Manager confirmed that patient (#11) should have been entered into the Central Log.


The hospital failed to ensure that their Central Log policy and procedure was followed as evidenced by failing to maintain a Central Log on Patient #11 who was brought the hospital campus on 9/28/2015 by two (2) prudent laypersons because of her behavior and appearance believed that she needed examination and treatment.

2406
Based on review of a medical records, Medical Staff Bylaws, Medical Staff Rules and Regulations, facility's policies, Sheriff's Office Case Report, physician's progress note statement, and On-call schedules, Physician credentialing file, staff and Sheriff's Officer interviews, it was determined that the facility failed to ensure one (1) individual (#11) of twenty (20) sampled patients received an appropriate Medical Screening Examination (MSE) that was within the capability of the hospital's emergency department to determine whether or an emergency medical condition existed for an individual (#11) who was found by 2 prudent laypersons walking the highway with an unsteady gait, twitching and carrying a young child.



Findings:

1. Review of the Medical Staff Bylaws, and Medical Staff Rules and Regulations, adopted by the Medical Staff and Approved by the Board on 04/22/2014, revealed MSE(s) within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition (EMC). Qualified medical personnel who can perform MSE(s) within applicable Hospital policies and procedures are defined as:
a. Emergency Department:
1. members of the Medical Staff with clinical privileges in Emergency Medicine;
2. other Active Staff members; and
3. appropriately credentialed allied health professionals.

2. Review of the facility's policy entitled EMTALA (Emergency Medical Treatment and Labor Act) - Georgia Medical Screening Examination and Stabilization Policy, number 806746, last revised 03/2013, revealed an EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and:
1. the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition, or
2. a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition.
The Medical Screening Examination (MSE) must be completed by an individual (i) qualified to perform such an examination to determine whether an emergency medical condition (EMC) exists. The procedure was as follows:
1. An MSE is required when:
a. The individual comes to a DED of a hospital and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition. .. Extent of the MSE (Medical Screening Examination) a. Determine if an EMC exists. The hospital must perform am MSE to determine if an EMC exists ...Definition of MSE. An MSE is the process required to reach within clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The Medical Screening examination must be appropriate to the patients presenting signs and symptoms and the capability and capacity of the hospital. "

2. The " September 20015: Doctor's Hospital Psychiatry " on-call schedule was reviewed. The review revealed that an on-all psychiatrist was on-call on 09/28/2015 when Patient #11 presented to the ED, and a request was made on the patients behalf by two prudent laypersons for an examination.


3. Review of the ______ County Sheriff's Office case report dated 09/28/2015 revealed in part, the officers were dispatched to Doctors Hospital in reference to a disturbance/nuisance. The report noted that upon arrival, the officer spoke with the driver that drove the individual to the ED entrance and was informed that the driver observed the individual walking and carrying a small child. The report noted that the driver reportedly made the decision to take the individual to Doctors Hospital because the individual had an unsteady gate ({sic}-gait), was fidgeting, making jerking motions, and informing the driver that she had post-traumatic stress disorder and several other issues. The officer noted that upon arrival, the individual refused to exit the car but eventually entered the ED and was taken to a room for an assessment. The officer noted that the individual was advised by staff at Doctors that due to the individual's lack of insurance coverage the individual would be better served at the Veterans' Administration Hospital.

4. The medical record for Patient #11 was obtained from the Veteran's Administration Hospital for review. Review of the medical record revealed that the patient arrived at the VAH on 9/29/2015 at 1:48 p.m. The Emergency Department (ED) physician documented the patient's chief complain as "Paranoid" (Mental illness-being suspicious, irrational obsessive distrust of others). The section entitled "History of Present illness" the Physician documented in part, "Pt (patient) was found wandering along a street reportedly hearing voices and responding to them. Per deputy pt was seen briefly at Doctors Hospital briefly and was sent here for eval (evaluation). Pt states that she is afraid that we are going to take out my heart and also take away her child which she is caring for currently ...Physical Exam (examination) Gen (general): agitated...Psychiatric: paranoid, pressured speech. No SI/HI (Suicidal Ideation- thoughts of wanting to kill oneself/Homicidal Ideation-thoughts of harming others), or AVH (auditory visual hallucinations). The Physician also documented that patient #11 attempted to elope from the VAH during workup. Patient #11 then required security restraint and was given Ativan (medication used to treat anxiety) intramuscularly. The patient was then placed on a 1013 ( a classification for a patient needing emergent in-patient mental health treatment) order. The physician further documented that Patient #11 was to be transferred to an outside facility for further care. The Social Worker documented that patient #11 attempted to elope from the Emergency Department with her baby in her arms. The VA(Veterans Administration ) police and 2 ED physicians, multiple nurses and the Social Worker were involved in patient #11's and her baby's safety. Documentation by the Social Worker revealed in part, "Veteran stated "Don't kill me" , " Please don't shoot me!" the veteran was calmed down and brought back into the ED. Further documentation by the Social Worker revealed that after the patient was brought back into the ED a nurse took the baby to another part of the ED where she could be evaluated further. The Social Worker also documented that the Department of Family and Children Services (DFCS) was called and notified of the situation related to patient #11's child. The DFCS worker contacted the local courts and the child was placed in temporary custody of the court, until patient #11's mother could make arrangements to come in and care for the child. Patient #11 was accepted for in-patient psychiatric care at a Behavioral Health Center.


5. The Progress Notes dated 10/6/2015 and provided by physician (#4) on 10/06/15 revealed the female's (#11) "1350 (1:50 p.m.)Visit date 9/28/2015" The physician noted that the patient's history of present illness was as follows: female brought to hospital against her will by two (2) bystanders who picked the female up when she was observed walking to get to the Veterans' Administration Hospital. The female arrived at Doctors Hospital and was asked to come into a room for an evaluation. The female initially refused but eventually was brought into the ED. Female (#11) reported that she does not want to be here and wants to go to the Veterans' Administration Hospital. The female stated she needed a refill on her medications and denies complaints. Specifically, denies suicidal/homicidal ideations, hallucinations, or delusions. She denies fever, vomiting, diarrhea, headache, numbness, tingling, weakness, trauma, rashes, upper respiratory infections, or urinary tract infection symptoms. Review of systems was negative as stated above. Past medical history was reported as psychiatric issues. Past surgical history is unknown. Physical examination findings were within normal limits and vital signs were refused. Female was alert and oriented to person, place and time. The female's mood was normal. The physician documented the Action/Plan in part, "Patient #11's last name of right refuses all care at Doctors Hospital." She (#11) had no sign of an EMC at this time. She refuses all care here and wishes to go to the Veterans' Administration Hospital. She agrees to go with the Sheriff's Officer for transport to the Veterans' Administration Hospital. She cannot be further treated "at Doctors" against her will. The physician documented patient #11's name and date of birth on the bottom of the progress note. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that an appropriate medical screening examination was provided for patient #11 on 9/28/2015 when 2 prudent laypersons observers concluded that patient #11's behavior walking along a highway with a child (unsteady gait and twitching) requested and needed an examination and treatment of an identified emergency medical condition. There was no documentation in the progress note to indicate with this patient s presenting signs and symptoms that the psychiatrist on-call was called to evaluate the patient. After Patient #11 was taken from Doctor's Hospital via the county police officer it was determined that she had an emergency psychiatric condition.

6. Review of two (2) of two (2) credential files revealed documented evidence of all required facility data. Physician #4 had EMTALA training in 08/2008 and physician #5 had EMTALA training in 03/2012.


INTERVIEWS


1. During a telephone interview on 10/07/2015 at 12:10 p.m. in the Board Room, the Chief Security Guard stated he remembered the episode regarding two (2) women driving up to the ED entrance with a female carrying a baby in the back seat. The Chief said that the driver's daughter informed him/her that they had observed the female walking down the road carrying a baby and that they offered the individual a ride. The Chief stated the two (2) ladies reported that they were concerned because the female was twitching and had informed them that she was a veteran. The Chief explained that the female refused to get out of the car and that the two (2) ladies wanted her out of their car and reported that they were not taking the female to another facility because they feared for their safety. The Chief said he/she was concerned for the baby and that the local Sheriff's Office was notified so that they could assist with getting the female out of the car. The Chief said that the ED Nurse Manager arrived, and that the Nurse Manager and the Sheriff's Officer got the female out of the car and took her into the ED. The Chief said that approximately five (5) to ten (10) minutes later, the female was escorted out of the hospital by the Sheriff's Officer, and they were taking her to the Veterans' Administration Hospital. The Chief stated he/she stayed outside talking with the driver and never went inside the hospital with the female.

2. During an interview on 10/06/2015 at 1:25 p.m. in the Board Room, the ED Nurse Manager (#3) confirmed that on 09/28/2015 a female (patient #11) was brought to the ED entrance by two ladies. The Manager explained that the facility's Security Guards responded and that the female did not want to get out of the car. The Manager said that the local police department was then notified. The Manager stated the female finally got out of the car and entered the ED. The Manager said he/she asked the female if she had any medical problems or needed to be seen in the ED and that the female stated no. The Manager further explained that the female reported that she wanted to go to the Veterans' Administration Hospital. The Manager explained that the ED physician (#4) talked with the individual and that the individual continued to refuse treatment and was requesting to go to the Veterans' Administration Hospital. The Manager said that after the physician spoke with the individual the individual said she did not have a ride to the other facility and that the local Sheriff's Officer offered to give the patient a ride to the Veterans' Administration Hospital.

3. During an interview on 10/06/2015 at 1:40 p.m., the ED physician (#4) stated he/she had been asked to see a female who had been walking and was picked-up by two (2) ladies and brought to the ED entrance. The physician stated the individual did not want to be treated at Doctors Hospital and that the individual stated she wanted to go to the Veterans' Administration Hospital where she had received psychiatric treatment and her medications. The physician said the individual ended up in the ED and that he/she spoke with the individual and tried to offer her treatment. The physician confirmed that the individual was holding her baby at the time. The physician explained that he/she asked the female if he/she could examine her and that the female replied no, I want to go to the Veterans' Administration Hospital. The physician said the female finally got on the examination bed, and that he/she did a mental evaluation of the female. The physician said the female was adamant that she did not want to receive treatment at Doctors Hospital. The physician said the individual was alert to person and place and that the Sheriff's Officer offered to drive the patient to the Veterans' Administration Hospital so that the patient could get her medications refilled. The physician said he/she even offered to refill the female's medications and that the female had refused.

4. During an interview on 10/07/2015 at 9:15 a.m., the Corporal (#9) with the _______ County Sheriff's Office stated he/she had been informed by his/her supervisor not to talk with the surveyors. The officer did confirm that he/she and two (2) other officers were present when the ED physician examined patient #11.


The facility failed to ensure that their Medical Staff by Laws and Medical Staff Rules and Regulations and the facility ' s EMTALA policy and procedures were followed as evidenced by failing to provide an appropriate medical screening examination that was within the capability (medical clearance, psychiatric evaluation,1013'd, laboratory tests, and appropriate care of the child that presented with patient #11) of the hospital when requested by 2 prudent laypersons that observed and concluded from Patient #11's behavior on 9/28/2015 needed an examination to determine the presence of an emergency medical condition.

Based on review of the facility's policies and procedures, on call schedules, Physician Progress note, medical record and staff interviews, it was determined that the facility failed to provide stabilizing treatment that was within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for an individual that was found wandering the highway with a child for one (1) individual (Patient #11) of twenty (20) sampled patients.

Findings:


1. Review of the facility's policy entitled EMTALA (Emergency Medical Treatment and Labor Act) - Georgia Medical Screening Examination and Stabilization Policy, number 806746, last revised 03/2013, revealed an EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) ...1. An MSE is required when: a. the individual comes to a DED of a hospital and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition. This policy noted that if an emergency medical condition (EMC) is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA.

2. The "September 20015: Doctor's Hospital Psychiatry" on-call schedule was reviewed. The review revealed that an on-all psychiatrist was on-call on 09/28/2015 when Patient #11 presented to the ED, and a request was made on her behalf by 2 prudent laypersons for treatment of a medical examination.


3. The medical record for Patient #11 was obtained from the Veteran ' s Administration Hospital for review. Review of the medical record revealed that the patient arrived at the VAH on 9/28/2015 at 1:48 p.m. The Emergency Department (ED) physician documented the patient s chief complain as "Paranoid " (Mental illness-being suspicious, irrational obsessive distrust of others). The section entitled " History of Present illness " the Physician documented in part, "Pt (patient) was found wandering along a street reportedly hearing voices and responding to them. Per deputy pt was seen briefly at Doctors Hospital briefly and was sent here for eval (evaluation). Pt states that she is afraid that we are going to take out my heart and also take away her child which she is caring for currently ...Physical Exam (examination) Gen (general): agitated...Psychiatric: paranoid, pressured speech. No SI/HI (Suicidal Ideations/Homicidal Ideations), or AVH (auditory visual hallucinations). The Physician also documented that patient #11 attempted to elope from the VAH during workup. Patient #11 then required security restraint and was given Ativan (medication used to treat anxiety) intramuscularly. The patient was then placed on a 1013 order. The physician further documented that Patient #11 was to be transferred to an outside facility for further care. The Social Worker documented that patient #11 attempted to elope from the Emergency Department with her baby in her arms. The VA(Veterans Administration ) police and 2 ED physicians, multiple nurses and the Social Worker were involved in patient #11's and her baby's safety. Documentation by the Social Worker revealed in part, " Veteran stated " Don't kill me", " Please don't shoot me!" the veteran was calmed down and brought back into the ED. Further documentation by the Social Worker revealed that after the patient was brought back into the ED a nurse took the baby to another part of the ED where she could be evaluated further. The Social Worker also documented that the Department of Family and Children Services (DFCS) was called and notified of the situation related to patient #11's child. The DFCS worker contacted the local courts and the child was placed in temporary custody of the court,until patient #11'++---s mother could make arrangements to come in and care for the child. Patient #11 was accepted for in-patient psychiatric care at a Behavioral Health Center.

4. The Progress Notes dated 10/6/2015 and provided by physician (#4) on 10/06/15 revealed the female's (#11) "1350 Visit date 9/28/2015." The physician noted that the patient's history of present illness was as follows: female brought to hospital against her will by two (2) bystanders who picked the female up when she was observed walking to get to the Veterans' Administration Hospital. The female arrived at Doctors Hospital and was asked to come into a room for an evaluation. The female initially refused but eventually was brought into the ED. Female (#11) reported that she does not want to be here and wants to go to the Veterans' Administration Hospital. The female stated she needed a refill on her medications and denies complaints. Specifically, denies suicidal/homicidal ideations, hallucinations, or delusions. She denies fever, vomiting, diarrhea, headache, numbness, tingling, weakness, trauma, rashes, upper respiratory infections, or urinary tract infection symptoms. Review of systems was negative as stated above. Past medical history was reported as psychiatric issues. Past surgical history is unknown. Physical examination findings were within normal limits and vital signs were refused. Female was alert and oriented to person, place and time. The female's mood was normal. The physician documented the Action/Plan in part, "Patient #11's last name of right refuses all care at Doctors Hospital " She (#11) had no sign of an EMC at this time. She refuses all care here and wishes to go to the Veterans' Administration Hospital. She agrees to go with the Sheriff's Officer for transport to the Veterans' Administration Hospital. She cannot be further treated " at Doctors " against her will.



INTERVIEWS

1. During an interview on 10/06/2015 at 1:25 p.m. in the Board Room, the ED Nurse Manager (#3) confirmed that on 09/28/2015 a female (patient #11) was brought to the ED entrance by two ladies. The Manager explained that the facility's Security Guards responded and that the female did not want to get out of the car. The Manager said that the local police department was then notified. The Manager stated the female finally got out of the car and entered the ED. The Manager said he/she asked the female if she had any medical problems or needed to be seen in the ED and that the female stated no. The Manager further explained that the female reported that she wanted to go to the Veterans' Administration Hospital. The Manager explained that the ED physician (#4) talked with the individual and that the individual continued to refuse treatment and was requesting to go to the Veterans' Administration Hospital. The Manager said that after the physician spoke with the individual the individual said she did not have a ride to the other facility and that the local Sheriff's Officer offered to give the patient a ride to the Veterans' Administration Hospital.

2. During an interview on 10/06/2015 at 1:40 p.m., the ED physician (#4) stated he/she had been asked to see a female who had been walking and was picked-up by two (2) ladies and brought to the ED entrance. The physician stated the individual did not want to be treated at Doctors Hospital and that the individual stated she wanted to go to the Veterans' Administration Hospital where she had received psychiatric treatment and her medications. The physician said the individual ended up in the ED and that he/she spoke with the individual and tried to offer her treatment. The physician confirmed that the individual was holding her baby at the time. The physician said the female finally got on the examination bed and that he/she did a mental evaluation of the female. The physician said he/she did not document the findings because the female was not entered into the system. The physician said the female was adamant that she did not want to receive treatment at Doctors Hospital. The physician said the individual was alert to person and place and that the Sheriff's Officer offered to drive the patient to the Veterans' Administration Hospital so that the patient could get her medications refilled. The physician said he/she even offered to refill the female's medications and that the female had refused.


The facility failed to ensure that their stabilization policy and procedure was followed as evidenced by failing to provide stabilizing treatment as required to patient #11 when she and her were brought to Doctor's Hospital's on 9/28/2015 by 2 prudent laypersons seeking treatment for a medical condition.

Based on review of the facility's policies and procedures, Hospital incident report, Police Officer Case Report, and staff interviews it was determined that the facility failed to follow their policy and procedure by failing to appropriately transfer an individual to another medical facility for 1 (one) individual (#11) of twenty (20) sampled patients who presented to the hospital's emergency department with a psychiatric emergency medical condition.

Findings:


1. Review of facility policy entitled EMTALA (Emergency Medical Treatment and Labor Act) - Transfer Policy, number 807019, last revised 03/2013, revealed any transfer of an individual with an Emergency Medical Condition (EMC) must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual's behalf or by a physician order with the appropriate physician certification as required under EMTALA. The policy also revealed the receiving hospital has agreed to accept the individual to provide appropriate medical treatment and that the receiving hospital has available space and qualified personnel for the treatment of an individual. Review of the Physician Certification form revealed an appropriate transfer included but was not limited to the following: --Medical Condition/diagnosis, --Reason for transfer,--Risks and benefits of the transfer, --Mode/support during transfer as determined by physician, --Receiving facility and individual, --Accompanying documentation,--Patient consent to medically indicated transfer or patient request for transfer.


3. The facility's incident report regarding patient #11 was reviewed. The incident report created on 10/7/2015 at 2:15 p.m. revealed in part, "At approximately 1243. Chief_____ and myself responded to an assistance call to ER (emergency room) Canopy. Once on the scene I observed an unknown_______ female with small child refusing to exit two visitors vehicle stating that she wanted to go to the VA hospital for her treatment. After continued attempts to get the unknown female out of the vehicle. ____ County Officer was called to assist with dealing with (Patient #11).______County Officer arrived on the scene to speak with (Patient #11) at 1250, getting her to exit the vehicle. (Patient #11) was transported by ____ County Officer to the VA as requested."

4. Review of the ________ County Sheriff's Office case report dated 09/28/2015 revealed the officers were dispatched to Doctors Hospital in reference to a disturbance/nuisance. The officer noted that he/she transported the individual and her baby to the Veterans' Administration Hospital and advised the receiving hospital staff that during transport the individual said that the voices in her head were saying they were going to kill her.


INTERVIEWS

1. During an interview on 10/06/2015 at 3:40 p.m. in the Board Room, the Security Lieutenant (#8) stated he/she remembered the episode on 09/28/2015 and that the female had been holding her baby. The Lieutenant explained that the individual was in the back seat of a car at the ED entrance. The Lieutenant said he/she spoke with the driver and was informed that the driver had picked the individual up when the individual was observed walking down the road. The Lieutenant stated the driver informed him/her that although the individual (Patient #11) wanted to go to the Veterans' Hospital the driver had brought the individual to Doctors Hospital. The Lieutenant explained that the individual did not want to get out of the car and that the ______ County Sheriff's Office was notified. The Lieutenant said that once the Sheriff's Officer and nurse arrived that he/she had left the scene and did not know where the individual went.

2. During a telephone interview on 10/07/2015 at 12:10 p.m. in the Board Room, the Chief Security Guard stated he remembered the episode regarding two (2) women driving up to the ED entrance with a female carrying a baby in the back seat. The Chief said that the driver's daughter informed him/her that they had observed the female walking down the road carrying a baby and that they offered the individual a ride. The Chief stated the two (2) ladies reported that they were concerned because the female was twitching and had informed them that she was a veteran. The Chief explained that the female refused to get out of the car and that the two (2) ladies wanted her out of their car and reported that they were not taking the female to another facility because they feared for their safety. The Chief said he/she was concerned for the baby and that the local Sheriff's Office was notified so that they could assist with getting the female out of the car. The Chief said that the ED Nurse Manager arrived and that the Nurse Manager and the Sheriff's Officer got the female out of the car and took her into the ED. The Chief said that approximately five (5) to ten (10) minutes later the female was escorted out of the hospital by the Sheriff's Officer and they were taking her to the Veterans' Administration Hospital. The Chief stated he/she stayed outside talking with the driver and never went inside the hospital with the female.

3. During an interview on 10/06/2015 at 1:25 p.m. in the Board Room, the ED Nurse Manager (#3) confirmed that on 09/28/2015 a female (patient #11) was brought to the ED entrance by two ladies. The Manager explained that the facility's Security Guards responded and that the female did not want to get out of the car. The Manager said that the local police department was then notified. The Manager stated the female finally got out of the car and entered the ED. The Manager said he/she asked the female if she had any medical problems or needed to be seen in the ED and that the female stated no. The Manager further explained that the female reported that she wanted to go to the Veterans' Administration Hospital. The Manager explained that the ED physician (#4) talked with the individual and that the individual continued to refuse treatment and was requesting to go to the Veterans' Administration Hospital. The Manager said that after the physician spoke with the individual the individual said she did not have a ride to the other facility and that the local Sheriff's Officer offered to give the patient a ride to the Veterans' Administration Hospital.

4. During an interview on 10/06/2015 at 1:40 p.m., the ED physician (#4) stated he/she had been asked to see a female who had been walking and was picked-up by two (2) ladies and brought to the ED entrance. The physician stated the individual did not want to be treated at Doctors Hospital and that the individual stated she wanted to go to the Veterans' Administration Hospital where she had received psychiatric treatment and her medications. The physician said the individual ended up in the ED and that he/she spoke with the individual and tried to offer her treatment. The physician confirmed that the individual was holding her baby at the time. The physician said the female was adamant that she did not want to receive treatment at Doctors Hospital. The physician said the individual was alert to person and place and that the Sheriff's Officer offered to drive the patient to the Veterans' Administration Hospital.


The facility staff was well aware that patient #11 was being transferred to VAH on 9/28/2015 and failed to notify the receiving hospital to obtain agreement and acceptance of the patient in order to provide appropriate medical treatment, and failing to ensure the receiving hospital (VAH) had available space and qualified personnel for treatment of the patient. The facility also failed to provide documentation that a written certification for transfer form was completed by the ED physician for patient #11. As this resulted in an inappropriate transfer for patient #11 on 9/28/2015.