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1. Based on review of medical records, policy and procedures, on-call schedules, facility license and medical staff and staff interviews the facility failed to ensure that an appropriate medical screening examination was provided according to the individual's presenting signs and symptoms, and was within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists for 1 (#15) of 20 sampled patients. Refer to findings in Tag A-2406.

2. Based on medical record review, policy and procedure review, bed census reports and facility License review, and staff interview the facility failed to provide medical treatment within its capacity that minimizes the risk to the individual's health as evidenced by transferring a patient to another acute care hospital when the transferring hospital had the capability and capacity to treat the emergency medical condition on an inpatient basis for 1 (#1) of 20 sampled patient records reviewed. Refer to findings in Tag A-2409.

Based on review of medical records, policy and procedures, on-call schedules, facility license and medical staff and staff interviews the facility failed to ensure that an appropriate medical screening examination was provided according to the individual's presenting signs and symptoms, and was within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists for 1 (#15) of 20 sampled patients.

The findings included:

1. Medical Record Review Patient #15

A review of the medical record revealed that patient #15 presented to the hospital on 1/24/2018 at 4:25 PM. The Emergency Department physician documented on the section of the HPI (History of Present illness) specified in part, "Fifty-two (52) year old. . .presents to the ED due to assumed seizure just prior to arrival to the ED. . . found pt. (patient) with seizure-like activity and rushed here to the ED. Associated symptoms include headaches, slurred speech, disorientation, confusion, and inability to control herself. She denies both suicidal and homicidal intentions. Pt. has a PM (past Medical) Hx (history) of seizures ...Pt began acting erratically in the ED flinging herself back and forth on the bed saying nonsensical things. . . Basic Physical Exam: Vital Signs Pulse Ox: 98 B/P:132/75 ...Temp: 97.9 Pulse: 87 Resp: 20 ... General/Const (constitution): awake. Alertness: Confused, Disoriented. Behavior: Uncooperative ...Head: Atraumatic, Normocephalic . . . Psychiatric: Not Suicidal, Not homicidal Abnormal Thinking/Perception; Judgement abnormal, Confused. The radiology results for the chest x-ray revealed no evidence for acute cardiopulmonary process. The CT scan of the brain impression was: "No CT evidence for acute intracranial pathology." The ED physician documented the patient's Clinical Impression: Primary Impression: Seizure and Secondary Impression: Acute psychosis. The ED physician documented for safety concerns Patient+ #15 was being transferred to an acute care hospital for further evaluation and treatment. Review of the EMTALA Memorandum of Transfer form dated 01/24/18 documents receiving facility (name of hospital) and documented under Section III Medical Benefits to include 'Obtain level of care/service unavailable at this facility - psychiatry/neurology.' The hospital failed to ensure that their policy and procedure was followed as evidenced by the hospital ancillary services, a neurologist and a psychiatrist were available to provide an evaluation for patient #15 on 1/24/2018. The hospital had a neurologist listed on-call and psychiatry was listed as available emergency medicine services for the hospital.


2. Facility P&P

The facility's Policy and procedure titled, "EMTALA Medical Screening Policy" Policy #4666, Effective date: 05/25/2016, Last revision Date: 05/25/2016 was reviewed. The policy stated in part, "The hospital with an emergency department must provide to an individual that is not a patient who "comes to the emergency department" an appropriate MSE (Medical Screening Examination) within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition ("EMC") exists. . .If an EMC is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer ... PROCEDURE: . . . Capabilities of a main hospital provider means the physical space, equipment, supplies and services (e.g., Trauma care, surgery, intensive care, pediatrics, obstetrics, burn unit, neonatal unit or psychiatry) including ancillary services available at the hospital . . . The capabilities of the hospital staff mean the level of care that the hospital's personnel can provide within the training and scope of their professional licenses . . . Emergency Medical Condition. . . A medical conditions manifesting itself by acute symptoms of sufficient severity (including sever pain, psychiatric disturbances and/.or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in jeopardy ...Medical Screening Examination ("MSE") is the process required to reach within clinical confidence, the point at which it can be determine whether or not an EMC exists. . .Such screening must be done within the facility's capability and available personnel, including on-call physicians.. . With respect to an individual with psychiatric symptoms, an MSE consists of both a medical and psychiatric screening. . . On Call list refers to the list that is required to maintain that defines those physicians who are "on-call" for duty after the initial MSE to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC. The purpose of the on-call list is to ensure that the dedicated emergency department is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide treatment necessary to stabilize individuals with EMC's. If a hospital offers a service to the public, the service should be available through on-call coverage of the emergency department . . . How to Provide the Medical Screening Examination . . . 9. . . The psychiatric MSE includes as assessment of suicide or homicide attempt or risk, orientation and assaultive behavior that indicates danger to self and others."

3. On-Call Schedule

Review of the January 2018 Neurology and Stroke Alert on-call physician list documents a physician on-call each day of the month. On January 24, 2018 a Neurologist, an ancillary service was on call and routinely available to the ED to provide further evaluation and treatment for patient #15.

4. Hospital State License

Review of the Hospital State License documents Psychiatry is included in the services the hospital provides.

5. Interviews

On 04/03/18 at 2:20 PM, an interview was conducted with the ED Director and ED Charge Nurse who stated their psychiatry services is for admitted inpatients and those patients who come through the ED on an involuntary basis are transferred out to hospitals that have a behavioral unit. The ED Director stated they would stabilize the medical condition and admit the patient for treatment and would have psychiatry assess the patient on an inpatient basis.

On 04/04/18 at 11:06 AM, an interview was conducted with the VP of Regulatory Compliance and Quality who confirmed they do not have psychiatry on call. She stated they have a psychiatry group consisting of 3 behavioral health specialist MDs who they call for inpatient consults. The VP of Regulatory Compliance and Quality confirmed they do have Neurology physicians on call 24/7 as they are a Stroke Center.

Based on medical record review, policy and procedure review, bed census reports and facility License review, and staff interview the facility failed to provide medical treatment within its capacity that minimizes the risk to the individual's health as evidenced by transferring a patient to another acute care hospital when the transferring hospital had the capability and capacity to treat the emergency medical condition on an inpatient basis for 1 of 20 sampled patient (#1) records reviewed.

The findings included:

Policy and Procedure

1. The facility's policy entitled "EMTALA Florida Transfer Policy" Original date: 1/1/99; Review date: 9/11, 5/12, 5/15, 12/17. The policy states in part, "Policy: 2. a. Transfer will be an appropriate transfer if: a. the transferring hospital provides medical treatment within its capacity that minimizes the risk to the individual's health ... Lateral Transfers - Transfers between hospitals of comparable resources and capabilities are not permitted unless the receiving facility would offer enhanced care benefits to the patient that would outweigh the risks of the transfer. Examples of such situations include a mechanical failure of equipment or no ICU beds available ..."

2. Review of the facility EMTALA Florida Medical Screening Examination and Stabilization policy states in part, 'Extent of the MSE (medical screening exam) - An on-going process: The individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC, and if he or she does, until the EMC is relieved or eliminated or the individual is appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided to the completion of the MSE and until discharge or transfer.... Individuals with psychiatric or behavioral symptoms: The medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicates danger to self or others.'

3. Medical Record Review Patient #1

Patient #1 presented to the Emergency Department (ED) on 03/10/18 at 9:24 PM initially with a chief complaint of pain to the right ankle. Review of the Nursing Progress Notes dated 03/10/18 at 9:24 PM documents the patient was brought in by family who stated the patient has been acting weird and erratic. Per the nursing notes 'Patient hasn't 'used' since 7 PM yesterday. Patient also states his right ankle hurts. Objective assessment - Alert, oriented x 1; acting erratic. Patient seems confused at times speaking of things not there.' The file documents the patient is uninsured.

An assessment was conducted by an ED Physician Assistant (PA) on 03/10/18 at 9:59 PM, documenting the chief complaint was right ankle pain. Blood and radiological studies were ordered; intravenous fluids and medications were administered. At the time of the initial assessment completed by the ED PA on 03/10/18 at 9:59 PM, he documented under Psychiatric - change mental status; confused, disoriented The ED physician further documents 'Patient family is concerned because patient has admitted to them before that he wants to end himself.' Further review of the clinical record revealed no evidence of any suicide safety precautions ordered or implemented for Patient #1.

Review of the laboratory studies completed, revealed the patient had critically abnormal liver study results. The x-ray of the right ankle was negative for fracture.

Further review of the clinical record revealed documentation by the ED PA on 03/11/18 at 12:23 AM stating 'ED MD is currently speaking to ICU. Patient will eventually go to ICU' (intensive care unit).

Documentation by the ED PA on 03/11/18 at 12:28 AM states 'Condition: Stable. Disposition Decision: Admit. Request Time: 12:28 AM.'

Review of an ED MD (medical doctor) documentation with notation the (attending) MD for the patient is the MD the ED PA was in communication with in reference to admitting the patient to ICU. The ED MD's Progress Note assessment dated 03/11/18 at 1:40 AM, now documents the patient's chief complaint is acute encephalopathy. The ED MD documented the patient was brought in by a 'family member' for acute confusion stated. 'Family member' concerned because patient has had issues of suicidality and was suspicious of intentional drug overdose. The ED MD further documented the patient is a known polysubstance abuser stating the details on the timing of ingestion and progression of encephalopathy are not available. Further review of the clinical record revealed no evidence of any suicide safety precautions ordered or implemented for Patient #1.

Review of a notation in the clinical record dated 03/11/18 at 1:51 AM, author undetermined, documents '(Name of Hospital) transfer coordinator refused this patient because of his poly substance abuse.'

Further review of the clinical record revealed a note dated 03/11/18 at 3:51 AM, author undetermined, documenting a request for transfer to another hospital.

Review of a Nursing Progress Notes dated 03/11/18 at 0351, documents '(Name of Hospital) Transplant Team denied patient because of substances he's on.'

Review of the Diagnosis, Assessment & Plan dated 03/11/18 at 4:20 AM, documentation by the ED MD documents under Impression: Acute encephalopathy/drug overdose; acute liver failure; acute kidney failure; query sepsis/lactic acidosis; query suicide attempt. Plan: discuss disposition with ED (attending MD) regarding transfer to liver transplant center.

Review of an ED Nursing Progress Note by the Registered Nurse (RN), dated 03/11/18 at 4:23 AM, documents a Suicide Assessment was completed, over 6 hours after the ED PA made notation of the patient's families concerns regarding possible suicidal ideations. The RN documented the patient was not at risk for suicide, despite the ED MD documenting in his final impression on 03/11/18 at 4:20 AM, query suicide attempt. At no point from when the patient presented to the ED on 03/10/18 to transfer to the accepting hospital were any suicide safety precautions implemented.

Review of an ED Nursing Progress Note by the same RN dated 03/11/18 at 5:29 AM, documents under Patient Disposition: Transfer. Chief complaint: Ingestion. Transfer Assessment- Reason for transfer: Services not offered. Services required for transfer: Surgical. Transferred via: Ambulance.

Review of the EMTALA Memorandum of Transfer form, dated 03/11/18, revealed a medical condition of Hepatic Failure and Polysubstance Abuse; no notation if the patient is stable; Medical Benefits to include: Obtain level of care / service unavailable at this facility - Service Liver Specialist and Psych; and Medical Benefits outweigh the risks; accepted by acute care hospital in Miami, Florida; and patient unable to sign a consent for the transfer.

Patient #1 was transferred out of the hospital on 03/11/18 at 5:31 AM per the ED RN's documentation on 03/11/18 at 5:29 AM in stabilized condition.

Review of the receiving hospital records, revealed Patient #1 was admitted to the receiving hospital on 03/11/18 with a diagnosis of past medical history of suicidal attempt, hepatitis C, polysubstance abuse and acute liver failure. Initially, the patient was to be admitted to the medical ICU, however with the administration of intravenous fluids and bed rest, his status improved. Review of the ED MD note, dated 03/11/18 at 12:59 PM, documents Patient #1 was improving, waking up and more alert. At 2:30 PM, the ED MD documented the patient is downgraded to telemetry and totally awake and ambulating and talking. Patient #1 was treated with intravenous fluids, medications and intravenous antibiotics. He was placed on a one to one sitter and psychiatry was consulted for past medical history of suicidal attempt. Patient #1 was not placed under an involuntary psychiatric admission status. On 03/15/18, Patient #1 was cleared by psychiatry and discharged from psychiatry with the one to one sitter discontinued. On 03/16/18, the blood cultures emerged positive for a bacteria and Patient #1 was admitted to a transitional care setting on 03/16/18 for intravenous antibiotic therapy for a diagnosis of cellulitis to the right forearm possible secondary to a recent intravenous line insertion site. Patient #1 completed the course of intravenous antibiotics and was subsequently discharged home to his family on 04/02/18.

4. Intensive Care Unit Bed Census Report

Review of the transferring hospital's Intensive Care Unit (ICU) status revealed a capacity of 16 beds. Review of the ICU Census Report for 03/10/18 revealed a census of 14. Review of the ICU Census Report for 03/11/18 revealed a census of 10.

5. Facility License

Review of the transferring hospital's State License effective 09/01/16 and expiring on 08/31/18, revealed the services offered at the facility include Emergency Services, Internal Medicine and Psychiatry.

6. Interview

On 04/05/18 at approximately 4:00 PM, during the exit conference with one of the attendees being the Chief Nursing Officer (CNO), were apprised of the issues identified and an inquiry was made if they monitor or track their patient transfers, to which the CNO stated, that has not been their practice to do so.
The facility failed to ensure that their own transfer policy and procedure was followed as evidenced by inappropriately transferring patient #1 on 3/11/2018 to another acute care hospital, when Northwest Medical Center had the capability and capacity to provide the care and treatment for the patient. As this resulted in an inappropriate transfer for patient #1 on 3/11/2018.