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Based on staff and patient interview and review of medical records and CAH policies, it was determined the hospital failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. The CAH failed to ensure MSE's were provided to 7 of 25 patients (#6, #8, #10, #14, #22, #23, and #25) whose records were reviewed. The CAH failed to ensure stabilizing treatment was provided to 1 of 25 patients (#6) whose records were reviewed. The CAH failed to ensure an appropriate transfer was provided to 1 of 7 patients (#6) who were transferred to an acute care hospital and whose records were reviewed. This resulted in the inability of the CAH to ensure patients with potential emergency medical conditions were cared for in a safe and effective manner. Findings include:

1. The policy "EMTALA Guidelines," dated 1/16/14, stated, if requested, "...the hospital must provide for an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists." This policy was not followed. Refer to C2406 as it relates to the failure of the hospital to provide appropriate MSEs to patients.

2. The policy "EMTALA Guidelines," dated 1/16/14, stated, before a patient was transferred, the CAH would "...provide medical treatment within its capacity that minimizes the risk to the individual's health..." This policy was not followed. Refer to C2407 as it relates to the failure of the hospital to ensure stabilizing treatment was provided to patients.

3. The policy "EMTALA Guidelines," dated 1/16/14, stated patients could not be transferred to another facility unless they had been informed of the CAH's obligations and the risks of transfer. The policy also required the patient or their representative must request the transfer in writing. Finally, the policy required the CAH to contact the receiving facility to confirm the receiving facility had space available and the capability to treat the patient. This policy was not followed. Refer to C2409 as it relates to the failure of the CAH to ensure an appropriate transfer was provided to patients.

The CAH failed to implement policies to ensure compliance with the requirements at 42 CFR Part 489.24.

Based on staff and patient interviews and review of medical records, it was determined the CAH failed to ensure MSE's were provided to 7 of 25 patients (#6, #8, #10, #14, #22, #23, and #25) whose records were reviewed. This resulted in the potential for emergency medical conditions to go undiagnosed. Findings include:

1. Patient #6's medical record documented a 34 year old male. His Registration Record stated he was admitted to the ED on 5/15/14 at 7:29 PM. His "Patient Profile report," dated 5/15/14 but not timed, stated his admitting complaint was "Overdose ingestion." All other information on the report was from previous admissions. For example, the section titled "Allergies" was dated 2/23/14.

Patient #6's ambulance report, titled "Comprehensive Report," was dated 5/15/14. The report stated the ambulance arrived at Patient #6's home at 7:08 PM. The report stated Patient #6 had " ...attempted suicide. The [patient] has taken multiple medications and left the residence ...We found the patient in the upstairs bedroom of his home. His wife is by his side. The [patient] is verbally responsive. The [patient's] wife gave him Ipecac. The [patient] threw up several pills. The [patient] is believed to have taken 30 Depakote 250 mg and several other unknown medications. He threw up about 10 pills. He took them about 40 minutes ago. He was released from jail this morning and was given the medications when he left. His meds were full this morning and now they are empty. He stated that he was trying to kill himself and he wished nobody found him. The [patient] is drowsy and has a hard time staying awake. We removed his sweatshirt. Vitals: BP=142/82, p=132, r=14, [oxygen saturation level] =98% on room air, EKG showing sinus tachycardia. We had to carry the [patient] down the stairs to our gurney. We tried to establish an IV but wasn't able to. [sic] The patient is a heavy IV drug user and has ruined most of his veins. We took the empty med packets with us to the hospital. We transported the [patient] to BMH. Upon arrival at BMH, they told us that they were full and that we needed to transport the [patient] to [an acute care hospital]. Before transporting him to [the acute care hospital] the ER staff tried establishing an IV on him but wasn't able to. [sic] We redirected to [the acute care hospital]. Vitals were monitored en route. The [patient's] mental status remained the same throughout the transport. The [patient] was transported without incident. [Patient] care turned over to the medical staff in the ER at [the acute care hospital]."

Except for patients who left without being seen, physicians documented their examinations and findings by hand on a Tsheet, a form for physicians to document examination findings in the ED. The medical records of all patients who were seen by a physician contained these Tsheet, except Patient #6. Patient #6's medical record did not contain a Tsheet. No physician documentation was present in Patient #6's medical record for 5/15/14. Instead, Patient #6's medical record contained an "EMERGENCY DEPARTMENT ADDENDUM" by the physician, dated 5/26/14, 11 days after the encounter. It stated "The patient is a young man who was brought to Bingham Memorial Hospital by emergency medical services after being reported by a family member as having taken a very large number of his seizure medicines, apparently with the intent to perform suicide. His girlfriend or wife was present and provided the history to the EMTs and paramedics who presented to the hospital with the patient. Vital signs from the paramedics were reviewed. Because the patient was conscious and responded to verbal stimuli and had good vital signs, he appeared to be in stable condition."

The physician addendum stated "See paramedic notes for particulars on vital signs. The patient had a good pulse. He opened his eyes easily to verbal command. He made some intelligible speech. He appeared comfortable. The patient had no evidence of trauma anywhere on the patient's body." A physical examination was documented and stated "A radial pulse was palpated and found to be somewhat tachycardic but strong. No peripheral edema." The paramedic notes referred to in the addendum were not present in the medical record.

The physician's addendum in Patient #6's medical record continued, "ER COURSE/ASSESSMENT AND PLAN: Young man with apparent intentional ingestion of seizure medications, in stable condition. The paramedics had stopped at Bingham Memorial Hospital as a matter of routine, and it became apparent that the hospital was completely full, that there were no inpatient beds available, and that this patient would likely require an intensive care unit admission. The paramedics became aware of the situation of the divert status for the hospital as they were backing into the ambulance gate, and rather than immediately diverting to an outside hospital a medical screening exam was performed on this patient. When he was deemed to be in stable condition and was able to safely transfer, his wife or girlfriend who was there expressed a preference that he be taken to [an acute care hospital]. After determining the stability of the patient and providing a medical screening exam, the patient was then taken by paramedics to the [acute care hospital's] emergency room in order to receive definitive treatment for his condition. Again, this was done at the request of a family member and because Bingham Memorial Hospital was on divert, but a medical screening exam was performed. The emergency room at Bingham Memorial Hospital was extremely busy that evening, and there were multiple patients in the waiting room and all beds were full. Nevertheless, all attention was diverted to said [Patient #6] and his condition in order that he might receive an evaluation before safely transferring. I neglected to call the emergency room physician at [the acute care hospital] after providing the medical screening examination, although we did verify afterwards that he had arrived safely and definitive care was initiated for this patient."

The physician addendum stated an MSE was performed for Patient #6, however, this was not documented in the medical record. The addendum mentioned "good vital signs" but no vital signs were documented in Patient #6's medical record. The record did not document a current medical history. The record did not contain a surgical history. The record did not document Patient #6's history of IV drug abuse. The record did not document which medications Patient #6 allegedly ingested. The record did not document any stabilizing treatment provided to Patient #6. The record did not document any orders. The record did not document Patient #6 had been given Ipecac earlier in the evening. The record did not document any transfer arrangements and did not indicate Patient #6 was stable for transfer to the receiving hospital.

No nursing progress notes were documented on Patient #6's medical record, dated 5/15/14. Instead, the medical record contained a witness statement by an RN. It was titled "ED ADDENDUM NURSES FLOW SHEET" and was dated 2 days later on 5/17/14 at 5:00 AM. It stated "Regarding the patient [Patient #6]. Ambulance call was placed to the ER. I answered the call. The EMT gave me a quick history & physical of the patient. I explained the hospital is on standby & asked if the patient was stable. The ambulance was currently pulling into the parking lot and stated we could determine. I immediately grabbed Dr. [name] out of room to assess [Patient #6.] [The physician] & myself did a full complaint assessment. I attempted...2 IV attempts and was unsuccessful. [The physician], after discussing the mechanism of overdose, with the EMTs & police officer and after a full assessment witnessed by myself, decided to send the patient to [the receiving hospital]. There the patient could receive care & be admitted where our hospital was on standby and no ICU beds available. The patient was [alert and oriented times] 4 & vital signs appropriate other than a heart rate of 110. [The physician] made the case to send the patient [illegible]. I felt had an earlier report from the EMS with the knowledge that we had been on standby for the past 3 days, the situation would have been more professionally handled. I felt the health professionals at BMH handled the situation appropriately regarding the particular circumstance of the hospital & the patient [illegible] status."

Patient #6's medical record also contained a triage report that was not filled out.

The ED record from the acute care hospital Patient #6 was transported to after leaving Bingham Memorial Hospital, stated he was triaged there at 8:04 PM on 5/15/14. The untitled ED form stated Patient #6 was triaged and assigned a level 2 designation which meant he was a high risk patient and required monitoring and stabilization. The record stated Patient #6 had a history of splenectomy and said 2/3 of his pancreas had been removed in the past. A nursing note in the ED record, titled "AMBULANCE," dated 5/15/14 at 8:08 PM, stated the ambulance transported Patient #6 after he ingested 30 250 mg Depakote and an unknown amount of Lithium. The note stated Patient #6 had a history of IV drug use and EMS personnel had not been able to obtain IV access prior to transport.

The BMH Quality Manager was interviewed on 9/30/14 beginning at 9:20 AM. She reviewed Patient #6's medical record. She stated except for the addendums, the information in Patient #6 ' s record was generated by the computerized medical record. She stated an MSE was not documented at the time of service.

The physician who saw Patient #6 in the CAH's ambulance bay was interviewed on 9/29/14 beginning at 3:35 PM. He confirmed he did not document on Patient #6 at the time of service. He stated the ED was "swamped" when Patient #6 presented to the ED. He stated the hospital was full and there were no beds available. He said the ambulance came to the bay. He stated he went to the ambulance and evaluated Patient #6. He stated he listened to Patient #6's chest. He stated the nurse advised him to send Patient #6 to the receiving hospital. He stated Patient #6's pupils were okay, his cardiac status was okay, and he was stable for transport. He confirmed he did not document in Patient #6's medical record at the time of service.

The RN who saw Patient #6 in the CAH's ambulance bay was interviewed on 9/30/14 beginning at 9:56 AM. He reviewed Patient #6's medical record. He stated he was on duty in the ED on 5/15/14 when Patient #6 arrived. He stated it was start of shift and the ED was very busy. He stated when the ambulance came he went out to the bay with the physician. He stated Patient #6 took a bunch of Depakote, a medication for seizures. He stated Patient #6 was in the ambulance with the vital sign machine attached. He stated he did not know what Patient #6's vital signs were. He stated the physician went into the ambulance. He stated he thought the physician examined Patient #6. He stated he, the RN, made 2 attempts to start an IV on Patient #6 but was unable to do so. He stated the physician felt Patient #6 was stable enough to be transported to the receiving hospital.

The Paramedic who was part of the ambulance crew on 5/15/14 was interviewed on 9/30/14 beginning at 1:00 PM. The Paramedic stated he picked up Patient #6 at his home and his wife drove behind the ambulance to the CAH. He stated Patient #6 had been released from jail that morning and the jail had given Patient #6 some packets containing at least a month's worth of 4 different medications. He stated he made 3 attempts to start an IV but was unable to access a vein. He stated the patient's wife told him Patient #6's veins had been ruined from IV drug use. He stated when the ambulance arrived at the CAH, the RN came out and said the CAH was on divert and the ambulance could not bring Patient #6 there. He stated the RN then said he would get the physician. He stated the physician came out to the ambulance and looked at Patient #6 and looked at the record of vital signs taken by EMS. He stated the physician then told him Patient #6 was stable. He stated the physician did not touch Patient #6. He stated he told the physician Patient #6 had taken several different medications and he had the empty packages for the physician to see. He stated the physician did not look at the medication packages. He stated Patient #6's level of consciousness was dropping. He stated he told the physician this. He stated the physician told him the nurse would start an IV but the nurse was not able to do so. He stated Patient #6's vital signs had been stable. He stated Patient #6 was not taken into the CAH.

The CAH did not perform an MSE for Patient #6.

2. Patient #23's medical record documented a 45 year old female who presented to the ED on 8/28/14 at 7:22 PM. Her "Patient Profile Report," dated 8/28/14 but not timed, stated she came to the ED with a complaint of abdominal pain. Aside from the presenting complaint, no current information was documented on her "Patient Profile Report," which contained information such as allergies, medications, past surgeries, etc., from past admissions.

Patient #23's "Emergency Department Triage Report" stated she arrived on 8/28/14 at 7:22 PM and said her chief complaint was abdominal pain. No other information was documented on the report.

A "Leaving Against Medical Advice" form, dated 8/28/14 at 9:21 PM, was present in Patient #23's medical record. The box on the form stated "Did not read form, just left," was checked. A comment section on the form stated "[Patient] was upset because another [patient] went back before her." It was signed by the Registration Clerk.

Patient #23 was at the CAH for 1 hour and 59 minutes. No documentation was present in her medical record that she was seen by a nurse or other medical personnel during that time. No documentation was present that she was offered a medical screening examination.

The Quality Manager, was interviewed on 10/01/14 beginning at 10:40 AM. She reviewed Patient #23's medical record. She confirmed no assessment was documented by the nurse or the physician. She stated an MSE was not documented.

The CAH did not perform an MSE for Patient #23.

3. Patient #10's medical record documented a 26 year old female who presented to the ED on 8/09/14 at 9:09 PM. Patient #10's Registration Record, dated 8/09/14 at 9:09 PM, documented she arrived by wheelchair and her presenting complaint was lower extremity pain. The "Patient Profile Report" stated Patient #10 was discharged on 8/09/14 but did not list a time. Patient #10's "Emergency Department Triage Report," dated 8/09/14 at 9:09 PM, was blank except for her demographics. Her triage acuity, vital signs, and pain assessment were not documented. An RN electronically signed Patient #10's "Emergency Department Triage Report" 12 days later, on 8/21/14 at 10:27 AM. No documentation was present in her record of an MSE or of an examination by a nurse or a physician. No documentation was present that Patient #10 left without being seen. Patient #10's record did not document what happened to her in the CAH or what her disposition was.

The Quality Manager was interviewed on 10/01/14 at 9:35 AM. She stated Patient's #10 left without being seen. She stated Patient #10's medical record did not document an MSE or what happened to her.

The CAH did not perform an MSE for Patient #10.

4. Patient #14's Registration Record documented a 22 month old male who was brought to the ED by his mother on 6/29/14 at 2:34 PM. Patient #14's presenting complaint was chemical exposure to his eye. The chemical Patient #14 was exposed to was not documented. Patient #14's "Emergency Department Triage Report," dated 6/29/14 at 2:34 PM, contained his demographics and stated his chief complaint was "Chemical exposure (eye)." Patient #14's triage acuity, vital signs, and pain assessment were not documented. The form was blank. No documentation was present in his record of an MSE or of an examination by a nurse or a physician. Patient #14's record did not document what happened to him in the CAH or what his disposition was.

A computer screen shot was presented with the medical record. The screen shot stated "Patient Detail" at the top. It said Patient #14 was discharged on 6/29/14 at 2:52 PM. A hand written line at the top of the page stated "-left without being seen." Neither the screen shot nor the hand written note documented who the author was nor did the record offer further explanation of what happened to Patient #14.

The BMH Quality Manager was interviewed on 10/01/14 at 9:35 AM. She stated Patient #14's medical record did not document what happened to the child or his mother. She stated Patient #14's medical record did not document an MSE or what happened to the patient.

The CAH did not perform an MSE for Patient #14.

5. Patient #22's "Registration Record" documented a 47-year-old female who presented to the ED on 9/21/14 at 5:19 PM. Patient #22's "Emergency Department Triage Report," dated 6/29/14 at 2:34 PM, contained her demographics and stated her chief complaint was "Headache." Patient #22's triage acuity, vital signs, and pain assessment were not documented. The form was blank. No documentation was present in her record of an MSE or of an examination by a nurse or a physician. Patient #22's record did not document what happened to her in the CAH or what her disposition was.

The Quality Manager was interviewed on 10/01/14 at 9:35 AM. She stated Patient #22 left without being seen. She stated Patient #22's medical record did not document an MSE or what happened to her.

The CAH did not perform an MSE for Patient #22.

6. Patient #8's medical record documented a 23 year old male patient who arrived at the ED on 7/31/14 at 8:35 PM. The "Emergency Department Triage Report," dated 7/31/14 at 8:48 PM, stated Patient #8 had a work injury while working with a rock crusher. The report stated a rock smashed his right hand and the hand was swollen. The report rated his pain at 7 out of 10. The report stated his vital signs on 7/31/14 at 8:48 PM were BP 142/97, pulse rate 91, and oxygen saturation level was 96 percent. There was no further documentation of vital signs in the medical record. There was no pain reassessment after the initial pain level was obtained. There was no documentation that Patient #8's pain was treated. The "Daily Focus Assessment Report" by an RN, dated 7/31/14 at 8:45 PM, stated an ice pack was provided for comfort measures. There was no further documentation by the RN and no documentation of examination or treatment by a physician.

Patient #8's medical record contained a form titled "Leaving Against Medical Advice," dated 7/31/14 at 9:39 PM. A box was checked stating "did not read form, just left." The form stated the reason Patient #8 left was because he had to wait too long to see a physician. It was signed by the Registration Clerk. A comments section on the form stated Patient #8 "...returned around 2200 & waited an hour then decided to go to [a physician office] in the morning." The form did not state exactly when Patient #8 left the second time.

An X-Ray Report, dated 7/31/14 at 8:47 PM, stated Patient #8's hand was not fractured. The report stated the X-ray was not dictated until the following day, 8/01/14 at 12:59 PM. There was no documentation to show the ED physician saw the report. Also, there was no order for the X-ray in the medical record.

On 9/30/14 at 4:15 PM a telephone interview was conducted with Patient #8. He stated he remembered his visit to the ED for his hand injury. He stated he waited in the lobby a while but he was not certain how long. He stated he was eventually moved into the ED and his wife waited with him. He stated he waited over 2 and ? hours with no pain control, not seeing a physician, and seeing the nurse only once. He stated his wife asked the ED RN when the physician would see her husband. He said she was told they were very busy. He stated he then decided to leave the CAH. He stated he did not sign any documents. He stated when he left, he went home.

On 9/30/14 at 11:45 AM the Registration Clerk, was interviewed. She stated Patient #8 left the hospital and then came back at 10:00 PM to see if the physician had read his X-ray. She stated she then gave Patient #8 an ice bag. She stated she told the RN Patient #8 had returned and the RN went out into the lobby to talk with the patient. None of this was documented.

The CAH did not perform an MSE for Patient #8.

7. Patient #25's record documented a 32 year old male patient who presented to the ED on 9/13/14 at 10:34 PM with a complaint of eye pain. The "Emergency Department Triage Report" was not filled out and was blank. There was no documentation of vital signs. A "Daily Focus Assessment Report" by an RN, dated 9/13/14 at 10:34 PM, stated Patient #25 was given normal saline to flush his eyes while he waited to be seen. There was no order for the saline. There was no history of his eye pain. There was no documentation of an examination by a nurse or a physician.

Patient #25's medical record contained a form titled "Leaving Against Medical Advice," dated 9/13/14 at 11:16 PM. The form contained a checked box that stated "did not read form, just left." The form stated the reason Patient #8 left was because he had to wait too long to see a physician. The form was signed by the Registration Clerk. It was not signed by Patient #25.

On 10/1/14 at 12:45 PM, a telephone interview was conducted with the RN who gave the saline flush to Patient #25. She stated he bought contact lenses at a swap meet. She stated he put the contact lenses in his eyes, and did not remove them when he went to sleep. She stated when he awoke, he removed the lenses and he had eye pain. She stated her interaction with Patient #25 and treatment directions to him regarding normal saline flushes to his eyes occurred in the ED lobby. The RN acknowledged she did not conduct a triage assessment. She stated she did not examine his eyes. She stated her instructions to Patient #25 were to go to the public restroom and flush his eyes with the normal saline. She stated she did not have a physician's order or protocol authorizing her to treat his eyes with the saline flush. The ED RN stated after about 20 minutes, the patient became upset, swore at the CNA/Registration, and walked out of the CAH. She confirmed she did not document this.

The CAH did not perform an MSE for Patient #25.

Based on staff and patient interview and review of medical records, it was determined the CAH failed to ensure stabilizing treatment was provided to 1 of 25 patients (#6) whose records were reviewed. This resulted in the potential for patients' conditions to deteriorate without such treatment. Findings include:

1. Patient #6's medical record documented a 34 year old male. His Registration Record stated he was admitted to the ED on 5/15/14 at 7:29 PM. His "Patient Profile report, "dated 5/15/14 but not timed, stated his admitting complaint was "Overdose ingestion." All other information on the report was from previous admissions. For example, the section titled "Allergies" was dated 2/23/14.

Patient #6's ambulance report, titled "Comprehensive Report," was dated 5/15/14. The report stated the ambulance arrived at the patient's home at 7:08 PM. The report stated Patient #6 had " ...attempted suicide. The [patient] has taken multiple medications and left the residence ...We found the patient in the upstairs bedroom of his home. His wife is by his side. The [patient] is verbally responsive. The [patient's] wife gave him Ipecac. The [patient] threw up several pills. The [patient] is believed to have taken 30 Depakote 250 mg and several other unknown medications. He threw up about 10 pills. He took them about 40 minutes ago. He was released from jail this morning and was given the medications when he left. His meds were full this morning and now they are empty. He stated that he was trying to kill himself and he wished nobody found him. The [patient] is drowsy and has a hard time staying awake. We removed his sweatshirt. Vitals: BP=142/82, p=132, r=14, [oxygen saturation level] =98% on room air, EKG showing sinus tachycardia. We had to carry the [patient] down the stairs to our gurney. We tried to establish an IV but wasn't able to. [sic] The patient is a heavy IV drug user and has ruined most of his veins. We took the empty med packets with us to the hospital. We transported the [patient] to BMH. Upon arrival at BMH, they told us that they were full and that we needed to transport the [patient] to [an acute care hospital]. Before transporting him to [the acute care hospital] the ER staff tried establishing an IV on him but wasn't able to. [sic] We redirected to [the acute care hospital]. Vitals were monitored en route. The [patient's] mental status remained the same throughout the transport. The [patient] was transported without incident. [Patient] care turned over to the medical staff in the ER at [the acute care hospital]."

No stabilizing treatment at the CAH was documented. No orders were documented. No IV was started. No laboratory testing was documented. No treatment of any kind by CAH personnel was documented at the time of Patient #6's visit.

Patient #6's medical record contained an "EMERGENCY DEPARTMENT ADDENDUM" by the physician, dated 5/26/14, 11 days after the encounter. It stated "The patient is a young man who was brought to Bingham Memorial Hospital by emergency medical services after being reported by a family member as having taken a very large number of his seizure medicines, apparently with the intent to perform suicide. His girlfriend or wife was present and provided the history to the EMTs and paramedics who presented to the hospital with the patient. Vital signs from the paramedics were reviewed. Because the patient was conscious and responded to verbal stimuli and had good vital signs, he appeared to be in stable condition."

The addendum stated an assessment was conducted by the physician. It said "See paramedic notes for particulars on vital signs. The patient had a good pulse. He opened his eyes easily to verbal command. He made some intelligible speech. He appeared comfortable. The patient had no evidence of trauma anywhere on the patient's body." A physical examination was documented and stated "A radial pulse was palpated and found to be somewhat tachycardic but strong. No peripheral edema." The paramedic notes referred to in the addendum were not present in the medical record.

The addendum in Patient #6's medical record continued, "ER COURSE/ASSESSMENT AND PLAN: Young man with apparent intentional ingestion of seizure medications, in stable condition. The paramedics had stopped at Bingham Memorial Hospital as a matter of routine, and it became apparent that the hospital was completely full, that there were no inpatient beds available, and that this patient would likely require an intensive care unit admission. The paramedics became aware of the situation of the divert status for the hospital as they were backing into the ambulance gate, and rather than immediately diverting to an outside hospital a medical screening exam was performed on this patient. When he was deemed to be in stable condition and was able to safely transfer, his wife or girlfriend who was there expressed a preference that he be taken to [an acute care hospital]. After determining the stability of the patient and providing a medical screening exam, the patient was then taken by paramedics to the [acute care hospital's] emergency room in order to receive definitive treatment for his condition."

No nursing progress notes were documented on Patient #6's medical record, dated 5/15/14. Instead, the medical record contained a witness statement by an RN. It was titled "ED ADDENDUM NURSES FLOW SHEET" and was dated 2 days later on 5/17/14 at 5:00 AM. It stated "Regarding the patient [Patient #6]...I immediately grabbed Dr. [name] out of room to assess [Patient #6.] [The physician] & myself did a full complaint assessment. I attempted...2 IV attempts and was unsuccessful. [The physician], after discussing the mechanism of overdose, with the EMTs & police officer and after a full assessment witnessed by myself, decided to send the patient to [the receiving hospital]. There the patient could receive care & be admitted where our hospital was on standby and no ICU beds were available."

The ED record from the acute care hospital Patient #6 was transported to after leaving Bingham Memorial Hospital, stated he was triaged there at 8:04 PM on 5/15/14. The record stated he arrived without an IV.

The physician who saw Patient #6 in the CAH's ambulance bay was interviewed on 9/29/14 beginning at 3:35 PM. He stated the ED was "swamped" when Patient #6 presented to the ED. He stated the hospital was full and there were no beds available. He stated Patient #6 was not brought into the hospital and no stabilizing treatment was provided.

The CAH RN who saw Patient #6 in the CAH's ambulance bay was interviewed on 9/30/14 beginning at 9:56 AM. He stated he was on duty in the ED on 5/15/14 when Patient #6 arrived. He stated it was start of shift and the ED was very busy. He stated when the ambulance came he went out to the bay with the physician. He stated he, the RN, made 2 attempts to start an IV on Patient #6 but was unable to do so. He stated the physician felt Patient #6 was stable enough to be transported to the receiving hospital. He said Patient #6 was then transferred.

The Paramedic who was part of the ambulance crew on 5/15/14 was interviewed on 9/30/14 beginning at 1:00 PM. He stated he was a member of the ambulance crew that brought Patient #6 to the CAH on 5/15/14. The Paramedic stated he picked up Patient #6 at his home and his wife drove behind the ambulance to the CAH. He stated Patient #6 had been released from jail that morning and the jail had given Patient #6 some packets containing at least a month's worth of 4 different medications. He stated he made 3 attempts to start an IV but was unable to access a vein. He stated the patient's wife told him Patient #6's veins had been ruined from IV drug use. He stated the physician came out to the ambulance and looked at Patient #6 and looked at the record of vital signs taken by EMS. He stated the physician then told him Patient #6 was stable. He stated the physician did not touch Patient #6. He stated Patient #6's level of consciousness was declining. He stated he told the physician this. He stated the physician told him the nurse would start an IV but the nurse was not able to do so. He stated Patient #6 was then transferred to the receiving hospital without being taken into the CAH.

The CAH did not provide stabilizing treatment to Patient #6.

Based on staff interview and review of medical records, it was determined the CAH failed to ensure an appropriate transfer was provided to 1 of 7 patients (#6) who were transferred to an acute care hospital and whose records were reviewed. This resulted in the potential for treatment delays at the receiving hospital. Findings include:

Patient #6's medical record documented a 34 year old male. His Registration Record stated he was admitted to the ED on 5/15/14 at 7:29 PM. His "Patient Profile report, "dated 5/15/14 but not timed, stated his admitting complaint was "Overdose ingestion."

Patient #6's ambulance report, titled "Comprehensive Report," was dated 5/15/14. The report stated the ambulance arrived at the patient's home at 7:08 PM. The report stated Patient #6 had attempted suicide by taking multiple medications. The report stated Patient #6 was taken to the CAH on 5/15/14. The time the ambulance arrived at the CAH was not documented. The report stated Patient #6 was then taken from the CAH at 8:02 PM on 5/15/14 to the receiving hospital.

No physician or nursing documentation was present in medical record at the time Patient #6 was at the ED. Patient #6's medical record contained an "EMERGENCY DEPARTMENT ADDENDUM" by the physician, dated 5/26/14, 11 days after the encounter. It stated "The patient is a young man who was brought to Bingham Memorial Hospital by emergency medical services after being reported by a family member as having taken a very large number of his seizure medicines, apparently with the intent to perform suicide...Because the patient was conscious and responded to verbal stimuli and had good vital signs, he appeared to be in stable condition."

The physician's addendum in Patient #6's medical record continued, "ER COURSE/ASSESSMENT AND PLAN: Young man with apparent intentional ingestion of seizure medications, in stable condition. The paramedics had stopped at Bingham Memorial Hospital as a matter of routine, and it became apparent that the hospital was completely full, that there were no inpatient beds available, and that this patient would likely require an intensive care unit admission...When he was deemed to be in stable condition and was able to safely transfer, his wife or girlfriend who was there expressed a preference that he be taken to [an acute care hospital]. After determining the stability of the patient and providing a medical screening exam, the patient was then taken by paramedics to the [acute care hospital's] emergency room in order to receive definitive treatment for his condition."

Patient #6's "EMERGENCY DEPARTMENT ADDENDUM" by the physician continued, "I neglected to call the emergency room physician at [the acute care hospital] after providing the medical screening examination, although we did verify afterwards that he had arrived safely and definitive care was initiated for this patient."

Patient #6's record did not document transfer arrangements or contact with the receiving hospital either by the physician or by a nurse. An order for the transfer was not documented. A statement by the physician that the benefits of transfer outweighed the risks was not documented. There was no documentation at the time of transfer that Patient #6 or his wife requested the transfer or granted permission for the transfer. Since there was no documentation at the time of the transfer, no documentation was sent to the receiving hospital.

The physician who saw Patient #6 in the CAH's ambulance bay was interviewed on 9/29/14 beginning at 3:35 PM. He stated he was on duty the night of 5/15/14 when Patient #6 presented to the ED. He confirmed he did not document on Patient #6 at the time of service. He stated the hospital's transfer procedure was not followed. He stated he made a mistake by not calling the physician at the receiving hospital about Patient #6.

The CAH did not conduct an appropriate transfer of Patient #6.