HospitalInspections.org

During an EMTALA investigation of complaint #42683 completed 10/23/17 to 11/2/17, Tennova Healthcare was found to be out of compliance with Requirements for the Responsibilities of Medicare Participating Hospitals in Emergency Cases 42 CFR PART 489.20 and 489.24. Based on review of facility policies, review of Medical Staff Bylaws, review of Medical Staff Rules and Regulations, medical record reviews, review of Psychiatric On-Call schedules, review of Behavioral Unit bed census records, and interviews, the facility failed to:

1. Ensure on-call physicians who were on-call and available came to the emergency department to provide further evaluation and treatment for 29 patients (#5, #8, #11, #13, #14, #17, #37, #40, #46, #78, #80, #86, #87, #88, #90, #93, #96, #97, #98, #102, #103, #112 #113, #120, #121, #123, #124, #171, and #180) of 84 psychiatric patients held in the Emergency Department (ED) awaiting inpatient psychiatric admission of 181 emergency records reviewed.

2. Ensure individuals who come to the emergency department (regardless of their ability to pay) were provided an appropriate medical screening examination(s) within the capability of the hospital's emergency department including providing ancillary services of the on-call psychiatrist who was routinely available to the emergency department for 29 patients (#5, #8, #11, #13, #14, #17, #37, #40, #46, #78, #80, #86, #87, #88, #90, #93, #96, #97, #98, #102, #103, #112 #113, #120, #121, #123, #124, #171, and #180) of 84 psychiatric patients held in the Emergency Department (ED) awaiting inpatient psychiatric admission of 181 emergency records reviewed.

3. Provide, within its capabilities, further examination and treatment as required to stabilize emergency psychiatric conditions for 29 patients (#5, #8, #11, #13, #14, #17, #37, #40, #46, #78, #80, #86, #87, #88, #90, #93, #96, #97, #98, #102, #103, #112 #113, #120, #121, #123, #124, #171, and #180) of 84 psychiatric patients held in the Emergency Department (ED) awaiting inpatient psychiatric admission of 181 emergency records reviewed.

4. Provide a Medical Screening Examination without delay in order to obtain information on patients method of payment and/or insurance status for 3 patients (#54, #74, and #76) of 181 emergency patients reviewed.

5. Admit patients determined to require inpatient psychiatric services to its inpatient psychiatric unit when the psychiatric unit had capability and capacity to provide care for 29 patients (#5, #8, #11, #13, #14, #17, #37, #40, #46, #78, #80, #86, #87, #88, #90, #93, #96, #97, #98, #102, #103, #112 #113, #120, #121, #123, #124, #171, and #180) of 84 psychiatric patients held in the Emergency Department (ED) awaiting inpatient psychiatric admission of 181 emergency records reviewed.

Refer to A-2404, A-2406, A-2407, A-2408, and A-2409.


30553

Based on review of 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 after the initial examination provided further evaluation and/or treatment necessary for patients with emergency psychiatric conditions for 29 patients (#5, #8, #11, #13, #14, #17, #37, #40, #46, #78, #80, #86, #87, #88, #90, #93, #96, #97, #98, #102, #103, #112 #113, #120, #121, #123, #124, #171, and #180) of 84 psychiatric patients held in the Emergency Department (ED) awaiting inpatient psychiatric admission of 181 emergency records reviewed.

The findings included:

Policies and Procedures:
Review of facility policy "Emergency Medical Treatment and Patient Transfer Policy" effective date 12/1/1998, revealed "...The Hospital shall maintain a list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an Emergency Medical Condition or woman in labor...during the Hospital's normal operating hours, all medical specialties represented on the medical staff should be available for emergency services..."

Medical Staff Bylaws:
Review of facility Medical Staff Bylaws adopted and approved 6/3/2016, revealed "...Article III - Medical Staff Membership...3.3 Basic Responsibilities of Staff Members...Abide by the Medical Staff Bylaws and other lawful standards, policies...and Rules & Regulations of the Medical Staff..."

Medical Staff Rules and Regulations:
Review of facility Medical Staff Rules and Regulations, undated, Article VI, Emergency Medical Screening, Treatment, Transfer, and On-call Roster Policy revealed "...6.1(a) Screening...(4) Services available to Emergency Department patients shall include all ancillary services routinely available to the Emergency Department, even if not directly located in the department..."

Medical record reviews:

1. Medical record review revealed Patient #5 presented to the ED at Hospital A's Main Campus on 10/5/17 at 2:56 PM for complaint of "...is suicidal..." Further review of the medical record revealed the patient was transferred as an involuntary admission to Hospital B on 10/7/17 at 12:48 PM.

Medical record review of a physician's note dated 10/5/17 at 2:57 PM revealed Patient #5 was provided a Medical Screening Examination (MSE) which included: a History of Present Illness (HPI), a medical and psychiatric history, a Review of Systems (ROS), and a physical exam. Further review of a physician's note dated 10/5/17 at 4:25 PM revealed "...Medically stable for further psychiatric care..." Continued review of a physician's note dated 10/7/17 at 12:47 PM revealed "...Will proceed with previously planned transfer to psychiatric hospital..." Further review of a physician's note dated 10/7/17 at 7:13 AM revealed "...Disposition Summary...Transfer ordered to [Hospital B]...Diagnosis is Suicidal Ideation..."

Medical record review revealed no documentation Patient #5 was evaluated or treated by Hospital A's on-call psychiatrist during the 1 day and 22 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 10/5/17, 10/6/17, and 10/7/17.

2. Medical record review revealed Patient #8 presented to the ED at Hospital A's Main Campus on 9/29/17 at 5:08 PM for complaint of psychiatric problems. Further review revealed the patient was diagnosed with Psychosis and Homicidal and Suicidal Ideation and was transferred to Hospital C on 10/4/17 at 2:44 PM.

Medical record review of an ED physician's notes dated 9/29/17 at 5:26 PM revealed Patient #8 was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam. Further review of the physician's notes dated 9/29/17 at 5:26 PM revealed "...reported a history of drug abuse...Patient does admit to me that he has a plan to hurt someone...is disorganized and agitated and paranoid..." Further review of physician's notes dated 10/2/17 at 3:11 PM revealed "...agitated, screaming obscenities..." Further review of ED physician's note dated 10/4/17 at 2:37 PM revealed "...Disposition summary...Transfer ordered to [Hospital C]...Diagnosis...Psychosis, Homicidal and Suicidal Ideation..."

Medical record review revealed no documentation Patient #8 was evaluated or treated by Hospital A's on-call psychiatrist during the 4 days and 22 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/29/17, 9/30/17, 10/1/17, 10/2/17, 10/3/17, and 10/4/17.

3. Medical record review revealed Patient #11 was admitted to Hospital A's Main Campus ED on 9/25/17 at 7:03 AM with diagnoses including Suicidal Ideation. Further review revealed the patient was transferred to Hospital C on 9/27/17 at 12:53 PM.

Medical record review of an ED Physician's Note dated 9/25/17 at 8:06 AM revealed "...presents complaining...I want to kill myself...hearing people[s] voices...seeing demons...felt this way for 1.5 months...prior to my evaluating...patient...he tried to pull something off the wall...actually used a piece of metal plating [to] cut his right...wrist..." Continued review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review of the ED Physician's Order revealed a consult for Mobile Crisis Unit (MCU) (a Tennessee Department of Mental Health agency which provides a response team consisting of mental health counselors) on 9/25/17 at 10:07 AM and a consult for Tennova Access (facility flow center which provides assistance with psychiatric patient placement) on 9/25/17 at 3:36 PM. Further review revealed the patient had a Certificate of Need (CON) For Emergency Involuntary Admission during the patient's stay at Hospital A's Main Campus signed on 9/25/17 at 3:32 PM and the patient remained in the ED until 9/27/17 at 12:53.

Medical record review revealed no documentation Patient #11 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 5 and 1/2 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/25/17, 9/26/17, and 9/27/17.

4. Medical record review revealed Patient #13 was admitted to Hospital A's Main Campus ED on 9/20/17 at 3:29 PM with a diagnoses including Suicidal Ideations, Substance Abuse, and Pregnancy. Further review revealed the patient was transferred to Hospital C on 9/23/17 at 8:32 AM.

Medical record review of an ED Physician's Note dated 9/20/17 at 4:19 PM revealed "...depressed...having suicidal thoughts...had a son...murdered 5 months ago...depressed...using opiates since that time...reports she is 4-5 months pregnant...she snorts or takes tablets..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review of an ED Physician's note dated 9/20/17 at 5:29 PM revealed "...tearful...despondent...out of concern for her safety...have completed a certificate of need...Gravida 3 [third pregnancy]...Pregnancy Verified...EDC [estimated date of conception] 1/13/2018...Gestational Age...23 weeks 5 days..."

Medical record review of an ED Physician's note dated 9/22/17 at 7:21 PM revealed "...Transfer ordered to [Hospital C]...Diagnosis...Suicidal Ideations...Substance Abuse...Pregnancy..."

Medical record review revealed no documentation Patient #13 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 17 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/20/17, 9/21/17, 9/22/17, and 9/23/17.

5. Medical record review revealed Patient #14 presented to the ED at Hospital A's Main Campus on 9/18/17 at 6:45 PM for complaint of "...threatening her mother...not used meth [methamphetamine] in 3 days..." Further review of the medical record revealed Patient #14 was diagnosed with Suicidal Ideation and was transferred to Hospital B on 9/21/17 at 4:01 PM.

Medical record review of an ED physician's notes dated 9/18/17 at 5:56 PM revealed Patient #14 was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam. Further review of the physician's notes dated 9/18/17 at 7:57 PM revealed "...Patient having thoughts of suicide. Plan for suicide is death by cop...refuses vs [vital signs] and blood draw, and urine testing...states he wants to die or go to jail...he will kill the next person that enters his room that is not a police officer with a taser [device used to disable an individual] or gun to kill him or to take him to jail..." Further review of the physician's notes dated 9/19/17 at 1:08 PM revealed "...Consult order...Mobile Crisis Unit..." Further review of the physician's notes dated 9/18/17 at 3:16 PM revealed "...Disposition summary...Transfer ordered to [Hospital B]...Diagnosis is Suicidal Ideation..."

Medical record review revealed no documentation Patient #14 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 21 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/18/17, 9/19/17, 9/20/17, and 9/21/17.

6. Medical record review revealed Patient #17 was admitted to Hospital A's Main Campus ED on 8/30/17 at 1:57 PM via Law Enforcement with diagnoses including Suicidal Ideations. Further review revealed the patient was transferred to Hospital C on 9/6/17 at 3:10 PM.

Medical record review of an ED Physician's Note dated 8/30/17 at 3:44 PM revealed "...presents...with a history of a suicide gesture...made 3 superficial cuts to his neck with...safety razor...schizoaffective disorder...was recently released from an inpatient psychiatric treatment facility...was visiting a group home with...parents...was being considered for...placement...he became very irate...violent...he made 3 superficial cuts to his neck...said...he was suicidal..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review of an ED Physician's note dated 9/1/17 at 10:03 AM revealed "...remains in the emergency department...awaiting placement for psychiatric illness...patient is not eating or taking any...medications...diagnosis of schizoaffective disorder...when he gets more confused he will not eat...he was completely nonverbal...standing in the corner of the room...just stares at me with saliva drooling from his mouth...he will not talk..."

Medical record review revealed no documentation Patient #17 was evaluated or treated by Hospital A's on-call psychiatrist during the 6 days and 23 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 8/30/17, 8/31/17, 9/1/17, 9/2/17, 9/3/17, 9/4/17, 9/5/17, and 9/6/17.

7. Medical record review revealed Patient #37 was admitted to Hospital A's North Campus ED on 9/15/17 at 11:06 PM with a diagnoses including Acute Psychosis and Abuse of Non-Psychoactive Substances. Further review revealed the patient was transferred to Hospital B 9/20/17 at 8:07 AM.

Medical record review of an ED Physician's note dated 9/15/17 at 11:57 PM revealed "...presents to ER...complaints of Psych problem...anxiety...depression...paranoia...states...overwhelmed...needs to stay in a psych hospital for a few days...having spiritual thoughts and is feeling anxious about them...has not taken Seroquel in several weeks..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review of an ED Physician's note dated 9/17/17 at 6:08 PM revealed "...has had intermittent delusions...agitation...transfer of care was delayed...transfer center stating [MCU] could not be involved unless...been declined by 5 facilities...she is...TennCare [Medicaid]...has been declined by multiple facilities due to not having been evaluated by [MCU]..."

Medical record review of an ED Physician's note dated 9/18/17 at 6:14 PM revealed "...behavior was erratic...continued hallucinations...placement...pending..."

Medical record review of an ED Physician's note dated 9/20/17 at 5:56 PM revealed "...Transfer ordered to Other Acute Care Facility...Diagnosis...Acute Psychosis...Abuse of Non-Psychoactive Substances...problem is new...symptoms are unchanged..."

Medical record review revealed no documentation Patient #37 was evaluated or treated by Hospital A's on-call psychiatrist during the 4 days and 9 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/15/17, 9/16/17, 9/17/17, 9/18/17, 9/19/17, and 9/20/17.

8. Medical record review revealed Patient #40 was a 17 year old admitted to the Hospital A's North Campus ED on 9/18/17 at 10:25 AM with a chief complaint of having Suicidal Ideations. Further review revealed the patient was transferred to Hospital B on 9/19/17 at 1:08 PM.

Medical record review of an ED Physician's Note dated 9/18/17 at 12:45 PM revealed "...complaints of Suicidal Ideations...presents with depression, suicidal ideations but no formulated plan...onset 2 weeks ago...has not experienced similar symptoms in the past...states started a relationship with a girl 2 months ago and 3 weeks ago the girl suggested that they talk less...states has also been failing some of his classes because of relationship issues...says it all makes him depressed and he feels like he does not want to be here anymore..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review revealed no documentation Patient #40 was evaluated or treated by Hospital A's on-call psychiatrist during the 1 day and 2 and ½ hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/18/17 and 9/19/17.

9. Medical record review revealed patient #46 presented to the North Campus ED on 9/26/17 at 6:05 PM with complaint of "...arguing with mother...took 30 pills..." Further review of the medical record revealed the patient was transferred to Hospital J on 9/28/17 at 9:14 PM.

Medical record review of an ED physician's notes dated 9/26/17 at 8:01 PM revealed Patient #46 was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam. Review of physician's notes dated 9/27/17 at 2:18 PM revealed "...Transfer ordered to Other Acute Care Facility. Diagnosis are Suicide Attempt, Suicidal Ideations..."

Medical record review revealed no documentation Patient #46 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 3 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/26/17, 9/27/16, and 9/28/17.

10. Medical record review revealed Patient #78 was admitted to Hospital A's West ED Campus on 1/5/17 at 3:14 PM with a chief complaint of depression and hearing voices. Further review revealed the patient was triaged at 3:33 PM and received a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam. Continued review revealed the patient was transferred to Hospital C on 1/9/17 at 9:35 AM.

Medical record review of a Physician's note dated 1/8/17 at 7:05 AM revealed "...psychosis...auditory hallucinations...visual hallucinations...bipolar disorder...delusions...suicide ideation..."

Medical record review revealed no documentation Patient #78 was evaluated or treated by Hospital A's on-call psychiatrist during the 3 days and 18 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 1/5/17, 1/6/17, 1/7/17, 1/8/17, and 1/9/17.

11. Medical record review revealed Patient #80 was admitted to Hospital A's West Campus ED on 1/25/17 at 3:35 PM via Emergency Medical Services (EMS) after wandering around a store and had a diagnosis of Psychosis. Continued review revealed the patient was transferred to Hospital C on 1/30/17 at 8:59 AM.

Medical record review of an ED Physician's Note dated 1/25/17 at 4:44 PM revealed "...presents to the ED with psychosis, has delusions...diagnosed 1 year ago while attending master's history program. Refused to take medications at that time and lives with parents. Patient felt as though he has been worsening over the last 2 weeks. Wandering, feeling confused, delusional..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review of an ED Physician's Order dated 1/25/17 at 7:42 PM revealed a Mobile Crisis Consult.

Medical record review revealed no documentation Patient #80 was evaluated or treated by Hospital A's on-call psychiatrist during the 4 days and 17 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 1/25/17, 1/26/17, 1/27/17, 1/28/17, 1/29/17, and 1/30/17.

12. Medical record review revealed Patient #86 was admitted to Hospital A's Main Campus ED on 10/19/16 at 7:41 PM with a diagnosis of Suicidal Ideations. Continued review revealed the patient was transferred to Hospital B on 10/25/16 at 5:44 AM.

Medical record review of an ED Physician's Note dated 10/19/16 at 8:11 PM revealed "...history of bipolar disorder here with thoughts of suicide. Patient states that she is being told to leave the house. Her adoptive mother no longer wants her living in the house. She now feels hopeless and does not have anywhere to go. She does not want to go to the homeless shelter. She is contemplating taking her life but does not have a plan..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review revealed no documentation Patient #86 was evaluated or treated by Hospital A's on-call psychiatrist during the 5 days and 10 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 10/19/16, 10/20/16, 10/21/16, 10/22/16, 10/23/16, 10/24/16, and 10/25/16.

13. Medical record review revealed Patient #87 was admitted to Hospital A's Main Campus ED on 11/5/16 at 6:59 PM with a chief complaint of Suicidal Ideations. Further review revealed the patient was transferred to Hospital B on 11/8/16 at 9:10 PM.

Medical record review of an ED Physician's Note dated 11/5/16 at 7:17 PM revealed "...suicidal for past 3 days off his bipolar medications for several weeks. Last opiate use was about a week ago but has relapsed into using. Has now been drinking...he has a plan to hang himself. Currently staying with his grandmother. He had been in North Dakota worked in construction but recently returned..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review of an ED Physician's Note dated 11/6/16 at 8:54 PM revealed "...prior to transport by mobile crisis patient escalated swinging at staff verbally aggressive, argumentative and apparently had to be physically controlled by security. Patient states he is still willing to go the hospital but currently he is angry, agitated and not himself...placed in seclusion. He is no longer appropriate for civilian transport, and [Hospital B] does not have any beds for committals. He will need repeat assessment by mobile crisis with alternate destination. Geodon ordered..."

Medical record review revealed no documentation Patient #87 was evaluated or treated by Hospital A's on-call psychiatrist during the 3 days and 2 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 11/5/16, 11/6/16, 11/7/16, and 11/8/17.

14. Medical record review revealed Patient #88 was admitted to Hospital A's Main Campus ED on 11/5/16 at 8:43 PM via EMS with a diagnoses including Depressive Psychosis. Further review revealed the patient was transferred to Hospital C on 11/8/16 at 9:12 PM.

Medical record review of an ED Physician's Note dated 11/5/16 at 9:18 PM revealed "...here with altered mental status...found in a hotel acting strange...chasing a child today..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review of an ED Physician's Note dated 11/8/16 at 7:03 PM revealed "...transfer ordered to Other Acute Care Facility...diagnosis...Acute Psychosis...problem is new...symptoms are unchanged..."

Medical record review revealed no documentation Patient #88 was evaluated or treated by Hospital A's on-call psychiatrist during the 3 days the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 11/5/16, 11/6/16, 11/7/16, and 11/8/16.

15. Medical record review revealed Patient #90 was admitted to Hospital A's Main Campus ED on 11/18/16 at 1:27 PM via EMS with a diagnoses including Suicidal Ideations. Continued review revealed the patient was 17 years old. Further review revealed the patient was transferred to Hospital B on 11/21/16 at 9:13 PM.

Medical record review of an ED Physician's Note dated 11/18/16 at 2:23 PM revealed "...presents...with depression...suicide gesture...gun under his chin...pulled the trigger...symptoms...began/occurred 3 months ago...symptoms were moderate severe in the [ED]...mother reports...in the past done some self cutting...patient has not experienced similar symptoms in the past...2:25 [PM]...multiple stressors...including the dissolution of his parents marriage...recent breakup with girlfriend...recent change in stools...2:26 [PM]...speech does seem somewhat pressured..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review of an ED Physician's Note dated 11/21/16 at 7:36 PM revealed "...Transfer ordered to Other Acute Care Facility...Diagnosis...Suicidal Ideations...condition is fair...problem is new..."

Medical record review revealed no documentation Patient #90 was evaluated or treated by Hospital A's on-call psychiatrist during the 3 days and 7 and ½ hours the patient was in the ED.

Review of Hospital A's physician on-call schedule for Psychiatrist revealed a Psychiatrist was on-call 24 hours a day on 11/18/16, 11/19/16, 11/20/16, and 11/21/16.

16. Medical record review revealed Patient #93 presented to the ED at Hospital A Main Campus on 2/16/17 at 5:05 AM for complaint of "...states he drinks way too much...wants to kill himself..." Further review of the medical record revealed Patient #93 was diagnosed with Psychosis and Homicidal Thoughts and was transferred to Hospital B for involuntary admission on 2/21/17 at 7:59 PM.

Medical record review of ED physician's notes dated 2/7/17 at 4:47 PM revealed Patient #91 was provided a MSE which included: a HPI, a medical history, a ROS, and a physical exam. Further review of physician's notes dated 2/21/17 at 5:56 AM revealed "...Disposition summary...Transfer ordered to [Hospital B] other Acute Care Facility...Diagnosis is psychosis, homicidal thought..."

Medical record review revealed no documentation Patient #93 was evaluated or treated by Hospital A's on-call psychiatrist during the 5 days and 15 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 2/16/17, 2/17/17, 2/18/17, 2/19/17, 2/20/17, and 2/21/17.

17. Medical record review revealed Patient #96 presented to the ED at Hospital A's Main Campus on 3/3/17 at 5:38 PM for complaint of homicidal ideation. Further review of the medical record revealed Patient #96 was diagnosed with schizophrenia with decompensated psychosis and was transferred to Hospital C on 3/7/17 at 10:14 PM.

Medical record review of ED physician's notes dated 3/3/17 at 5:50 PM revealed Patient #96 was provided a MSE which included: a HPI, a medical history and psychiatric history, a ROS, and a physical exam. Further review of physician's notes dated 3/7/17 at 12:43 PM revealed "...Disposition summary...Transfer ordered to other Acute Care Facility [Hospital B]...Diagnosis is schizophrenia with decompensated psychosis..."

Medical record review revealed no documentation Patient #96 was evaluated or treated by Hospital A's on-call psychiatrist during the 4 days and 4 and ½ hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 3/3/17, 3/4/17, 3/5/17, 3/6/17, and 3/7/17.

18. Medical record review revealed Patient #97 presented to the ED at Hospital A Main Campus on 3/4/17 at 4:01 PM for complaint of "...suicidal thoughts...was on the bridge about to jump..." Further review of the medical record revealed Patient #97 was diagnosed with Suicidal Ideation and was transferred to Hospital C on 3/8/17 at 9:52 PM.

Medical record review of ED physician's notes dated 3/4/17 at 4:25 PM revealed Patient #97 was provided a MSE which included: a HPI, a medical history and psychiatric history, a ROS, and a physical exam. Further review of a physician's note dated 3/8/17 at 3:56 PM revealed "...Disposition summary...Transfer ordered to [Hospital C] Other Acute Care Facility...Diagnosis is Suicidal Ideation..."

Medical record review revealed no documentation Patient #97 was evaluated or treated by Hospital A's on-call psychiatrist during the 4 days and 5 and ½ hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 3/4/17, 3/5/37, 3/6/17, 3/7/17, and 3/8/17.

19. Medical record review revealed Patient #98 presented to the ED at Hospital A Main Campus on 3/6/17 at 7:03 PM for complaint of "...having auditory hallucinations..." Further review of the medical record revealed Patient #98 was diagnosed with Acute Psychosis and was transferred to Hospital B on 3/14/17 at 6:37 PM.

Medical record review of ED physicians notes dated 3/6/17 at 7:58 PM revealed Patient #98 was provided a MSE which included: a HPI, a medical history and psychiatric history, a review of systems, and a physical exam. Further review of physicians notes dated 3/12/17 at 2:33 PM revealed "...Day 6 in the emergency department for psychosis...he most recently was performing yoga sitting on the floor naked..." Further review of physician's notes dated 3/14/17 at 3:21 PM revealed "...Disposition summary...Transfer ordered to [Hospital B] Other Acute Care Facility...Diagnosis is Acute Psychosis..."

Medical record review revealed no documentation Patient #98 was evaluated or treated by Hospital A's on-call psychiatrist during the 7 days and 23 and 1/2 hours the patient was in the ED at Hospital A

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 3/6/17, 3/7/17, 3/8/17, 3/9/17, 3/10/17, 3/11/17, 3/12/17, 3/13/17, and 3/14/17.

20. Medical record review revealed Patient #102 was admitted to Hospital A's Main Campus ED on 4/1/17 at 3:04 PM with a diagnoses including Psychosis. Further review revealed the patient was transferred to Hospital C on 4/5/17 at 10:31 PM.

Medical record review of an ED Physician's Note dated 4/1/17 at 8:34 PM revealed "...with abnormal behavior...has been verbally...physically threatening to her kids and husband...she thinks that she has been set on fire...has not been sleeping...has been attempting to leave the house..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review of an ED Physician's Note dated 4/4/17 at 10:16 PM revealed "...transfer ordered to Other Acute Care Facility...Diagnosis is Psychosis...condition is fair...problem is new...symptoms are unchanged..."

Medical record review revealed no documentation Patient #102 was evaluated or treated by Hospital A's on-call psychiatrist during the 4 days and 7 and ½ hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 4/1/17, 4/2/17, 4/3/17, 4/4/17, and 4/5/17.

21. Medical record review revealed Patient #103 was admitted to Hospital A's Main Campus ED on 4/6/17 at 7:41 PM with a chief complaint of delusions and suicidal ideations. Further review revealed the patient was transferred to Hospital C on 4/9/17 at 9:19 AM.

Medical record review of an ED Physician's Note dated 4/6/17 at 7:58 PM revealed "...33 year old female presents to ER [emergency room] with complaints of suicidal ideations. Very poor historian patient says she is not suicidal but she does frequently give tangential answers. She knows she is at the [named hospital] but she cannot tell me why...she had 3 cousins here with her who say she has become increasingly erratic and bizarre satanic and hyper religious overtones with suicidal statements. She apparently gets a monthly mental health injection uncertain diagnosis and when her menstrual period coincides with the medication wearing off she gets this way, which apparently has happened frequently..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review of an ED Physician's Note dated 4/8/17 at 12:56 PM revealed "...d/w [discussed with] [named psychiatrist at Hospital C]. Overnight psychiatrist requested CT [computed tomography] of the Head for the patient...the indication for CT scan is not clear. CT scan in absence of clear benefit in this patient is not without risk as it exposes patient to potentially unnecessary radiation and conscious sedation. [Hospital C dayshift psychiatrist] based on review of the clinical information, agrees that a CT is not indicated but reports that she does not have the authority to override the overnight physician's order. She reports since it is the weekend, no one will be available until Monday to override the request. She recommends either sedating the patient for the CT or finding a different facility than [Hospital C]. Risk of conscious sedation/radiation again addressed with [Hospital C's physician]. She will notify her medical director, [named physician] to call and discuss case..."

Medical record review of an ED Physicians Note dated 4/9/17 at 7:29 AM revealed "...CT performed, pt. cooperative for exam...CT negative....pt. accepted to Hospital C..."
Medical record review revealed no documentation Patient #103 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 13 and 1/2 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 4/6/17, 4/7/17, 4/8/17, and 4/9/17.

22. Medical record review revealed Patient #112 presented to the ED at Hospital A's Main Campus on 7/12/17 at 4:10 PM for complaint of "...I am having suicidal thoughts..." Further review of the medical record revealed Patient #112 was diagnosed with Suicidal Ideations and was transferred to Hospital C on 7/16/17 at 8:42 PM.

Medical record review of ED Physician's Note dated 7/12/17 at 5:34 PM revealed Patient #112 was provided a MSE which included: a HPI, a medical history and psychiatric history, a ROS, and a physical exam. Further review of physician's notes dated 7/12/17 at 9:56 PM revealed "...Consult Orders - Mobile Crisis Unit..." Further review of physician's notes dated 7/16/17 at 1:12 PM revealed "...Disposition summary...Transfer ordered to [Hospital C]...Diagnosis is Suicidal Ideation...

Based on review of 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 after the initial examination provided further evaluation and/or treatment necessary for patients with emergency psychiatric conditions for 29 patients (#5, #8, #11, #13, #14, #17, #37, #40, #46, #78, #80, #86, #87, #88, #90, #93, #96, #97, #98, #102, #103, #112 #113, #120, #121, #123, #124, #171, and #180) of 84 psychiatric patients held in the Emergency Department (ED) awaiting inpatient psychiatric admission of 181 emergency records reviewed.

The findings included:

Policies and Procedures:
Review of facility policy "Emergency Medical Treatment and Patient Transfer Policy" effective date 12/1/1998, revealed "...The Hospital shall maintain a list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an Emergency Medical Condition or woman in labor...during the Hospital's normal operating hours, all medical specialties represented on the medical staff should be available for emergency services..."

Medical Staff Bylaws:
Review of facility Medical Staff Bylaws adopted and approved 6/3/2016, revealed "...Article III - Medical Staff Membership...3.3 Basic Responsibilities of Staff Members...Abide by the Medical Staff Bylaws and other lawful standards, policies...and Rules & Regulations of the Medical Staff..."

Medical Staff Rules and Regulations:
Review of facility Medical Staff Rules and Regulations, undated, Article VI, Emergency Medical Screening, Treatment, Transfer, and On-call Roster Policy revealed "...6.1(a) Screening...(4) Services available to Emergency Department patients shall include all ancillary services routinely available to the Emergency Department, even if not directly located in the department..."

Medical record reviews:

1. Medical record review revealed Patient #5 presented to the ED at Hospital A's Main Campus on 10/5/17 at 2:56 PM for complaint of "...is suicidal..." Further review of the medical record revealed the patient was transferred as an involuntary admission to Hospital B on 10/7/17 at 12:48 PM.

Medical record review of an ED nurses notes dated 10/5/17 revealed Patient #5 was triaged at 2:57 PM. Further review of the nurses notes dated 10/5/17 at 3:24 PM revealed "...Delusions are religious...Hallucinations are auditory...having thoughts of suicide...Substantial risk for suicide...1:1 sitter [constant visual, arms reach observation by sitter/staff] with patient..." Further review of the nurses notes dated 10/7/17 at 5:00 AM revealed "...Patient kicking the walls, screaming and cursing at staff...Patient refuses to comply with commands and unable to redirect patient...Patient placed in seclusion per order of [ED physician]...Patient proceeded to tear the trim from the door frame and use to strike the mirror in the corner of the room...[police] called in order to safely extricate the patient from the room..." Further review of the nurses notes dated 10/7/17 at 12:48 PM "...Patient left the ED..."

Medical record review of a physician's note dated 10/5/17 at 2:57 PM revealed Patient #5 was provided a Medical Screening Examination (MSE) which included: a History of Present Illness (HPI), a medical and psychiatric history, a Review of Systems (ROS), and a physical exam. Continued review of the physician's note dated 10/5/17 at 4:25 PM revealed "...Medically stable for further psychiatric care..." Further review of the physician's note dated 10/7/17 at 12:47 PM revealed "...Will proceed with previously planned transfer to psychiatric hospital..." Continued review of the physician's note dated 10/7/17 at 7:13 AM revealed "...Disposition Summary...Transfer ordered to [Hospital B]...Diagnosis is Suicidal Ideation..."

Medical record review of Mobile Crisis Unit (MCU) (a Tennessee Department of Mental Health agency which provides a response team consisting of mental health counselors) notes dated 10/5/17, not timed, revealed "...at time [patient] is SI (suicidal ideation) and HI (homicidal ideation) with psychosis, involuntary treatment recommended..."

Medical record review revealed no documentation Patient #5 was evaluated or treated by Hospital A's on-call psychiatrist during the 1 day and 22 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 10/5/17, 10/6/17, and 10/7/17.

2. Medical record review revealed Patient #8 presented to the ED at Hospital A's Main Campus on 9/29/17 at 5:08 PM for complaint of psychiatric problems. Further review revealed the patient was diagnosed with Psychosis and Homicidal and Suicidal Ideation and was transferred to Hospital C on 10/4/17 at 2:44 PM.

Medical record review of ED nurses notes dated 9/29/17 revealed Patient #8 was triaged at 6:09 PM and the patient was placed on continuous observation. Further review of the nurses notes dated 9/30/17 at 6:32 PM revealed "...security alerted nurse [the] patient was getting agitated...went to give the patient medications, patient started cursing while walking out of room 21...[patient stated] I am going to punch you in the face..." Further review of the nurses notes dated 10/1/17 at 6:15 PM revealed "...patient has been declined by [Hospital D]...and no beds available at [Hospital B, I, and E]..." Further review of nurses notes dated 10/2/17 at 7:43 AM revealed "...patient is being reviewed at [Hospital P]...declined at [Hospital D and E]...pending at [Hospital M and I] due to no beds available..." Further review of nurses notes dated 10/2/17 at 4:13 PM revealed "...patient was declined by [Hospital E, M, D, I, and B]..." Further review of nurses notes dated 10/3/17 at 3:16 AM revealed "...declined at [Hospital D] due to history of violence, declined at [Hospital B] due to delirium...[Hospital I] has no beds...[Hospital E] declined due to history of violence..." Review of nurses notes dated 10/4/17 at 5:49 AM revealed "...pt threw a full canister of ice at security guards head...pt placed in seclusion at this time. Restraints applied at [5:50 AM] Patient was restrained...seclusion room..." Further review of the nurses notes dated 10/4/17 at 2:55 PM "...Patient left the ED..."

Medical record review of ED physician's notes dated 9/29/17 at 5:26 PM revealed Patient #8 was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam. Further review of the physician's notes dated 9/29/17 at 5:26 PM revealed "...reported a history of drug abuse...Patient does admit to me that he has a plan to hurt someone...is disorganized and agitated and paranoid..." Further review of physician's notes dated 10/2/17 at 3:11 PM revealed "...agitated, screaming obscenities..." Further review of ED physician's note dated 10/4/17 at 2:37 PM revealed "...Disposition summary...Transfer ordered to [Hospital C]...Diagnosis...Psychosis, Homicidal and Suicidal Ideation..."

Medical record review of a Certificate of Need (CON) for Emergency Involuntary Admission completed for Patient #8 on 9/30/17 at 1:05 AM revealed "...Pt presents with reported manic behavior and homicidal ideation. Patient is a potential danger to others and potentially himself..."

Medical record review revealed no documentation Patient #8 was evaluated or treated by Hospital A's on-call psychiatrist during the 4 days and 22 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/29/17, 9/30/17, 10/1/17, 10/2/17, 10/3/17, and 10/4/17.

3. Medical record review revealed Patient #11 was admitted to Hospital A's Main Campus ED on 9/25/17 at 7:03 AM with diagnoses including Suicidal Ideation. Further review revealed the patient was triaged at 7:13 AM and received a MSE on 9/25/17 at 7:15 AM.

Medical record review of an ED nurses note dated 9/25/17 at 7:11 AM revealed "...SI...with plan to OD [overdose]...I had a bunch of pills in my hand...I've been fighting with my wife...pushing her around...I feel like I'm a danger to her and myself...having auditory...visual hallucinations...7:37 [AM]...mood...sad...hallucinations are auditory...visual...having thoughts of suicide...plan...overdose...placed in safe environment...continuous observation...[named] security at bedside..."

Medical record review of an ED Physician's Note dated 9/25/17 at 8:06 AM revealed "...presents complaining...I want to kill myself...hearing people[s] voices...seeing demons...felt this way for 1.5 months...prior to my evaluating...patient...he tried to pull something off the wall...actually used a piece of metal plating [to] cut his right...wrist..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review of an ED Nurses Note dated 9/25/17 at 8:29 AM revealed "...patient took a piece of metal off of the wall in room...cut his right wrist with the object...10:07 [AM]...consult called into MCU...chart...faxed...3:37 [PM]...being [assessed] by Access Tennova [facility flow center which provides assistance with psychiatric patient placement] for psych [psychiatric] placement...3:49 [PM]...will be an involuntary commitment...commitment papers completed..."

Medical record review of the ED Physician's Order revealed a consult for MCU on 9/25/17 at 10:07 AM and a consult for Tennova Access on 9/25/17 at 3:36 PM. Further review revealed the patient had a CON during the patient's stay at Hospital A's Main Campus signed on 9/25/17 at 3:32 PM and the patient remained in the ED until 9/27/17 at 12:53.

Medical record review revealed no documentation Patient #11 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 5 and ½ hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/25/17, 9/26/17, and 9/27/17.

4. Medical record review revealed Patient #13 was admitted to Hospital A's Main Campus ED on 9/20/17 at 3:29 PM with a diagnoses including Suicidal Ideations, Substance Abuse, and Pregnancy. Further review revealed the patient was triaged at 3:49 PM and received a MSE on 9/20/17 at 3:59 PM.

Medical record review of an ED nurses note dated 9/20/17 at 3:47 PM revealed "...suicidal thoughts after son was brutally murdered...plan...overdose..."

Medical record review of an ED Physician's Note dated 9/20/17 at 4:19 PM revealed "...depressed...having suicidal thoughts...had a son...murdered 5 months ago...depressed...using opiates since that time...reports she is 4-5 months pregnant...she snorts or takes tablets..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review of an ED nurses note dated 9/20/17 at 4:59 PM revealed "...mood...sad...having thoughts of suicide...plan for suicide is overdose...placed in safe environment...continuous observation...[named] security at bedside...5:33 [PM]...chart faxed to MCU...consult...called...6:18 [PM]...MCU evaluating patient..."

Medical record review revealed a CON for Patient #13 was signed on 9/20/17 at 5:20 PM and the patient remained in the ED until 9/23/17 at 8:32 AM.

Medical record review of an ED Physician's note dated 9/20/17 at 5:29 PM revealed "...tearful...despondent...out of concern for her safety...have completed a certificate of need...Gravida 3 [third pregnancy]...Pregnancy Verified...EDC [estimated date of conception] 1/13/2018...Gestational Age...23 weeks 5 days..."

Medical record review of an ED Nurses Note dated 9/22/17 at 9:00 AM revealed "...mood...irritable...having thoughts of suicide...is challenging...affect is flat...7:17 [PM]...accepted to [Hospital C]..."

Medical record review of an ED Physician's note dated 9/22/17 at 7:21 PM revealed "...Transfer ordered to [Hospital C]...Diagnosis...Suicidal Ideations...Substance Abuse...Pregnancy..."

Medical record review revealed no documentation Patient #13 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 17 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/20/17, 9/21/17, 9/22/17, and 9/23/17.

5. Medical record review revealed Patient #14 presented to the ED at Hospital A's Main Campus on 9/18/17 at 6:45 PM for complaint of "...threatening her mother...not used meth [methamphetamine] in 3 days..." Further review of the medical record revealed Patient #14 was diagnosed with Suicidal Ideation (SI) and was transferred to Hospital B on 9/21/17 at 4:01 PM.

Medical record review of a nurses notes dated 9/18/17 revealed Patient #14 was triaged at 6:45 PM. Further review of a nurses notes dated 9/18/17 at 6:52 PM revealed "...Substantial risk for suicide...patient placed in safe environment..." Further review of the nurses notes dated 9/18/17 at 8:16 PM revealed "...[patient] stated he would kill anyone wherever he was sent...Pt becoming violent toward staff..." Further review of the nurses notes dated 9/21/17 at 4:01 PM revealed "...Patient left the ED..."

Medical record review of an ED physician's notes dated 9/18/17 at 5:56 PM revealed Patient #14 was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam. Further review of the physician's notes dated 9/18/17 at 7:57 PM revealed "...Patient having thoughts of suicide. Plan for suicide is death by cop...refuses vs [vital signs] and blood draw, and urine testing...states he wants to die or go to jail...he will kill the next person that enters his room that is not a police officer with a taser [device used to disable an individual] or gun to kill him or to take him to jail..." Further review of the physician's notes dated 9/19/17 at 1:08 PM revealed "...Consult order...Mobile Crisis Unit..." Further review of the physician's notes dated 9/18/17 at 3:16 PM revealed "...Disposition summary...Transfer ordered to [Hospital B]...Diagnosis is Suicidal Ideation..."

Medical record review of a CON for Patient #14 dated and signed by the physician on 9/18/17 at 9:02 PM revealed "...Depression with aggressive behavior and suicidal thoughts...needs care to avoid harm to self and others..."

Medical record review revealed no documentation Patient #14 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 21 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/18/17, 9/19/17, 9/20/17, and 9/21/17.

6. Medical record review revealed Patient #17 was admitted to Hospital A's Main Campus ED on 8/30/17 at 1:57 PM via Law Enforcement with diagnoses including Suicidal Ideations. Further review revealed the patient was triaged at 2:21 PM and received a MSE on 8/30/17 at 10:09 PM.

Medical record review of an ED Nurses Note dated 8/30/17 at 2:15 PM revealed "...was released from [Hospital C] on Friday [5 days prior] after a 3 week stay...been on and off his medications...trying to get him into a residential home...altercation with dad today...reports suicidal thoughts...superficial lacerations noted to neck...2:25 [PM]...placed in safe environment...continuous observation...[named] security at bedside..."

Medical record review of an ED Physician's Note dated 8/30/17 at 3:44 PM revealed "...presents...with a history of a suicide gesture...made 3 superficial cuts to his neck with...safety razor...schizoaffective disorder...was recently released from an inpatient psychiatric treatment facility...was visiting a group home with...parents...was being considered for...placement...he became very irate...violent...he made 3 superficial cuts to his neck...said...he was suicidal..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review of an ED Nurses Note dated 8/30/17 at 5:53 PM revealed "...is being assessed by Access Tennova...9:50 [PM]...will be a voluntary commitment..."

Medical record review of an ED Nurses Note dated 8/31/17 at 1:15 PM revealed "...refused to eat or drink anything for lunch...3:07 [PM]...continuing...refuses food...drink...medications...5:54 [PM]...continuing to refuse drinks...food...medications..."

Medical record review of an ED Nurses Note dated 9/1/17 at 7:30 AM revealed "...patient is not eating or drinking...not answering any questions...8:37 [AM]...displayed extreme agitation...threat to harm self or others...reported suicide ideation...psychotic symptoms...hallucinations...delusions...paranoid ideas...thought disorder...unusual or agitated behavior..."

Medical record review of an ED Physician's note dated 9/1/17 at 10:03 AM revealed "...remains in the emergency department...awaiting placement for psychiatric illness...patient is not eating or taking any...medications...diagnosis of schizoaffective disorder...when he gets more confused he will not eat...he was completely nonverbal...standing in the corner of the room...just stares at me with saliva drooling from his mouth...he will not talk..."

Medical record review of an ED nurses note dated 9/1/17 at 11:05 AM revealed "...refused breakfast...spoke with [named on-call Psychiatrist]...medicine service refused to admit...he has been declined by 10 facilities at this time...11:20 [AM]...moved to room 11 for IV [intravenous] hydration...sitter remains at bedside...12:16 [PM]...trying to get out of bed...refusing to cooperate...able to get him back in bed x [times] 3 staff members...2:48 [PM]...sitting in the floor...[named Physician]...tried to help him up...patient lunged towards him...patient then jumped over the door into the hallway....intercepted by security officer...placed into seclusion...5:00 [PM]...remains in a catonic [catatonic, unresponsive stupor]...state...6:00 [PM]...remains in a catonic state...7:15 [PM]...remains in seclusion...standing in the middle of the floor...will not speak ...is drooling...will not sit....will not move...does make eye contact...8:07 [PM]...displayed a distorted perception of reality..."

Medical record review of an ED nurses note dated 9/2/17 at 4:53 AM revealed "...spoke at length with [patient]...assessing to take...out of seclusion...expressed frustration at being forced to take pills against his will...[patient stated] I feel like a prisoner...I should be able to choose how to live...appears to be very frustrated by his circumstances...lack of control in is life...7:37 [AM]...refused US [ultrasound]...when [named security company] went into room to talk him into it...[patient] grabbed her by the throat...security intervened...8:30 [AM]...lunging towards security...threatening to leave...subdued by security...9:45 [AM]...remains standing in the middle of the room nonverbal...staring...10:50 [AM]...guided to one of the rooms...he is scaring some of the other people...2:32 [PM]...displayed extreme agitation...displayed physically/verbally aggressive behavior...displayed a distorted perception of reality...signs of depression...reported threat to harm self or others...suicide ideation...psychotic symptoms...hallucinations...delusions...paranoid ideas...thought disorder...unusual or agitated disorder...5:23 [PM]...blood on corner of...sheet...came from his hand...abrasions on his hand..."

Medical record review of an ED nurses note dated 9/3/17 at 7:18 AM revealed "...mood is sad...hallucinations are auditory...having thoughts of suicide...affect is flat...9:02 [AM]...refused medications...fluids...food...11:59 [AM]...has been declined by...[Hospital A]..."

Medical record review of an ED nurses note dated 9/5/17 at 8:14 PM revealed "...finally agreed to take medications...has refused x 3 today..."

Medical record review of an ED nurses note dated 9/6/17 at 8:11 AM revealed "...mood is sad...hallucinations are auditory...having thoughts of suicide...affect is flat...11:01 [AM]...accepted to [Hospital C]...12:30 [PM]...patient refused [medications]...1:05 [PM]...transfer order by MD...3:10 [PM]...patient left ED..."

Medical record review revealed the CON was completed and signed by the physician on 9/1/17 at 12:12 PM. Continued review revealed the patient remained in the ED until 9/6/17 at 3:10 PM.

Medical record review revealed no documentation Patient #17 was evaluated or treated by Hospital A's on-call psychiatrist during the 6 days and 23 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 8/30/17, 8/31/17, 9/1/17, 9/2/17, 9/3/17, 9/4/17, 9/5/17, and 9/6/17.

7. Medical record review revealed Patient #37 was admitted to Hospital A's North Campus ED on 9/15/17 at 11:06 PM with a diagnoses including Acute Psychosis and Abuse of Non-Psychoactive Substances. Further review revealed the patient was triaged at 11:42 PM and received a medical examination on 9/16/17 at 12:33 AM.

Medical record review of an ED nurses note dated 9/15/17 at 11:37 PM revealed "...presenting complaint...feels overwhelmed...stressed...thinks she needs to be placed in a psych hospital...to...calm herself..."

Medical record review of an ED Physician's note dated 9/15/17 at 11:57 PM revealed "...presents to ER...complaints of Psych problem...anxiety...depression...paranoia...states...overwhelmed...needs to stay in a psych hospital for a few days...having spiritual thoughts and is feeling anxious about them...has not taken Seroquel in several weeks..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review of an ED nurses note dated 9/16/17 at 3:14 AM revealed "...mood is irritable...delusions are religious...hallucinations are auditory...having thoughts of irritable...talking about god...heaven...demons...different things...uncooperative...restless...affect is inappropriate..."

Medical record review of an ED nurses note dated 9/17/17 at 9:30 AM revealed "...pacing in room...having loud outbursts...yells out profanity at times...11:26 [AM]...extremely agitated...yelling out profanity...stating she is...spiritually annoyed...pestered...12:09 [PM]...called transfer center...still on waiting list at [Hospital B]...declined at [Hospital D]...declined at [Hospital I]...when asked about getting...on [Hospital C]...waiting list...reported...had...to have...[MCU]...consult...asked to get...[MCU]...consult...reported [MCU]...would not evaluate...until...had been declined by 5 facilities...called [Hospital E Valley Campus]...to inquire about...bed availability...when told...had [named insurance]...reported [Hospital E Valley Campus staff] by law in state of tn [Tennessee]...had to be evaluated by [MCU]...due to [state Medicaid program in Tennessee]...called [MCU] gave information...asked why...been in er so many days without...consulting them...informed...transfer center...trying to place...agreed...did have to be evaluated by them [MCU]..."

Medical record review of an ED Physician's note dated 9/17/17 at 6:08 PM revealed "...has had intermittent delusions...agitation...transfer of care was delayed...transfer center stating [MCU] could not be involved unless...been declined by 5 facilities...she is...TennCare...has been declined by multiple facilities due to not having been evaluated by [MCU]..."

Medical record review of an ED nurses note dated 9/18/17 at 3:40 AM revealed "...awaiting [Hospital B]...[Hospital I]...has been refused everywhere else...8:00 [AM]...mood is angry...irritable...delusions are religious...hallucinations are auditory...uncooperative...irritable...restless...affect is blunted...inappropriate..."

Medical record review of an ED Physician's note dated 9/18/17 at 6:14 PM revealed "...behavior was erratic...continued hallucinations...placement...pending..."

Medical record review of an ED nurses note dated 9/18/17 at 6:46 PM revealed "...accepted at [Hospital B]...waiting on a bed...9:25 [PM]...transfer center called...[Hospital B]...call back around 10 AM...no beds tonight..."

Medical record review of an ED nurses note dated 9/19/17 at 10:35 AM revealed "...[Hospital B]...will not have available beds until later this afternoon...2:00 [PM]...mood is angry...irritable...delusions are religious...hallucinations are auditory...irritable...restless...affect is flat...inappropriate...sitter at bedside...9:00 [PM]...pacing..."

Medical record review of an ED nurses note dated 9/20/17 at 3:00 AM revealed "...agitated...angry...combative...9:23 [AM]...transfer center stated...declined by ten facilities...on...waiting list at...[Hospital B]...going to review...chart at ten this morning...call back around noon today...recheck...status...12:31 [PM]...accepted at [Hospital B]...on waiting list still...waiting on a bed to open...no time frame can be given...5:56 [PM]...transfer ordered by MD..."

Medical record review of an ED Physician's note dated 9/20/17 at 5:56 PM revealed "...Transfer ordered to Other Acute Care Facility...Diagnosis...Acute Psychosis...Abuse of Non-Psychoactive Substances...problem is new...symptoms are unchanged..."

Medical record review of an ED Nurses Note dated 9/20/17 at 8:07 PM revealed "...patient left the ED..."

Medical record review revealed a CON for Patient #37 was completed and signed by the physician on 9/16/17 at 7:00 AM. Continued review revealed the patient remained in the ED until 9/20/17 at 8:07 AM.

Medical record review of an "Emergency Services Patient Transfer Form" dated 9/20/17 at 5:37 PM revealed "...The patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide..."

Medical record review revealed no documentation Patient #37 was evaluated or treated by Hospital A's on-call psychiatrist during the 4 days and 9 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/15/17, 9/16/17, 9/17/17, 9/18/17, 9/19/17, and 9/20/17.

8. Medical record review revealed Patient #40 was a 17 year old admitted to the Hospital A's North Campus ED on 9/18/17 at 10:25 AM with a chief complaint of having Suicidal Ideations. Further review revealed the patient was triaged at 10:38 AM and received a MSE at 11:37 AM by the ED Physician.

Medical record review of an ED Nurses Triage record dated 9/18/17 at 10:38 AM revealed "...states intermittently having suicidal thoughts for the past 3 weeks and states that his parents found out today so they came in to the hospital. Denies a plan. Feeling depressed..."

Medical record review of an ED Physician's Note dated 9/18/17 at 12:45 PM revealed "...complaints of Suicidal Ideations...presents with depression, suicidal ideations but no formulated plan...onset 2 weeks ago...has not experienced similar symptoms in the past...states started a relationship with a girl 2 months ago and 3 weeks ago the girl suggested that they talk less...states has also been failing some of his classes because of relationship issues...says it all makes him depressed and he feels like he does not want to be here anymore..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Medical record review of an ED nurses note dated 9/18/17 at 2:02 PM revealed "...chart faxed to transfer center...7:40 [PM] Spoke with transfer center who states they need information faxed to [Hospital B]..."

Medical record review of a Tennova intake center behavioral health preadmission screening completed by a Licensed Clinical Social Worker (LCSW) dated 9/18/17 at 3:00 PM revealed the patient received a psychiatric assessment. Further review revealed "...admits to SI [suicidal ideation] without a plan. States stressors are a girlfriend he met online that is parents are opposed to...struggling with classes..." Further review revealed "...patient very hesitant to answer questions and soft spoken as if to keep anyone else from overhearing...feels depressed for past 3 weeks..." Further review revealed "...disposition: admit/transfer to Inpatient behavioral health...involuntary type..."

Medical record review of a CON completed and signed by the ED physician dated 9/18/17 at 3:00 PM revealed "...depression/possible overdose...patient has threatened suicide by text to multiple friends...mother abandonment at age of 5...high achiever is currently suicidal over a break up and is failing calculus and physics...patient has strong abandonment issues due to mother...has been angry and parents feels he will go through with it..."

Medical record review of an ED nurses note dated 9/19/17 at 10:31 AM revealed "...contacted mobile crisis to check status of pt and stated pt is referred to [Hospital M and Hospital E]..." Further review revealed "...11:35 [AM] contacted transfer center for transport...pt accepted at [Hospital B]...police department to transport..."

Medical record review of an ED Discharge Summary dated 9/19/17 at 1:03 PM revealed the patient was transferred to Hospital B with a diagnosis of Depression and Suicidal Ideations.

Medical record review of an ED nurses note dated 9/19/17 at 1:08 PM revealed "...patient transferred by police department...pt left the ED..."

Medical record review revealed no documentation Patient #40 was evaluated or treated by Hospital A's on-call psychiatrist during the 1 day and 2 and ½ hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/18/17 and 9/19/17.

9. Medical record review revealed patient #46 presented to facility A's North Campus ED on 9/26/17 at 6:05 PM with complaint of "...arguing with mother...took 30 pills..." Further review of the medical record revealed the patient was transferred to Hospital J for involuntary admission on 9/28/17 at 9:14 PM.

Medical record review of an ED nurses notes revealed patient #46 was triaged on 9/26/17 at 6:20 PM. Further review of nurses notes dated 9/25/17 at 6:27 PM revealed "...minimal noted risk for suicide..." Further review of nurses notes dated 9/27/17 at 8:28 PM revealed "...Call made to mobile crisis to check patient placement status...Mother declined to drive to [Hospital E, valley campus] to sign patient in..." Further review of nurses notes dated 9/28/17 at 7:25 AM revealed "...spoke with...mobile crisis; states [Hospital M] has no beds...[Hospital K] is on diversion...still on waiting list at [Hospital B]..." Further review of nurses notes dated 9/28/17 at 2:40 PM revealed "...mother wants to know why she cannot sign pt out and take her home; informed pt is committal and cannot be signed out..." Further review of nurses notes dated 9/28/17 at 9:14 PM revealed "...Patient left the ED..."

Medical record review of an ED physician's notes dated 9/26/17 at 8:01 PM revealed Patient #46 was provided a MSE by a MD which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam. Review of physician's notes dated 9/27/17 at 2:18 PM revealed "...Transfer ordered to Other Acute Care Facility. Diagnosis are Suicide Attempt, Suicidal Ideations..." Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.

Further review revealed the patient was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam.
Medical record review pf a CON completed and signed by the ED physician dated 9/28/17 at 2:15 PM revealed "...Pt tried to commit suicide with pills...very depressed..."

Medical record review revealed no documentation Patient #46 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 3 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/26/17, 9/27/16, and 9/28/17.

10. Medical record review revealed Patient #78 was admitted to Hospital A's West ED Campus on 1/5/17 at 3:14 PM with a chief complaint of depression and hearing voices. Further review revealed the patient was triaged at 3:33 PM and received a MSE by the ED

Based on review of Medical Staff Bylaws, review of Medical Staff Rules and Regulations, review of facility policies, medical record reviews, review of Medical Staff On-Call Schedules, review of facility's bed census reports, and interviews, the facility failed to provide within the hospital's capabilities (staff and facilities) services available for further evaluation and treatment as required to stabilize the patient's emergency psychiatric condition(s) for 29 patients (#5, #8, #11, #13, #14, #17, #37, #40, #46, #78, #80, #86, #87, #88, #90, #93, #96, #97, #98, #102, #103, #112 #113, #120, #121, #123, #124, #171, and #180) of 84 psychiatric patients held in the Emergency Department (ED) awaiting inpatient psychiatric admission of 181 emergency records reviewed.

The findings included:

Policies and Procedures:
Review of facility policy "Emergency Medical Treatment and Patient Transfer Policy" effective date 12/1/1998 revealed "...The Hospital shall maintain a list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an Emergency Medical Condition or woman in labor...during the Hospital's normal operating hours, all medical specialties represented on the medical staff should be available for emergency services..."

Medical Staff Bylaws:
Review of facility Medical Staff Bylaws adopted and approved 6/3/2016, revealed "...Article III - Medical Staff Membership...3.3 Basic Responsibilities of Staff Members...Abide by the Medical Staff Bylaws and other lawful standards, policies...and Rules & Regulations of the Medical Staff..."

Medical Staff Rules and Regulations:
Review of facility Medical Staff Rules and Regulations, undated, Article VI, Emergency Medical Screening, Treatment, Transfer, and On-call Roster Policy revealed "...6.1(a) Screening...(4) Services available to Emergency Department patients shall include all ancillary services routinely available to the Emergency Department, even if not directly located in the department..."

Medical record reviews:

1. Medical record review revealed Patient #5 presented to the ED at Hospital A's main campus on 10/5/17 at 2:56 PM for complaint of "...is suicidal..." Further review of the medical record revealed the patient was transferred as an involuntary admission to Hospital B on 10/7/17 at 12:48 PM.

Medical record review of an ED nurses notes dated 10/5/17 revealed Patient #5 was triaged at 2:57 PM. Further review of the nurses notes dated 10/5/17 at 3:24 PM revealed "...Delusions are religious...Hallucinations are auditory...having thoughts of suicide...Substantial risk for suicide...1:1 sitter [constant visual, arms reach observation by sitter/staff] with patient..." Further review of the nurses notes dated 10/7/17 at 5:00 AM revealed "...Patient kicking the walls, screaming and cursing at staff...Patient refuses to comply with commands and unable to redirect patient...Patient placed in seclusion per order of [ED physician]...Patient proceeded to tear the trim from the door frame and use to strike the mirror in the corner of the room...[police] called in order to safely extricate the patient from the room..." Further review of the nurses notes dated 10/7/17 at 12:48 PM "...Patient left the ED..."

Medical record review of a physician's note dated 10/5/17 at 2:57 PM revealed Patient #5 was provided a Medical Screening Examination (MSE) which included: a History of Present Illness (HPI), a medical and psychiatric history, a Review of Systems (ROS), and a physical exam. Further review of the physician's note dated 10/5/17 at 4:25 PM revealed "...Medically stable for further psychiatric care..." Further review of the physician's note dated 10/7/17 at 12:47 PM revealed "...Will proceed with previously planned transfer to psychiatric hospital..." Further review of the physician's note dated 10/7/17 at 7:13 AM revealed "...Disposition Summary...Transfer ordered to [Hospital B]...Diagnosis is Suicidal Ideation..."

Medical record review of Mobile Crisis Unit (MCU) (a Tennessee Department of Mental Health agency which provides a response team consisting of mental health counselors) notes dated 10/5/17, not timed, revealed "...at time [patient] is SI (suicidal ideation) and HI (homicidal ideation) with psychosis, involuntary treatment recommended..."

Medical record review revealed no documentation Patient #5 was evaluated or treated by Hospital A's on-call psychiatrist during the 1 day and 22 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 10/5/17, 10/6/17, and 10/7/17.

2. Medical record review revealed Patient #8 presented to the ED at Hospital A's Main Campus on 9/29/17 at 5:08 PM for complaint of psychiatric problems. Further review revealed the patient was diagnosed with Psychosis and Homicidal and Suicidal Ideation and was transferred to Hospital C on 10/4/17 at 2:44 PM.

Medical record review of ED nurses notes dated 9/29/17 revealed Patient #8 was triaged at 6:09 PM and the patient was placed on continuous observation. Further review of the nurses notes dated 9/30/17 at 6:32 PM revealed "...security alerted nurse [the] patient was getting agitated...went to give the patient medications, patient started cursing while walking out of room 21...[patient stated] I am going to punch you in the face..." Further review of the nurses notes dated 10/1/17 at 6:15 PM revealed "...patient has been declined by [Hospital D]...and no beds available at [Hospital B, I, and E]..." Further review of nurses notes dated 10/2/17 at 7:43 AM revealed "...patient is being reviewed at [Hospital P]...declined at [Hospital D and E]...pending at [Hospital M and I] due to no beds available..." Further review of nurses notes dated 10/2/17 at 4:13 PM revealed "...patient was declined by [Hospital E, M, D, I, and B]..." Further review of nurses notes dated 10/3/17 at 3:16 AM revealed "...declined at [Hospital D] due to history of violence, declined at [Hospital B] due to delirium...[Hospital I] has no beds...[Hospital E] declined due to history of violence..." Review of nurses notes dated 10/4/17 at 5:49 AM revealed "...pt threw a full canister of ice at security guards head...pt placed in seclusion at this time. Restraints applied at [5:50 AM] Patient was restrained...seclusion room..." Further review of the nurses notes dated 10/4/17 at 2:55 PM "...Patient left the ED..."

Medical record review of ED physician's notes dated 9/29/17 at 5:26 PM revealed Patient #8 was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam. Further review of the physician's notes dated 9/29/17 at 5:26 PM revealed "...reported a history of drug abuse...Patient does admit to me that he has a plan to hurt someone...is disorganized and agitated and paranoid..." Further review of physician's notes dated 10/2/17 at 3:11 PM revealed "...agitated, screaming obscenities..." Further review of ED physician's note dated 10/4/17 at 2:37 PM revealed "...Disposition summary...Transfer ordered to [Hospital C]...Diagnosis...Psychosis, Homicidal and Suicidal Ideation..."

Medical record review of a Certificate of Need (CON) completed for Patient #8 on 9/30/17 at 1:05 AM revealed "...Pt presents with reported manic behavior and homicidal ideation. Patient is a potential danger to others and potentially himself..."

Medical record review revealed no documentation Patient #8 was evaluated or treated by Hospital A's on-call psychiatrist during the 4 days and 22 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/29/17, 9/30/17, 10/1/17, 10/2/17, 10/3/17, and 10/4/17.

3. Medical record review revealed Patient #11 was admitted to Hospital A's Main Campus ED on 9/25/17 at 7:03 AM with diagnoses including Suicidal Ideation. Further review revealed the patient was triaged at 7:13 AM and received a MSE on 9/25/17 at 7:15 AM.

Medical record review of an ED nurses note dated 9/25/17 at 7:11 AM revealed "...SI [suicidal ideation]...with plan to OD [overdose]...I had a bunch of pills in my hand...I've been fighting with my wife...pushing her around...I feel like I'm a danger to her and myself...having auditory...visual hallucinations...7:37 [AM]...mood...sad...hallucinations are auditory...visual...having thoughts of suicide...plan...overdose...placed in safe environment...continuous observation...[named] security at bedside..."

Medical record review of an ED Physician's Note dated 9/25/17 at 8:06 AM revealed "...presents complaining...I want to kill myself...hearing people[s] voices...seeing demons...felt this way for 1.5 months...prior to my evaluating...patient...he tried to pull something off the wall...actually used a piece of metal plating [to] cut his right...wrist..." Continued review revealed the patient was provided a MSE which included: a HPI, a medical history and psychiatric history, a review of systems, and a physical exam.

Medical record review of an ED Nurses Note dated 9/25/17 at 8:29 AM revealed "...patient took a piece of metal off of the wall in room...cut his right wrist with the object...10:07 [AM]...consult called into MCU...chart...faxed...3:37 [PM]...being [assessed] by Access Tennova [facility flow center which provides assistance with psychiatric patient placement] for psych [psychiatric] placement...3:49 [PM]...will be an involuntary commitment...commitment papers completed..."

Medical record review of the ED Physician's Order revealed a consult for MCU on 9/25/17 at 10:07 AM and a consult for Tennova Access on 9/25/17 at 3:36 PM. Further review revealed the patient had a CON For Emergency Involuntary Admission during the patient's stay at Hospital A's Main Campus signed on 9/25/17 at 3:32 PM and the patient remained in the ED until 9/27/17 at 12:53.

Medical record review revealed no documentation Patient #11 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 5 and ½ hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/25/17, 9/26/17, and 9/27/17.

4. Medical record review revealed Patient #13 was admitted to Hospital A's Main Campus ED on 9/20/17 at 3:29 PM with a diagnoses including Suicidal Ideations, Substance Abuse, and Pregnancy. Further review revealed the patient was triaged at 3:49 PM and received a MSE on 9/20/17 at 3:59 PM.

Medical record review of an ED nurses note dated 9/20/17 at 3:47 PM revealed "...suicidal thoughts after son was brutally murdered...plan...overdose..."

Medical record review of an ED Physician's Note dated 9/20/17 at 4:19 PM revealed "...depressed...having suicidal thoughts...had a son...murdered 5 months ago...depressed...using opiates since that time...reports she is 4-5 months pregnant...she snorts or takes tablets..." Continued review revealed the patient was provided a MSE which included: a HPI, a medical history and psychiatric history, a review of systems, and a physical exam.

Medical record review of an ED nurses note dated 9/20/17 at 4:59 PM revealed "...mood...sad...having thoughts of suicide...plan for suicide is overdose...placed in safe environment...continuous observation...[named] security at bedside...5:33 [PM]...chart faxed to MCU...consult...called...6:18 [PM]...MCU evaluating patient..."

Medical record review of an ED Physician's Note dated 9/20/17 at 5:29 PM revealed "...tearful...despondent...out of concern for her safety...have completed a certificate of need...Gravida 3 [third pregnancy]...Pregnancy Verified...EDC [estimated date of conception] 1/13/2018...Gestational Age...23 weeks 5 days..."

Medical record review revealed a CON for Patient #13 was signed on 9/20/17 at 5:20 PM and the patient remained in the ED until 9/23/17 at 8:32 AM.

Medical record review of an ED Nurses Note dated 9/22/17 at 9:00 AM revealed "...mood...irritable...having thoughts of suicide...is challenging...affect is flat...7:17 [PM]...accepted to [Hospital C]..."

Medical record review of an ED Physician's note dated 9/22/17 at 7:21 PM revealed "...Transfer ordered to [Hospital C]...Diagnosis...Suicidal Ideations...Substance Abuse...Pregnancy..."

Medical record review revealed no documentation Patient #13 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 17 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/20/17, 9/21/17, 9/22/17, and 9/23/17.

5. Medical record review revealed Patient #14 presented to the ED at Hospital A's Main Campus on 9/18/17 at 6:45 PM for complaint of "...threatening her mother...not used meth [methamphetamine] in 3 days..." Further review of the medical record revealed Patient #14 was diagnosed with Suicidal Ideation and was transferred to Hospital B on 9/21/17 at 4:01 PM.

Medical record review of a nurses notes dated 9/18/17 revealed Patient #14 was triaged at 6:45 PM. Further review of a nurses notes dated 9/18/17 at 6:52 PM revealed "...Substantial risk for suicide...patient placed in safe environment..." Further review of the nurses notes dated 9/18/17 at 8:16 PM revealed "...[patient] stated he would kill anyone wherever he was sent...Pt becoming violent toward staff..." Further review of the nurses notes dated 9/21/17 at 4:01 PM revealed "...Patient left the ED..."

Medical record review of an ED physician's notes dated 9/18/17 at 5:56 PM revealed Patient #14 was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam. Further review of the physician's notes dated 9/18/17 at 7:57 PM revealed "...Patient having thoughts of suicide. Plan for suicide is death by cop...refuses vs [vital signs] and blood draw, and urine testing...states he wants to die or go to jail...he will kill the next person that enters his room that is not a police officer with a taser [device used to disable an individual] or gun to kill him or to take him to jail..." Further review of the physician's notes dated 9/19/17 at 1:08 PM revealed "...Consult order...Mobile Crisis Unit..." Further review of the physician's notes dated 9/18/17 at 3:16 PM revealed "...Disposition summary...Transfer ordered to [Hospital B]...Diagnosis is Suicidal Ideation..."

Medical record review of a CON for Patient #14 dated and signed by the physician on 9/18/17 at 9:02 PM revealed "...Depression with aggressive behavior and suicidal thoughts...needs care to avoid harm to self and others..."

Medical record review revealed no documentation Patient #14 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 21 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/18/17, 9/19/17, 9/20/17, and 9/21/17.

6. Medical record review revealed Patient #17 was admitted to Hospital A's Main Campus ED on 8/30/17 at 1:57 PM via Law Enforcement with diagnoses including Suicidal Ideations. Further review revealed the patient was triaged at 2:21 PM and received a MSE on 8/30/17 at 10:09 PM.

Medical record review of an ED Nurses Note dated 8/30/17 at 2:15 PM revealed "...was released from [Hospital C] on Friday [5 days prior] after a 3 week stay...been on and off his medications...trying to get him into a residential home...altercation with dad today...reports suicidal thoughts...superficial lacerations noted to neck...2:25 [PM]...placed in safe environment...continuous observation...[named] security at bedside..."

Medical record review of an ED Physician's Note dated 8/30/17 at 3:44 PM revealed "...presents...with a history of a suicide gesture...made 3 superficial cuts to his neck with...safety razor...schizoaffective disorder...was recently released from an inpatient psychiatric treatment facility...was visiting a group home with...parents...was being considered for...placement...he became very irate...violent...he made 3 superficial cuts to his neck...said...he was suicidal..." Continued review revealed the patient was provided a MSE which included: a HPI, a medical history and psychiatric history, a review of systems, and a physical exam.

Medical record review of an ED Nurses Note dated 8/30/17 at 5:53 PM revealed "...is being assessed by Access Tennova...9:50 [PM]...will be a voluntary commitment..."

Medical record review of an ED Nurses Note dated 8/31/17 at 1:15 PM revealed "...refused to eat or drink anything for lunch...3:07 [PM]...continuing...refuses food...drink...medications...5:54 [PM]...continuing to refuse drinks...food...medications..."

Medical record review of an ED Nurses Note dated 9/1/17 at 7:30 AM revealed "...patient is not eating or drinking...not answering any questions...8:37 [AM]...displayed extreme agitation...threat to harm self or others...reported suicide ideation...psychotic symptoms...hallucinations...delusions...paranoid ideas...thought disorder...unusual or agitated behavior..."

Medical record review of an ED Physician's note dated 9/1/17 at 10:03 AM revealed "...remains in the emergency department...awaiting placement for psychiatric illness...patient is not eating or taking any...medications...diagnosis of schizoaffective disorder...when he gets more confused he will not eat...he was completely nonverbal...standing in the corner of the room...just stares at me with saliva drooling from his mouth...he will not talk..."

Medical record review of an ED nurses note dated 9/1/17 at 11:05 AM revealed "...refused breakfast...spoke with [named on-call Psychiatrist]...medicine service refused to admit...he has been declined by 10 facilities at this time...11:20 [AM]...moved to room 11 for IV [intravenous] hydration...sitter remains at bedside...12:16 [PM]...trying to get out of bed...refusing to cooperate...able to get him back in bed x [times] 3 staff members...2:48 [PM]...sitting in the floor...[named MD]...tried to help him up...patient lunged towards him...patient then jumped over the door into the hallway....intercepted by security officer...placed into seclusion...5:00 [PM]...remains in a catonic [catatonic, unresponsive stupor]...state...6:00 [PM]...remains in a catonic state...7:15 [PM]...remains in seclusion...standing in the middle of the floor...will not speak ...is drooling...will not sit....will not move...does make eye contact...8:07 [PM]...displayed a distorted perception of reality..."

Medical record review of an ED nurses note dated 9/2/17 at 4:53 AM revealed "...spoke at length with [patient]...assessing to take...out of seclusion...expressed frustration at being forced to take pills against his will...[patient stated] I feel like a prisoner...I should be able to choose how to live...appears to be very frustrated by his circumstances...lack of control in is life...7:37 [AM]...refused US [ultrasound]...when [named security company] went into room to talk him into it...[patient] grabbed her by the throat...security intervened...8:30 [AM]...lunging towards security...threatening to leave...subdued by security...9:45 [AM]...remains standing in the middle of the room nonverbal...staring...10:50 [AM]...guided to one of the rooms...he is scaring some of the other people...2:32 [PM]...displayed extreme agitation...displayed physically/verbally aggressive behavior...displayed a distorted perception of reality...signs of depression...reported threat to harm self or others...suicide ideation...psychotic symptoms...hallucinations...delusions...paranoid ideas...thought disorder...unusual or agitated disorder...5:23 [PM]...blood on corner of...sheet...came from his hand...abrasions on his hand..."

Medical record review of an ED nurses note dated 9/3/17 at 7:18 AM revealed "...mood is sad...hallucinations are auditory...having thoughts of suicide...affect is flat...9:02 [AM]...refused medications...fluids...food...11:59 [AM]...has been declined by...[Hospital A]..."

Medical record review of an ED nurses note dated 9/5/17 at 8:14 PM revealed "...finally agreed to take medications...has refused x 3 today..."

Medical record review of an ED nurses note dated 9/6/17 at 8:11 AM revealed "...mood is sad...hallucinations are auditory...having thoughts of suicide...affect is flat...11:01 [AM]...accepted to [Hospital C]...12:30 [PM]...patient refused [medications]...1:05 [PM]...transfer order by MD...3:10 [PM]...patient left ED..."

Medical record review revealed the CON was completed and signed by the physician on 9/1/17 at 12:12 PM. Continued review revealed the patient remained in the ED until 9/6/17 at 3:10 PM.

Medical record review revealed no documentation Patient #17 was evaluated or treated by Hospital A's on-call psychiatrist during the 6 days and 23 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 8/30/17, 8/31/17, 9/1/17, 9/2/17, 9/3/17, 9/4/17, 9/5/17, and 9/6/17.

7. Medical record review revealed Patient #37 was admitted to Hospital A's North Campus ED on 9/15/17 at 11:06 PM with a diagnoses including Acute Psychosis and Abuse of Non-Psychoactive Substances. Further review revealed the patient was triaged at 11:42 PM and received a medical examination on 9/16/17 at 12:33 AM.

Medical record review of an ED nurses note dated 9/15/17 at 11:37 PM revealed "...presenting complaint...feels overwhelmed...stressed...thinks she needs to be placed in a psych hospital...to...calm herself..."

Medical record review of an ED Physician's note dated 9/15/17 at 11:57 PM revealed "...presents to ER...complaints of Psych problem...anxiety...depression...paranoia...states...overwhelmed...needs to stay in a psych hospital for a few days...having spiritual thoughts and is feeling anxious about them...has not taken Seroquel in several weeks..."

Medical record review of an ED nurses note dated 9/16/17 at 3:14 AM revealed "...mood is irritable...delusions are religious...hallucinations are auditory...having thoughts of irritable...talking about god...heaven...demons...different things...uncooperative...restless...affect is inappropriate..."

Medical record review of an ED nurses note dated 9/17/17 at 9:30 AM revealed "...pacing in room...having loud outbursts...yells out profanity at times...11:26 [AM]...extremely agitated...yelling out profanity...stating she is...spiritually annoyed...pestered...12:09 [PM]...called transfer center...still on waiting list at [Hospital B]...declined at [Hospital D]...declined at [Hospital I]...when asked about getting...on [Hospital C]...waiting list...reported...had...to have...[MCU]...consult...asked to get...[MCU]...consult...reported [MCU]...would not evaluate...until...had been declined by 5 facilities...called [Hospital E Valley Campus]...to inquire about...bed availability...when told...had [named insurance]...reported [Hospital E Valley Campus staff] by law in state of tn [Tennessee]...had to be evaluated by [MCU]...due to [state Medicaid program in Tennessee]...called [MCU] gave information...asked why...been in er so many days without...consulting them...informed...transfer center...trying to place...agreed...did have to be evaluated by them [MCU]..."

Medical record review of an ED Physician's note dated 9/17/17 at 6:08 PM revealed "...has had intermittent delusions...agitation...transfer of care was delayed...transfer center stating [MCU] could not be involved unless...been declined by 5 facilities...she is...TennCare...has been declined by multiple facilities due to not having been evaluated by [MCU]..." Continued review revealed the patient was provided a MSE which included: a HPI, a medical history and psychiatric history, a review of systems, and a physical exam.

Medical record review of an ED nurses note dated 9/18/17 at 3:40 AM revealed "...awaiting [Hospital B]...[Hospital I]...has been refused everywhere else...8:00 [AM]...mood is angry...irritable...delusions are religious...hallucinations are auditory...uncooperative...irritable...restless...affect is blunted...inappropriate..."

Medical record review of an ED Physician's note dated 9/18/17 at 6:14 PM revealed "...behavior was erratic...continued hallucinations...placement...pending..."

Medical record review of an ED nurses note dated 9/18/17 at 6:46 PM revealed "...accepted at [Hospital B]...waiting on a bed...9:25 [PM]...transfer center called...[Hospital B]...call back around 10 AM...no beds tonight..."

Medical record review of an ED nurses note dated 9/19/17 at 10:35 AM revealed "...[Hospital B]...will not have available beds until later this afternoon...2:00 [PM]...mood is angry...irritable...delusions are religious...hallucinations are auditory...irritable...restless...affect is flat...inappropriate...sitter at bedside...9:00 [PM]...pacing..."

Medical record review of an ED nurses note dated 9/20/17 at 3:00 AM revealed "...agitated...angry...combative...9:23 [AM]...transfer center stated...declined by ten facilities...on...waiting list at...[Hospital B]...going to review...chart at ten this morning...call back around noon today...recheck...status...12:31 [PM]...accepted at [Hospital B]...on waiting list still...waiting on a bed to open...no time frame can be given...5:56 [PM]...transfer ordered by MD..."

Medical record review of an ED Physician's note dated 9/20/17 at 5:56 PM revealed "...Transfer ordered to Other Acute Care Facility...Diagnosis...Acute Psychosis...Abuse of Non-Psychoactive Substances...problem is new...symptoms are unchanged..."

Medical record review of an ED Nurses Note dated 9/20/17 at 8:07 PM revealed "...patient left the ED..."

Medical record review revealed a CON for Patient #37 was completed and signed by the physician on 9/16/17 at 7:00 AM. Continued review revealed the patient remained in the ED until 9/20/17 at 8:07 AM.

Medical record review of an "Emergency Services Patient Transfer Form" dated 9/20/17 at 5:37 PM revealed "...The patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide..."

Medical record review revealed no documentation Patient #37 was evaluated or treated by Hospital A's on-call psychiatrist during the 4 days and 9 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/15/17, 9/16/17, 9/17/17, 9/18/17, 9/19/17, and 9/20/17.

8. Medical record review revealed Patient #40 was a 17 year old admitted to the Hospital A's North Campus ED on 9/18/17 at 10:25 AM with a chief complaint of having Suicidal Ideations. Further review revealed the patient was triaged at 10:38 AM and received a MSE at 11:37 AM by the ED Physician.

Medical record review of an ED Nurses Triage record dated 9/18/17 at 10:38 AM revealed "...states intermittently having suicidal thoughts for the past 3 weeks and states that his parents found out today so they came in to the hospital. Denies a plan. Feeling depressed..."

Medical record review of an ED Physician's Note dated 9/18/17 at 12:45 PM revealed "...complaints of Suicidal Ideations...presents with depression, suicidal ideations but no formulated plan...onset 2 weeks ago...has not experienced similar symptoms in the past...states started a relationship with a girl 2 months ago and 3 weeks ago the girl suggested that they talk less...states has also been failing some of his classes because of relationship issues...says it all makes him depressed and he feels like he does not want to be here anymore..." Continued review revealed the patient was provided a MSE which included: a HPI, a medical history and psychiatric history, a review of systems, and a physical exam.

Medical record review of an ED nurses note dated 9/18/17 at 2:02 PM revealed "...chart faxed to transfer center...7:40 [PM] Spoke with transfer center who states they need information faxed to [Hospital B]..."

Medical record review of a Tennova intake center behavioral health preadmission screening completed by a Licensed Clinical Social Worker (LCSW) dated 9/18/17 at 3:00 PM revealed the patient received a psychiatric assessment. Further review revealed "...admits to SI [suicidal ideation] without a plan. States stressors are a girlfriend he met online that is parents are opposed to...struggling with classes..." Further review revealed "...patient very hesitant to answer questions and soft spoken as if to keep anyone else from overhearing...feels depressed for past 3 weeks..." Further review revealed "...disposition: admit/transfer to Inpatient behavioral health...involuntary type..."

Medical record review of a CON completed and signed by the ED physician dated 9/18/17 at 3:00 PM revealed "...depression/possible overdose...patient has threatened suicide by text to multiple friends...mother abandonment at age of 5...high achiever is currently suicidal over a break up and is failing calculus and physics...patient has strong abandonment issues due to mother...has been angry and parents feels he will go through with it..."

Medical record review of an ED nurses note dated 9/19/17 at 10:31 AM revealed "...contacted mobile crisis to check status of pt and stated pt is referred to [Hospital M and Hospital E]..." Further review revealed "...11:35 [AM] contacted transfer center for transport...pt accepted at [Hospital B]...police department to transport..."

Medical record review of an ED Discharge Summary dated 9/19/17 at 1:03 PM revealed the patient was transferred to Hospital B with a diagnosis of Depression and Suicidal Ideations.

Medical record review of an ED nurses note dated 9/19/17 at 1:08 PM revealed "...patient transferred by police department...pt left the ED..."

Medical record review revealed no documentation Patient #40 was evaluated or treated by Hospital A's on-call psychiatrist during the 1 day and 2 and ½ hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/18/17 and 9/19/17.

9. Medical record review revealed patient #46 presented to the North Campus ED on 9/26/17 at 6:05 PM with complaint of "...arguing with mother...took 30 pills..." Further review of the medical record revealed the patient was transferred to Hospital J for involuntary admission on 9/28/17 at 9:14 PM.

Medical record review of an ED nurses notes revealed patient #46 was triaged on 9/26/17 at 6:20 PM. Further review of nurses notes dated 9/25/17 at 6:27 PM revealed "...minimal noted risk for suicide..." Further review of nurses notes dated 9/27/17 at 8:28 PM revealed "...Call made to mobile crisis to check patient placement status...Mother declined to drive to [Hospital E, valley campus] to sign patient in..." Further review of nurses notes dated 9/28/17 at 7:25 AM revealed "...spoke with...mobile crisis; states [Hospital M] has no beds...[Hospital K] is on diversion...still on waiting list at [Hospital B]..." Further review of nurses notes dated 9/28/17 at 2:40 PM revealed "...mother wants to know why she cannot sign pt [patient] out and take her home; informed pt is committal and cannot be signed out..." Further review of nurses notes dated 9/28/17 at 9:14 PM revealed "...Patient left the ED..."

Medical record review of an ED physician's notes dated 9/26/17 at 8:01 PM revealed Patient #46 was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam. Review of physician's notes dated 9/27/17 at 2:18 PM revealed "...Transfer ordered to Other Acute Care Facility. Diagnosis are Suicide Attempt, Suicidal Ideations..."

Medical record review pf a CON completed and signed by the ED physician dated 9/28/17 at 2:15 PM revealed "...Pt tried to commit suicide with pills...very depressed..."

Medical record review revealed no documentation Patient #46 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 3 hours the patient was in the ED at Hospital A.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/26/17, 9/27/16, and 9/28/17.

10. Medical record review revealed Patient #78 was admitted to Hospital A's West ED Campus on 1/5/17 at 3:14 PM with a chief complaint of depression and hearing voices. Further review revealed the patient was triaged at 3:33 PM and received a MSE by the ED physician at 3:32 PM. Further review revealed the patient was transferred to Hospital C on 1/9/17 at

Based on facility policy reviews, medical record reviews, and interviews, the facility failed to prevent a delay in providing an appropriate medical screening examination in order to obtain information on the patients method of payment and/or insurance status for 3 patients (#54, #74, and #76) of 84 psychiatric patients held in the Emergency Department (ED) awaiting inpatient psychiatric admission of 181 emergency records reviewed.

The findings included:

Review of facility policy "Emergency Medical Treatment and Patient Transfer Policy" original effective date 12/1/98 revealed "...Even if it causes no delay, the hospital may not contact the insurance plan for verification or authorization until after it has provided for the MSE [medical screening examination] and initiated any medical treatment that is required..."

Review of the facility's "Quick Registration Checklist and Registration Process Time Flow" with no time or date, revealed "...clerk initiates full registration process...may not request insurance information until pt. [patient] seen by doctor...otherwise it's an EMTALA violation..."

Medical record review revealed Patient #54 was admitted to Hospital A's North Campus ED on 10/9/17 at 7:59 PM with a chief complaint of Suicidal Ideations.

Medical record review revealed a credit report for Patient #54 was obtained on 10/9/17 at 8:04 PM Eastern Standard Time (EST).

Medical record review of an ED Physician's note revealed the MSE was performed on 10/9/17 at 8:49 PM EST (45 minutes after the credit report was obtained).

Medical record review revealed Patient #74 was admitted to Hospital A's Main Campus ED on 10/24/17 at 7:24 PM with a chief complaint of Altered Mental Status.

Medical record review revealed a credit report for Patient #74 was obtained on 10/24/17 at 7:58 PM EST.

Medical record review of an ED Physician's note revealed a MSE was performed on 10/24/17 at 8:11 PM EST (13 minutes after the credit report was obtained).

Medical record review revealed Patient #76 was admitted to Hospital A's Main Campus ED on 8/15/17 at 4:32 PM by the local police department with a diagnosis of Psychotic Disorder with Hallucination due to known Physiological Condition.

Medical record review revealed an Insurance Eligibility Form was dated 8/15/17 at 4:50 PM EST.

Medical record review of an ED Physician's note revealed a MSE was performed on 10/25/17 at 5:24 PM EST (34 minutes after the insurance eligibility report was obtained).

Interview with the Director of Admissions on 11/2/17 at 11:30 AM, in the conference room, revealed "...all patients who come in to the ED go through a quick registration to get the name, date of birth, and social security number to be able to generate a chart for the patient...this can be done at the registration desk or at the bedside..." Further interview confirmed "...it is my expectation that insurance or copays are not to be done until after a medical screening examination by a physician has been performed for the patient..." Further interview confirmed the reports were obtained for Patient #52, #74, and #76 prior to the medical screening examination by the ED Physician.

Based on review of facility policies, medical record reviews, bed census reports, and interviews, the facility inappropriately transferred individuals with identified emergency psychiatric conditions, the hospital failed to admit those individuals determined to require inpatient psychiatric services to its psychiatric unit which had the capability and capacity to provide inpatient psychiatric treatment/milieu; and failed to minimize the risks to the individuals health as evidenced by inappropriately transferring individuals deemed to require inpatient hospitalization for emergency psychiatric conditions in that these individuals spent more than 24 hours in the hospital's emergency department with documented behavioral disorders by the emergency physician requiring inpatient treatment; and inappropriately transferred individuals to a facility with the same level of care for 29 patients (#5, #8, #11, #13, #14, #17, #37, #40, #46, #78, #80, #86, #87, #88, #90, #93, #96, #97, #98, #102, #103, #112 #113, #120, #121, #123, #124, #171, and #180) of 84 psychiatric patients held in the Emergency Department (ED) awaiting inpatient psychiatric admission of 181 emergency records reviewed.

The findings included:

Policies and Procedures:
Review of facility policy "Emergency Medical Treatment and Patient Transfer Policy" effective date 12/1/1998, revealed "...The Hospital shall maintain a list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an Emergency Medical Condition or woman in labor...during the Hospital's normal operating hours, all medical specialties represented on the medical staff should be available for emergency services..."

Medical Staff Bylaws:
Review of facility Medical Staff Bylaws adopted and approved 6/3/2016, revealed "...Article III - Medical Staff Membership...3.3 Basic Responsibilities of Staff Members...Abide by the Medical Staff Bylaws and other lawful standards, policies...and Rules & Regulations of the Medical Staff..."

Medical Staff Rules and Regulations:
Review of facility Medical Staff Rules and Regulations, undated, Article VI, Emergency Medical Screening, Treatment, Transfer, and On-call Roster Policy revealed "...6.1(a) Screening...(4) Services available to Emergency Department patients shall include all ancillary services routinely available to the Emergency Department, even if not directly located in the department..."

Medical record reviews:

1. Medical record review revealed Patient #5 presented to the ED at Hospital A's main campus on 10/5/17 at 2:56 PM for complaint of "...is suicidal..." Further review of the medical record revealed the patient was transferred as an involuntary admission to Hospital B on 10/7/17 at 12:48 PM.

Medical record review of a physician's note dated 10/5/17 at 2:57 PM revealed Patient #5 was provided a Medical Screening Examination (MSE) which included: a History of Present Illness (HPI), a medical and psychiatric history, a Review of Systems (ROS), and a physical exam. Further review of the physician's note dated 10/5/17 at 4:25 PM revealed "...Medically stable for further psychiatric care..." Further review of the physician's note dated 10/7/17 at 12:47 PM revealed "...Will proceed with previously planned transfer to psychiatric hospital..." Further review of the physician's note dated 10/7/17 at 7:13 AM revealed "...Disposition Summary...Transfer ordered to [Hospital B]...Diagnosis is Suicidal Ideation..."

Medical record review of an Emergency Services Patient Transfer Form dated 10/7/17 at 12:33 PM revealed the patient was transferred to Hospital B. Further review revealed "... the patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of stabilizing and/or treating the patient's Emergency Medical Condition, including psychiatric emergencies..."

Medical record review revealed no documentation Patient #5 was evaluated or treated by Hospital A's on-call psychiatrist during the 1 day and 22 hours the patient was in the ED at Hospital A.

Review of Hospital Census records revealed the 32 bed Behavioral Unit's census was: 20 (12 vacancies) on 10/5/17; 15 (17 vacancies) on 10/6/17; and 18 (14 vacancies) on 10/7/17.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 10/5/17, 10/6/17, and 10/7/17.

2. Medical record review revealed Patient #8 presented to the ED at Hospital A's Main Campus on 9/29/17 at 5:08 PM for complaint of psychiatric problems. Further review revealed the patient was diagnosed with Psychosis and Homicidal and Suicidal Ideation and was transferred to Hospital C on 10/4/17 at 2:44 PM.

Medical record review of ED physician's notes dated 9/29/17 at 5:26 PM revealed Patient #8 was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam. Further review of the physician's notes dated 9/29/17 at 5:26 PM revealed "...reported a history of drug abuse...Patient does admit to me that he has a plan to hurt someone...is disorganized and agitated and paranoid..." Further review of physician's notes dated 10/2/17 at 3:11 PM revealed "...agitated, screaming obscenities..." Further review of ED physician's note dated 10/4/17 at 2:37 PM revealed "...Disposition summary...Transfer ordered to [Hospital C]...Diagnosis...Psychosis, Homicidal and Suicidal Ideation..."

Medical record review of an Emergency Services Patient Transfer Form dated 10/4/17 at 5:05 PM revealed the patient was transferred to Hospital C. Further review revealed "... the patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of stabilizing and/or treating the patient's Emergency Medical Condition, including psychiatric emergencies..."

Medical record review revealed no documentation Patient #8 was evaluated or treated by Hospital A's on-call psychiatrist during the 4 days and 22 hours the patient was in the ED at Hospital A.

Review of Hospital Census records revealed the 32 bed Behavioral Unit's census was: 20 (12 vacancies) on 9/30/17; 21 (11 vacancies) on 10/1/7 through 10/3/17; and 20 (12 vacancies) on 10/4/17.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/29/17, 9/30/17, 10/1/17, 10/2/17, 10/3/17, and 10/4/17.

3. Medical record review revealed Patient #11 was admitted to Hospital A's Main Campus ED on 9/25/17 at 7:03 AM with diagnoses including Suicidal Ideation. Further review revealed the patient was transferred to Hospital B on 9/27/17 at 12:53 PM.

Medical record review of an ED Physician's Note dated 9/25/17 at 8:06 AM revealed "...presents complaining...I want to kill myself...hearing people[s] voices...seeing demons...felt this way for 1.5 months...prior to my evaluating...patient...he tried to pull something off the wall...actually used a piece of metal plating [to] cut his right...wrist..." Continued review revealed the patient was provided a MSE which included: a HPI, a medical history and psychiatric history, a review of systems, and a physical exam.

Medical record review of an Emergency Services Patient Transfer Form dated 9/26/17 at 11:40 PM revealed the patient was transferred to Hospital B. Further review revealed "... the patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of stabilizing and/or treating the patient's Emergency Medical Condition, including psychiatric emergencies..."

Medical record review revealed no documentation Patient #11 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 5 and ½ hours, and 51 minutes the patient was in the ED at Hospital A.

Review of Hospital A's Census records revealed the 32 bed Behavioral Unit's census was: 19 (13 vacancies) on 9/25/17; 19 (13 vacancies) on 9/26/17; and 19 (13 vacancies) on 9/27/17.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/25/17, 9/26/17, and 9/27/17.

4. Medical record review revealed Patient #13 was admitted to Hospital A's Main Campus ED on 9/20/17 at 3:29 PM with a diagnoses including Suicidal Ideations, Substance Abuse, and Pregnancy. Further review revealed the patient was transferred to Hospital C on 9/23/17 at 8:32 AM.

Medical record review of an ED Physician's Note dated 9/20/17 at 4:19 PM revealed "...depressed...having suicidal thoughts...had a son...murdered 5 months ago...depressed...using opiates since that time...reports she is 4-5 months pregnant...she snorts or takes tablets..." Continued review of an ED Physician's note dated 9/20/17 at 5:29 PM revealed "...tearful...despondent...out of concern for her safety...have completed a certificate of need...Gravida 3 [third pregnancy]...Pregnancy Verified...EDC [estimated date of conception] 1/13/2018...Gestational Age...23 weeks 5 days..." Further review of an ED Physician's note dated 9/22/17 at 7:21 PM revealed "...Transfer ordered to [Hospital C]...Diagnosis...Suicidal Ideations...Substance Abuse...Pregnancy..." Continued review revealed the patient was provided a MSE which included: a HPI, a medical history and psychiatric history, a review of systems, and a physical exam.

Medical record review of an Emergency Services Patient Transfer Form dated 9/22/17 at 7:00 PM revealed the patient was transferred to Hospital C. Further review revealed "... the patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of stabilizing and/or treating the patient's Emergency Medical Condition, including psychiatric emergencies..."

Medical record review revealed no documentation Patient #13 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 17 hours the patient was in the ED at Hospital A.

Review of Hospital A's Census records revealed the 32 bed Behavioral Unit's census was: 19 (13 vacancies) on 9/20/17; 19 (13 vacancies) on 9/21/17; 16 (16 vacancies) on 9/22/17; and 17 (15 vacancies) on 9/23/17.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/20/17, 9/21/17, 9/22/17, and 9/23/17.

5. Medical record review revealed Patient #14 presented to the ED at Hospital A's Main Campus on 9/18/17 at 6:45 PM for complaint of "...threatening her mother...not used meth [methamphetamine] in 3 days..." Further review revealed the patient was transferred to Hospital B on 9/21/17 at 4:01 PM.

Medical record review of an ED physician's notes dated 9/18/17 at 5:56 PM revealed Patient #14 was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam. Further review of the physician's notes dated 9/18/17 at 7:57 PM revealed "...Patient having thoughts of suicide. Plan for suicide is death by cop...refuses vs [vital signs] and blood draw, and urine testing...states he wants to die or go to jail...he will kill the next person that enters his room that is not a police officer with a taser [device used to disable an individual] or gun to kill him or to take him to jail..." Further review of the physician's notes dated 9/19/17 at 1:08 PM revealed "...Consult order...Mobile Crisis Unit..." Further review of the physician's notes dated 9/18/17 at 3:16 PM revealed "...Disposition summary...Transfer ordered to [Hospital B]...Diagnosis is Suicidal Ideation..."

Medical record review of an Emergency Services Patient Transfer Form dated 9/21/17 3:15 PM revealed the patient was transferred to Hospital B. Further review revealed "... the patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of stabilizing and/or treating the patient's Emergency Medical Condition, including psychiatric emergencies..."

Medical record review revealed no documentation Patient #14 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 21 hours the patient was in the ED at Hospital A.

Review of Hospital A's Census records revealed the 32 bed Behavioral Unit's census was: 21 (11 vacancies) on 9/18/17; 20 (12 vacancies) on 9/19/17; 19 (13 vacancies) on 9/20/17 and 19 (13 vacancies) on 9/21/17.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/18/17, 9/19/17, 9/20/17, and 9/21/17.

6. Medical record review revealed Patient #17 was admitted to Hospital A's Main Campus ED on 8/30/17 at 1:57 PM via Law Enforcement with diagnoses including Suicidal Ideations. Further review revealed the patient was transferred to Hospital C on 9/6/17 at 3:10 PM.

Medical record review of an ED Physician's note dated 8/30/17 at 3:44 PM revealed "...presents...with a history of a suicide gesture...made 3 superficial cuts to his neck with...safety razor...schizoaffective disorder...was recently released from an inpatient psychiatric treatment facility...was visiting a group home with...parents...was being considered for...placement...he became very irate...violent...he made 3 superficial cuts to his neck...said...he was suicidal..." Continued review of an ED Physician's note dated 9/1/17 at 10:03 AM revealed "...remains in the emergency department...awaiting placement for psychiatric illness...patient is not eating or taking any...medications...diagnosis of schizoaffective disorder...when he gets more confused he will not eat...he was completely nonverbal...standing in the corner of the room...just stares at me with saliva drooling from his mouth...he will not talk..." Continued review revealed the patient was provided a MSE which included: a HPI, a medical history and psychiatric history, a review of systems, and a physical exam.

Medical record review of an Emergency Services Patient Transfer Form dated 9/6/17 at 12:36 PM revealed "... the patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of stabilizing and/or treating the patient's Emergency Medical Condition, including psychiatric emergencies..."

Medical record review revealed no documentation Patient #17 was evaluated or treated by Hospital A's on-call psychiatrist during the 6 days and 23 hours the patient was in the ED at Hospital A.

Review of Hospital A's Census records revealed the 32 bed Behavioral Unit's census was: 18 (14 vacancies) on 8/30/17; 17 (15 vacancies) on 8/31/17; 14 (18 vacancies) on 9/1/17; 15 (17 vacancies) on 9/2/17; 15 (17 vacancies) on 9/3/17; 17 (vacancies) on 9/4/17, 13 (19 vacancies) on 9/5/17; and 17 (15 vacancies) on 9/6/17.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 8/30/17, 8/31/17, 9/1/17, 9/2/17, 9/3/17, 9/4/17, 9/5/17, and 9/6/17.

7. Medical record review revealed Patient #37 was admitted to Hospital A's North Campus ED on 9/15/17 at 11:06 PM with a diagnoses including Acute Psychosis and Abuse of Non-Psychoactive Substances. Further review revealed the patient was transferred to Hospital B on 9/20/17 at 8:07 PM.

Medical record review of an ED Physician's note dated 9/15/17 at 11:57 PM revealed "...presents to ER...complaints of Psych [psychiatric] problem...anxiety...depression...paranoia...states...overwhelmed...needs to stay in a psych hospital for a few days...having spiritual thoughts and is feeling anxious about them...has not taken Seroquel in several weeks..." Continued review of an ED Physician's note dated 9/17/17 at 6:08 PM revealed "...has had intermittent delusions...agitation...transfer of care was delayed...transfer center stating [MCU] could not be involved unless...been declined by 5 facilities...she is...TennCare [Medicaid]...has been declined by multiple facilities due to not having been evaluated by [MCU]..." Further review of an ED Physician's note dated 9/18/17 at 6:14 PM revealed "...behavior was erratic...continued hallucinations...placement...pending..." Continued review of an ED Physician's note dated 9/20/17 at 5:56 PM revealed "...Transfer ordered to Other Acute Care Facility...Diagnosis...Acute Psychosis...Abuse of Non-Psychoactive Substances...problem is new...symptoms are unchanged..."

Medical record review revealed no documentation Patient #37 was evaluated or treated by Hospital A's on-call psychiatrist during the 4 days and 9 hours the patient was in the ED at Hospital A.

Medical record review of an "Emergency Services Patient Transfer Form" dated 9/20/17 at 5:37 PM revealed "...The patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide..."

Review of Hospital A's Census records revealed the 32 bed Behavioral Unit's census was: 20 (12 vacancies) on 9/15/17; 22 (10 vacancies) on 9/16/17; 25 (7 vacancies) 9/17/17; 21 (11 vacancies) on 9/18/17; 20 (12 vacancies) on 9/19/17; and 19 (13 vacancies) on 9/20/17.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/15/17, 9/16/17, 9/17/17, 9/18/17, 9/19/17, and 9/20/17.

8. Medical record review revealed Patient #40 was a 17 year old admitted to the Hospital A's North Campus ED on 9/18/17 at 10:25 AM with a chief complaint of having Suicidal Ideations. Further review revealed the patient transferred to Hospital B on 9/19/17 at 1:08 PM.

Medical record review of an ED Physician's Note dated 9/18/17 at 12:45 PM revealed "...complaints of Suicidal Ideations...presents with depression, suicidal ideations but no formulated plan...onset 2 weeks ago...has not experienced similar symptoms in the past...states started a relationship with a girl 2 months ago and 3 weeks ago the girl suggested that they talk less...states has also been failing some of his classes because of relationship issues...says it all makes him depressed and he feels like he does not want to be here anymore..." Continued review revealed the patient was provided a MSE which included: a HPI, a medical history and psychiatric history, a review of systems, and a physical exam.

Medical record review of an Emergency Services Patient Transfer Form dated 9/19/17 at 12:23 PM revealed the patient was transferred to Hospital B. Further review revealed "... the patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of stabilizing and/or treating the patient's Emergency Medical Condition, including psychiatric emergencies..."

Medical record review revealed no documentation Patient #40 was evaluated or treated by Hospital A's on-call psychiatrist during the 1 day and 2 and ½ hours, and 43 minutes the patient was in the ED at Hospital A.

Review of Hospital A's Census records revealed the 32 bed Behavioral Unit's census was: 21 (11 vacancies) on 9/18/17; and 20 (12 vacancies) on 9/19/17.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/18/17 and 9/19/17.

9. Medical record review revealed patient #46 presented to the North Campus ED on 9/26/17 at 6:05 PM with complaint of "...arguing with mother...took 30 pills..." Further review of the medical record revealed the patient was transferred to Hospital J on 9/28/17 at 9:14 PM.

Medical record review of an ED physician's notes dated 9/26/17 at 8:01 PM revealed Patient #46 was provided a MSE which included: a HPI, a medical and psychiatric history, a ROS, and a physical exam. Review of physician's notes dated 9/27/17 at 2:18 PM revealed "...Transfer ordered to Other Acute Care Facility. Diagnosis are Suicide Attempt, Suicidal Ideations..."

Medical record review of an Emergency Services Patient Transfer Form dated 9/28/17 at 2:15 PM revealed the patient was transferred to Hospital J. Further review revealed "... the patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of stabilizing and/or treating the patient's Emergency Medical Condition, including psychiatric emergencies..."

Medical record review revealed no documentation Patient #46 was evaluated or treated by Hospital A's on-call psychiatrist during the 2 days and 3 hours the patient was in the ED at Hospital A.

Review of Hospital A's Census records revealed the 32 bed Behavioral Unit's census was: 19(13 vacancies) on 9/26/17; 19 (13 vacancies) on 9/27/17; and 18 (12 vacancies) on 9/28/17.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 9/26/17, 9/27/16, and 9/28/17.

10. Medical record review revealed Patient #78 was admitted to Hospital A's West ED Campus on 1/5/17 at 3:14 PM with a chief complaint of depression and hearing voices. Further review revealed the patient was transferred to Hospital C on 1/9/17 at 9:35 AM.

Medical record review of a Physician's note dated 1/8/17 at 7:05 AM revealed "...psychosis...auditory hallucinations...visual hallucinations...bipolar disorder...delusions...suicide ideation..." Continued review revealed the patient was provided a MSE which included: a HPI, a medical history and psychiatric history, a review of systems, and a physical exam.

Medical record review of an Emergency Services Patient Transfer Form dated 1/9/17 at 2:55 AM revealed the patient was transferred to Hospital C. Further review revealed "... the patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of stabilizing and/or treating the patient's Emergency Medical Condition, including psychiatric emergencies..."

Medical record review revealed no documentation Patient #78 was evaluated or treated by Hospital A's on-call psychiatrist during the 3 days and 18 hours the patient was in the ED at Hospital A.

Review of Hospital A's Census records revealed the 32 bed Behavioral Unit's census was: 24 (8 vacancies) on 1/5/17; 24 (8 vacancies) on 1/6/17; 23 (9 vacancies) on 1/7/17; 20 (12 vacancies) on 1/8/17; and 19 (13 vacancies) on 1/9/17.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 1/5/17, 1/6/17, 1/7/17, 1/8/17, and 1/9/17.

11. Medical record review revealed Patient #80 was admitted to Hospital A's West Campus ED on 1/25/17 at 3:35 PM via EMS after wandering around a store and had a diagnosis of Psychosis. Further review revealed the patient was transferred to Hospital C on 1/30/17 at 8:59 AM.

Medical record review of an ED Physician's Note dated 1/25/17 at 4:44 PM revealed "...presents to the ED with psychosis, has delusions...diagnosed 1 year ago while attending master's history program. Refused to take medications at that time and lives with parents. Patient felt as though he has been worsening over the last 2 weeks. Wandering, feeling confused, delusional..." Continued review of an ED Physician's note dated 1/25/17 at 7:42 PM revealed an order for a MCU Consult. Continued review revealed the patient was provided a MSE which included: a HPI, a medical history and psychiatric history, a review of systems, and a physical exam.

Medical record review of an Emergency Services Patient Transfer Form dated 1/30/17 at 8:40 AM revealed the patient was transferred to Hospital C. Further review revealed "... the patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of stabilizing and/or treating the patient's Emergency Medical Condition, including psychiatric emergencies..."

Medical record review revealed no documentation Patient #80 was evaluated or treated by Hospital A's on-call psychiatrist during the 4 days and 17 hours the patient was in the ED at Hospital A.

Review of Hospital A's Census records revealed the 32 bed Behavioral Unit's census was: 24 (8 vacancies) on 1/5/17; 24 (8 vacancies) on 1/6/17; 23 (9 vacancies) on 1/7/17; 20 (12 vacancies) on 1/8/17; and 19 (13 vacancies) on 1/9/17.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 1/25/17, 1/26/17, 1/27/17, 1/28/17, 1/29/17, and 1/30/17.

12. Medical record review revealed Patient #86 was admitted to Hospital A's Main Campus ED on 10/19/16 at 7:41 PM with a diagnosis of Suicidal Ideations. Continued review revealed the patient was transferred to Hospital B on 10/25/16 at 5:44 AM.

Medical record review of an ED Physician's Note dated 10/19/16 at 8:11 PM revealed "...history of bipolar disorder here with thoughts of suicide. Patient states that she is being told to leave the house. Her adoptive mother no longer wants her living in the house. She now feels hopeless and does not have anywhere to go. She does not want to go to the homeless shelter. She is contemplating taking her life but does not have a plan..." Continued review revealed the patient was provided a MSE which included: a HPI, a medical history and psychiatric history, a review of systems, and a physical exam.

Medical record review of an Emergency Services Patient Transfer Form dated 10/13/17 at 2:20 PM revealed the patient was transferred to Hospital B. Further review revealed "... the patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of stabilizing and/or treating the patient's Emergency Medical Condition, including psychiatric emergencies..."

Medical record review revealed no documentation Patient #86 was evaluated or treated by Hospital A's on-call psychiatrist during the 5 days and 10 hours the patient was in the ED at Hospital A.

Review of Hospital A's Census records revealed the 32 bed Behavioral Unit's census was: 24 (8 vacancies) on 10/21/16; 19 (13 vacancies) on 10/22/16; 19 (13 vacancies) 10/23/16; 17 (13 vacancies); 17 (13 vacancies) on 10/24/16 and 17 (15 vacancies) on 10/25/16.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 10/19/16, 10/20/16, 10/21/16, 10/22/16, 10/23/16, 10/24/16, and 10/25/16.

13. Medical record review revealed Patient #87 was admitted to Hospital A's Main Campus ED on 11/5/16 at 6:59 PM with a chief complaint of Suicidal Ideations. Further review revealed the patient was transferred to Hospital C on 11/8/16 at 9:10 PM.

Medical record review of an ED Physician's Note dated 11/5/16 at 7:17 PM revealed "...suicidal for past 3 days off his bipolar medications for several weeks. Last opiate use was about a week ago but has relapsed into using. Has now been drinking...he has a plan to hang himself. Currently staying with his grandmother. He had been in North Dakota worked in construction but recently returned..." Continued review revealed the patient was provided a MSE which included: a HPI, a medical history and psychiatric history, a review of systems, and a physical exam.

Medical record review of an Emergency Services Patient Transfer Form dated 11/8/16 at 8:40 AM revealed the patient was transferred to Hospital C. Further review revealed "... the patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of stabilizing and/or treating the patient's Emergency Medical Condition, including psychiatric emergencies..."

Medical record review revealed no documentation Patient #87 was evaluated or treated by Hospital A's on-call psychiatrist during the 3 days and 2 hours the patient was in the ED at Hospital A.

Review of Hospital A's Census records revealed the 32 bed Behavioral Unit's census was: 20 (12 vacancies) on 11/5/16; 17 (15 vacancies) on 11/6/16; 25 (7 vacancies) on 11/7/16; and 18 (14 vacancies) on 11/8/16.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 11/5/16, 11/6/16, 11/7/16, and 11/8/17.

14. Medical record review revealed Patient #88 was admitted to Hospital A's Main Campus ED on 11/5/16 at 8:43 PM via EMS with a diagnoses including Depressive Psychosis. Further review revealed the patient was transferred to Hospital C for involuntary admission on 11/8/16 at 7:03 PM.

Medical record review of an ED Physician's Note dated 11/5/16 at 9:18 PM revealed "...here with altered mental status...found in a hotel acting strange...chasing a child today..." Continued review revealed the patient was provided a MSE which included: a HPI, a medical history and psychiatric history, a review of systems, and a physical exam.

Medical record review of an Emergency Services Patient Transfer Form dated 11/8/16 at 4:30 PM revealed the patient was transferred to Hospital C. Further review revealed "... the patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of stabilizing and/or treating the patient's Emergency Medical Condition, including psychiatric emergencies..."

Medical record review of an ED Physician's Note dated 11/8/16 at 7:03 PM revealed "...transfer ordered to Other Acute Care Facility...diagnosis...Acute Psychosis...problem is new...symptoms are unchanged..."

Medical record review revealed no documentation Patient #88 was evaluated or treated by Hospital A's on-call psychiatrist during the 3 days the patient was in the ED at Hospital A.

Review of Hospital A's Census records revealed the 32 bed Behavioral Unit's census was: 27 (5 vacancies) on 11/5/16; 29 (3 vacancies) on 11/6/16; 25 (7 vacancies) on 11/7/16; and 18 (14 vacancies) on 11/8/16.

Review of Hospital A's Psychiatry on-call schedule revealed a psychiatrist was on-call 24 hours/day on 11/5/16, 11/6/16, 11/7/16, and 11/8/16.

15. Medical record review revealed Patient #90 was admitted to Hospital A's Main Campus ED on 11/18/16 at 1:27 PM via EMS with a diagnoses including Suicidal Ideations. Continued review revealed the patient was 17 years old. Further review revealed the patient was transferred to B for involuntary admission on 11/21/16 at 9:13 PM.

Medical record review of an ED Physician's Note dated 11/18/16 at 2:23 PM revealed "...presents...with depression...suicide gesture...gun under his chin...pulled the trigger...symptoms...began/occurred 3 months ago...symptoms were moderate severe in the [ED]...mother reports...in the past done some self cutting...patient has not experienced similar symptoms in the past...2:25 [PM]...multiple stressors...including the dissolution of his parents marriage...recent breakup with girlfriend...recent change in stools...2:26 [PM]...speech does seem somewhat pressured..." Continued review revealed the patient was provided a MSE which included: a HPI, a medical history and psychiatric history, a review of systems, and a physical exam.

Medical record review of an ED Physician's Note dated 11/21/16 at 7:36 PM revealed "...Transfer ordered to Other Acute Care Facility...Diagnosis...Suicidal Ideations...condition is fair...problem is new..."

Medical record review of an Emergency Services Patient Transfer Form dated 11/21/16 at 7:50 PM revealed the patient was transferred to Hospital B. Further review revealed "... the patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of stabilizing and/or treating the patient's Emergency Medical Condition, including psychiatric emergencies..."

Medical record review revealed no documentation Patient #90 was evaluated or treated by Hospital A's on-call psychiatrist during the 3 days and 7 and ½ hours and 14 minutes the patient was in the ED.

Review of Hospital A's Census records revealed the 32 bed Behavioral Unit's census was: 26 (6 vacancies) on 11/18/16; 24 (8 vacancies) on 11/19/16; 24 (8 vacancies) on 11/20/16; and 23 (9 vacancies) on 11/21/16.

Review of Hospital A's physician on-call schedule for Psychiatrist revealed a Psychiatrist was on-call 24 hours a day on 11/18/16, 11/19/16, 11/20/16, and 11/21/16.

16. Medical record review revealed Patient #93 presented to the ED at Hospital A Main Campus on 2/16/17 at 5:05 AM for complaint of "...states he drinks way too much...wants to kill himself..." Further review of the medical record revealed Patient #93 was diagnosed with Psychosis and Homicidal Thoughts and was transferred to Hospital