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Based on review of Hospital policy, Emergency Department (ED) records, Police Department report, and staff interview, it was determined that in 1 of 20 (Pt #1) ED records reviewed, the Hospital failed to ensure compliance with 42 CFR 489.24 .

Findings include:

1. The Hospital failed to ensure the patient was stabilized prior to transfer. See deficiency at A 2407.

2. The Hospital failed to ensure a proper transfer was provided. See deficiency at A 2409.

Based on review of Hospital policy, Emergency Department (ED) records and staff interview, it was determined that for 1 of 11 (Pt #1) ED records reviewed of patients with suicidal diagnoses, the Hospital failed to ensure the patient was stabilized prior to transfer.

Findings include:

1. Hospital policy entitled, "EMTALA," (reviewed/revised 5/15/11) required, "H. EMTALA and Psychiatric Patient. 1. In the case of psychiatric emergencies, an individual expressing suicidal or homicidal thoughts or gestures if determined dangerous to self or others, would be considered to have an EMC (Emergency Medical Condition). For individuals with psychiatric symptoms, the medical records should indicate an assessment of suicide or homicide attempt or risk,..3. Psychiatric patients are considered stable when they are protected and prevented from injuring him/herself or others. The administration of chemical or physical restraints for the purpose of transferring an individual from one facility to another may stabilize a psychiatric patient for a period of time...8. Refusal of Transfer by a Psychiatric Patient. If a psychiatric patient has an EMC and refuses hospitalization, then an order for civil commitment, formal petition for commitment, or an emergency hospital order will be pursued. If obtained, the patient can be admitted or transferred against his/her wishes without an EMTALA violation.

2. The Emergency Department (ED) record of Pt #1 was reviewed on 7/24/12 at approximately 9:00 AM. Pt #1 was a 27 year old male that presented to the Hospital's ED via ambulance on 7/19/12 at 2:24 AM, with complaint of Aspirin Overdose. Pt #1's Medical Screening Examination (MSE) dated 7/19/12 at 2:30 AM included a chief complaint, "OD (overdose) of unknown time -1/2 bottle of 100 tabs of 81 milligram enteric coated aspirin." Also the MSE, Pt #1 had a history of Bipolar Disorder. During the course of Pt #1's MSE, blood work was obtained which included; Complete Blood Count, Basic Metabolic Profile, Salicylate level (aspirin), and Arterial Blood Gases. All of which were documented as within normal limits. The poison control center was contacted regarding the alleged Aspirin overdose (no time documented by the physician), with recommendations for treatment, which included Salicylate levels every 2 hours. Physician documentation dated 7/19/12 at 4:02 AM indicated, "left ER (Emergency Room), police looking for him." At 4:40 AM, physician documentation included, "Police brought him to ER." At 4:52 AM physician documentation included, "Cops found him outside ...Still refusing treatment at (Hospital), police to take away."

At 5:03 AM on 7/19/12, the physician's documentation included, "Clinical Insight/Diagnostic/Impression: OD Salicylate, ETOH (alcohol) Intoxication, AMA (against Medical Advice. Disposition: AMA - Advised of risk of death or disability, witnessed by (E #2)." Physician's documentation dated 7/19/12 at 5:03 AM lacked a diagnosis of suicide attempt. At no time during the MSE was Pt #1 placed on suicide precautions or diagnosed as suicidal.

3. On 7/25/12 between 7:30 AM and 8:00 AM Pt #1's ED treating physician (E #1) was interviewed. During the interview, E #1 read from his notes the history completed for Pt #1 on 7/19/12. E #1 stated, "He (Pt #1) was uncooperative and abusive with the staff. He had a history of Bipolar Disorder. He refused most ordered treatment but finally relented and allowed lab work which included an aspirin level. The level returned at less than 5, however since the pills were enteric coated the level could rise later, therefore the patient needed to be admitted to an ICU bed for stabilization. Pt #1 was not medically stable to be admitted directly to a psychiatric unit and needed an ICU bed instead. If I had known that the patient was going to leave, maybe then I would have restrained him and started involuntary commitment papers. He never lacked the capacity to make his own decisions for himself. I had a plan in mind to make arrangements for transfer to another Hospital for ICU stabilization prior to Psychiatric placement but never had the chance to finish my assessment. When the patient left with the PD I thought he was going to jail. "

4. Nursing documentation dated 7/19/12 at 2:24 AM included that Pt #1 was triaged as a Level 2 with admitting vital signs: temperature 98.8, pulse 90, respirations 16 and blood pressure 139/87 and received a medical screening exam that included blood test, intravenous fluids (IVF), and a consult with the poison control center. At 3:14 AM Pt #1 stated that he tried to kill himself, and that he wanted his family to die, not in a fire but just smoke inhalation. Nursing documentation timed 3:50 AM included that Pt #1 pulled out his IVF, removed his monitor, got dressed and at 4:02 AM Pt #1 walked out of the ED. At 4:52 AM the treating physician notified the police that Pt #1 is not medically stable. The clinical record of Pt #1 lacked documentation that Pt #1 was prevented from leaving the ED and lacked documentation of an order for civil commitment and/or a formal petition for commitment, to ensure stabilization.

Based on review of Hospital policy, clinical records, police reports, and staff interview, it was determined that in 1 of 11 (Pt #1) Emergency clinical records reviewed of patients transferred to another Hospital, the Hospital failed to ensure a proper transfer, was provided.

Findings include.

1. Hospital policy entitled, "EMTALA," (reviewed/revised 5/15/11) required, "C. Discharge of a Patient. 2. Transfer of a Stable and Unstable Patient: a. A physician will direct all patient transfers. The physician must sign a certification specific to the condition of the patient upon transfer stating: i. The reason(s) for transfer..ii. The benefits to be expected from appropriate care at the receiving (recipient) facility; and iii. Any risk associated with the transfer. 3. Appropriate Transfer Requirements Include: a. The transferring Hospital provides medical treatment within its capacity that minimizes the risks to the patient's health. b. The receiving facility has agreed to accept transfer of the patient..c. The GMC (Genesis Medical Center) should document its communication with the receiving hospital...d. The transferring hospital sends to the receiving facility all medical records related to the patient's EMC...e. Transfer is effected through qualified personnel and transportation equipment.

2. The Emergency Department (ED) record of Pt #1 was reviewed on 7/24/12 at approximately 9:00 AM. Pt #1 was a 27 year old male that presented to the Hospital's ED via ambulance on 7/19/12 at 2:24 AM with complaints of Aspirin Overdose. Pt #1 was triaged as a Level 2 with admitting vital signs: temperature 98.8, pulse 90, respirations 16 and blood pressure 139/87 and received a medical screening exam that included blood test, intravenous fluids (IVF), and a consult with the poison control center. At 3:14 AM Pt #1 stated that he tried to kill himself, and that he wanted his family to die, not in a fire but just smoke inhalation. Nursing documentation timed 3:50 AM included that Pt #1 pulled out his IVF, removed his monitor, got dressed and at 4:02 AM Pt #1 walked out of the ED. At 4:03 AM the Silvis police were called and notified that the is patient is suicidal and left the ED. Nursing documentation included that Pt #1 was returned to the ED by the police and at 4:47 AM documentation included that Pt #1 refused treatment. At 4:52 AM the treating physician notified the police that Pt #1 is not medically stable. At 4:55 AM nursing documentation included, "Pt walks out of ED accompany by PD officers...PD is taking patient to (receiving Hospital).

The clinical record lacked documentation of certifying documentation of the need to transfer Pt #1, the acceptance of the receiving Hospital, that the required documents were sent with patient #1, and that Pt #1 was transferred by appropriate personnel.

3. The Police Investigation report dated 7/19/12 at 4:01 AM included, "(Pt #1) said he was going to walk out of the ER (emergency room) again and at that point, the decision was made to transfer (Pt #1) to the (Receiving Hospital) where he said he would voluntarily sign himself in...Officer transported (Pt #1) to (receiving Hospital)."

4. On 7/25/12 between 7:30 AM and 8:00 AM Pt #1's ED treating physician (E #1) was interviewed. During the interview, E #1 stated, "I did not call the receiving Hospital regarding Pt #1 coming to them and do not remember if I talked with the patient regarding being transferred to another Hospital. When the patient left the ED with the Police Department, I thought he was going to jail."

5. The Registered Nurse (E #2) caring for Pt #1 on 7/19/12 was interviewed on 7/25/19 between 8:10 AM an 8:30 AM. "We (the Hospital) did not notify the receiving Hospital and did not make formal arrangements for transportation. The PD took Pt #1 to the receiving Hospital."

6. Pt #1 ' s ED record from the receiving Hospital was reviewed on 7/26/12 at approximately 9:30 AM. Pt #1 was a 27 year old male who arrived in the receiving Hospital ' s ED on 7/19/12 at 5:40 AM. Pt #1 was taken to the ED by the PD. Triage documentation included Pt #1 was a category 2 with vital signs: temperature 97.4, pulse 105, respirations 13, and blood pressure 148/72. Nursing documentation at 5:40 AM states, " Nurse received call from patient ' s mother stating that pt was being brought here by PD. That he had been in (sending Hospital) ED because he had overdosed on aspirin and he ripped everything off and left there and security couldn't touch him so they called police to find him and they were to bring him here. Pt arrived per PD ...security notified, pt belligerent, uncooperative. States I admitted myself, I can sign myself out. " At 5:45 nursing documentation included that the transferring Hospital was contacted and records faxed. At 6:25 AM Pt #1 ' s labs were drawn. At 6:34 AM the PD officer that transferred Pt #1 filled out involuntary commitment papers. At 7:12 AM nursing documentation indicated of a critically high Salicylate (aspirin) level of 55.1 (Hospital ' s reference range 0 - 20). A Physician ' s note dated 7:19/12 at 9:00 AM included that Pt #1 was admitted to the Hospital ' s Psychiatric Unit in " improved and stable condition. " Pt #1 ' s admitting diagnoses included Suicide Attempt, Aspirin Toxicity, and Alcohol Intoxication.

Pt #1's Discharge Summary from the receiving Hospital dictated 7/20/12 at 9:36 AM was reviewed on 7/27/12 at approximately 8:30 AM. The Discharge Summary included, "In summary, the patient, was brought to the emergency room by police because he took a handful of aspirin. The patient found to have salicylate toxicity because of the salicylate overdose. He tried to attempt suicide. The patient was admitted to surgical ICU because of close monitoring and was started on IV fluids and started on IV bicarbonate drip ...The patient was seen by Dr. (psychiatry). His recommendation was that the patient can be discharged home when medically cleared and need to follow up with (psychiatric center) as an outpatient ....Follow up." Patient is discharged home as he is cleared by psychiatry and nephrology. He is told to take the medications ..." Pt #1's discharge diagnoses from the receiving Hospital included: 1) Salicylate Overdose, 2) Salicylate toxicity, 3) Suicidal Attempt, 4) Alcohol Intoxication, and 5) Possible Bipolar Disorder.