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Based on review of medical records, policy and procedures, facility license,and interview, the hospital failed to ensure that an appropriate a medical screening examination was conducted that was within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed for 1 (#1) of 20 patient medical records reviewed. (Refer to findings in Tag 2406)

Based on review of medical records, Hospital license, and Policy and Procedure, the facility failed to ensure that stabilizing treatment was provided as required that was within the capability of the staff and facilities available at the hospital for further medical evaluation and treatment for 3 (Patient #1, Patient #2, and Patient #3) of 20 ED patient medical records reviewed.
(Refer to findings in Tag 2407)

Based on medical record review, and review of Policies and Procedures the hospital failed to ensure the safe and an appropriate transfer by failing to call the receiving hospital to inquire if the hospital had available space and qualified personnel for the treatment of the individual; failing to obtain acceptance of the transfer of the individual; and failing to obtain a written certificate of transfer for 1 (#2) of 20 sampled patients who was exhibiting suicidal ideations.
( Refer to findings in Tag 2409)

Based on review of medical records, policy and procedures, facility license, and interview, the hospital failed to ensure that an appropriate medical screening examination was conducted that was within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed for 1 (#1) of 20 patient medical records reviewed.

The findings included:

Review of the clinical record for Patient #1 revealed the patient arrived to the Emergency Department (ED) on 03/10/17 at 9:31 PM with a chief complaint of suicidal ideation, hallucinations and hearing voices.

Review of the ED record revealed a Registered Nurse (RN) triaged the patient at 9:43 PM with triage completed at 9:51 PM. After the patient was triaged in the waiting room waiting for a bed assignment, the Patient exhibited a psychiatric melt down. Review of the RN progress notes documents the patient was pacing and yelling and hospital security was called, who in turn called the County Sheriff's department.

Further review of the ED record revealed RN documentation stating an ED bed was being arranged, however the patient's behavior escalated and the patient was Baker Acted by a County deputy and was transported to a Baker Act receiving hospital on 03/10/17 at 10:30 PM. Further review of the ED record revealed Patient #1 did not receive a medical screening exam by a physician to ensure medical clearance for transfer to a hospital with a psychiatric unit.


The medical record from the hospital where Patient #1 was taken by the County Sheriff police was reviewed. The medical record revealed that Patient #1 arrived to the ED on 3/10/2017 at 11:04 PM. He was Baker Acted by the County Police due to auditory hallucinations, delusional and paranoid thoughts. Review of the Baker Act stated that Patient #1 was having delusions of people next to him and hearing voices. The patient suffers from Schizophrenia and bipolar disorders. Documentation under "Transportation to Receiving Facility" stated the patient was dropped off by a family member at Cleveland Clinic hospital and began getting disruptive in the ED. Patient #1 was evaluated by the ED MD (Medical Doctor) on 3/10/2017 at 11:11 PM. Further review of the medical record revealed that laboratory blood work and a urinalysis were ordered and obtained. All lab work was reviewed and interpreted by the ED physician. The section of the medical record titled "Medical Decision Making" revealed in part, "ED Course/Re-Evaluation ...No clinical evidence of drug induced psychosis, meningitis, encephalitis, sepsis, thyroid disease, hypoglycemia, withdrawal syndrome, hypoxemia, electrolyte disturbance, CVA/TIA or traumatic brain injury ...CLINICAL IMPRESSION: Diagnosis: Acute Psychosis ...ED Disposition: ...Transfer Patient transferred to psych for further evaluation." The patient was medically cleared for transfer to the psychiatric unit.

The facility's Policy titled "Emergency Department Plan for Providing Care/Services", effective 07/26/2013, Date Last Approved/Reviewed: 12/20/2016 was reviewed. The policy revealed in part, "POLICY: The Emergency Department provides level II emergency care services to any patient across the age life span from newborn to geriatric ...Emergency Department care quality is based on conforming to established standards of emergency medicine and nursing practices, continuous monitoring to evaluate and reevaluate outcomes resulting from treatment of care rendered. Emphasis is given to appropriate triage, timely medical screening examination, patient safety, and ...quality care ... Purpose: To provide quality Emergency Department treatment and care to a variety of patients ...timely manner consistent with the mission statement of the Cleveland Clinic Hospital. The needs of the patient and the capability of the Emergency Department delineated the scope of care and services within the Emergency Department ...It provides emergency medical screening examination, treatment and care to all patients ...Procedure: ...c. The Emergency Department physician staff shall be composed of physicians who are board certified or eligible for board certification in emergency medicine.
III. Services provided: A. the Emergency Department provides initial access for any patient to variety of inpatient and outpatient services to meet the patient needs ...D. Ancillary services


The facility's license revealed Cleveland Clinic is an acute care Class 1 Hospital. The description of the hospital's services capability were listed in part as "Dedicated Emergency Department, Emergency Services ...Emergency Medicine ...Psychiatry."

On 05/17/17 at 3:00 PM, an interview was conducted with the hospital's Director of Quality Assurance who confirmed Patient #1 did not receive a physician examination or medical clearance prior to transfer to a hospital with a psychiatric unit. The facility failed to ensure that their Policy was followed as evidenced by transferring of
Patient #1 on 03/10/17 to another hospital without receiving a physician assessment/evaluation prior to transfer.

Based on review of medical records, Hospital license, and Policy and Procedure, the facility failed to ensure that stabilizing treatment was provided as required that was within the capability of the staff and facilities available at the hospital for further medical evaluation and treatment for 3 (Patient #1, Patient #2, and Patient #3) of 20 ED patient medical records reviewed.

The findings included:

The facility's Policy titled "Emergency Department Plan for Providing Care/Services. Effective 07/26/2013 Date Last Approved/Reviewed: 12/20/2016 was reviewed. The policy revealed in part, "III. Services Provided ...C. Emergency management and stabilization of the patient."

Review of the hospital's licensure revealed the hospital is licensed to provide emergency services and psychiatry services.

1) Review of the ED (Emergency Department) clinical record for Patient #1 revealed the patient arrived to the ED on 03/10/17 at 9:31 PM with a chief complaint of suicidal ideation, hallucinations and hearing voices.

Review of the ED record revealed a Registered Nurse (RN) triaged Patient #1 at 9:43 PM with triage completed at 9:51 PM. After the patient was triaged, while in the waiting room pending a bed assignment, the patient exhibited a psychiatric melt down. Review of the RN progress notes documents the patient was pacing and yelling. Hospital security was called, who in turn called the County Sheriff's department.

Further review of the ED record revealed RN documentation stating an ED bed was being arranged, however the patient's behavior escalated and the patient was Baker Acted by a County deputy and transported to a Baker Act receiving hospital.

Further review of the ED record revealed an ED physician or a psychiatrist did not assess Patient #1 to receive further evaluation and treatment to stabilize his condition, prior to his transfer to another hospital on 3/10/2017.

2) Review of the ED clinical record revealed Patient #2 arrived to the ED on 09/25/16 at 9:12 PM with a chief complaint of suicidal ideations.

Patient #2 was triaged at 9:19 PM and brought into an ED bed at 9:27 PM. The ED physician assessed the patient at 9:28 PM. Review of the ED physician note documented Patient #2 was medically cleared for a psychiatric evaluation.


Further review of the ED clinical record revealed Patient #2 was subsequently discharged from the ED on 09/26/16 at 1:30 AM under the care of a family member with discharge instructions pertaining to suicidal ideations, and recommendations for Patient #2 to seek treatment at a hospital that had a pediatric psychiatric unit.

Further review of Patient #2's ED clinical record revealed no evidence of a consult or assessment by a psychiatrist prior to Patient #2 being discharged to the care of a family member on 09/26/2016.

3) Review of the ED clinical record revealed Patient #3 arrived to the ED on 04/12/17 at 12:16 PM with a chief complaint of right flank pain that began a week ago and nausea and vomiting. The patient also reported a pain score of 6 out of 10 in intensity and sharp. A RN triaged Patient #3 at 12:48 PM. Further review of the ED clinical record revealed Patient #3 had a CT scan of the abdomen completed at 2:01 PM with the results showing an obstructing right renal pelvis calculus (stone). A urology consult was ordered. The ED plan was for Patient #3 to be admitted for further treatment.

Further review of the ED clinical record revealed Patient #3 had a urology physician consult at 4:00 PM on 04/12/17, indicating the patient be discharged home with oral antibiotics, and recommended a percutaneous nephrolithotomy (a procedure to remove medium size or larger stones from a patient's urinary tract by inserting a needle through the skin into the urinary collection system, the collection system near the stone is dilated and the stone is grasped and/or crushed) procedure as an outpatient. Documentation revealed in part, "he feels it is inflammation from the stone."

Further review of the clinical record revealed Patient #3 did not have medical insurance. Hospital case management was called in to assist the patient with state funded resources with follow up as an outpatient at another facility. The Case Management Discharge Note dated 4/12/2017 at 5:32 PM was reviewed. The note revealed, "LOS (length of stay): 0 (zero) days. The discharge arrangement listed the name of an acute care hospital and a telephone number, and Patient #3 was to follow up at this facility on 4/13/2017. Further review revealed in part, "Patient examined and discharged from the ED per MD notes, recommends discharge with Cipro (an antibiotic) and analgesics (pain medication) to control her discomfort for now. She will require percutaneous nephrolithotomy to manage her stones and this can be managed as an outpatient."

Review of the hospital's licensure reveals the hospital is licensed to provide emergency services, nephrology and urology services. Patient #3 was on an admitted status and was discharged from the emergency department on 04/12/17 at 6:23 PM; without being offered urology-stabilizing services to include the percutaneous nephrolithotomy procedure that was available at the hospital on 4/12/2017.

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to provide stabilizing psychiatric treatment as required for Patient #1, Patient #2; and failing to provide within the capabilities of the medical facility (equipment , supplies) urology / nephrology stabilizing treatment (percutaneous nephrolithotomy) for
Patient #3.

Based on medical record review, and review of policies and procedures the hospital failed to ensure the safe and an appropriate transfer by failing to call the receiving hospital to inquire if the hospital had available space and qualified personnel for the treatment of the individual; failing to obtain acceptance of the transfer of the individual; and failing to obtain a written certification of transfer for 1 (#2) of 20 sampled patients who was exhibiting suicidal ideations. This resulted in an inappropriate transfer of Patient #2.

The findings included:

Review of the Emergency Department (ED) clinical record revealed Patient #2 arrived to the ED on 09/25/16 at 9:12 PM with a chief complaint of suicidal ideations.

Review of the ED physician notes revealed Patient #2 was assessed by the ED physician and was medically cleared. Documentation by the RN at 1:44 AM. revealed in part, "Dr. (Physician's Name) spoke with mother and instructed her that he will discharge pt. (patient) under her care on the condition that she immediately take her to (name of another acute care hospital ED was listed) Emergency room to continue pt. care to receive pediatric psychiatric services and mother agreed to take pt. to (name of acute care hospital listed here) upon discharge right away to follow-up as directed by Dr.(Physician's Name)."

Further review of the ED clinical record revealed Patient #2 was subsequently discharged from the ED on 09/26/16 at 1:30 AM under the care of a family member with discharge instructions pertaining to suicidal ideations, and recommendations Patient #2's follow- up instructions were to report to (Hospital's Name) "Children's Hospital" to seek treatment at a hospital that had a pediatric psychiatric unit.

Further review of the ED clinical record revealed no evidence the pediatric receiving hospital was aware Patient #2 would be seeking treatment at their hospital; no evidence the hospital assisted with transportation arrangements to the pediatric hospital; and no evidence that the facility called the receiving hospital to obtain acceptance of Patient #2 on 9/26/2016. The facility failed to ensure that a written certification for transfer was completed for Patient #2 on 9/26/2016, after telling the patient's mother to go to a pediatric hospital for further evaluation and treatment of her child's unstable psychiatric emergency medical condition.

The medical record from the Pediatric hospital was reviewed. The ED record review revealed that Patient #2 arrived at the hospital on 9/26/2016 at 2:00 AM. The Chief Complaint was Patient told mother to take her to the hospital because felt like hurting herself. The patient denied any particular reason why she felt like hurting herself. Mom took patient to the facility where they attempted to transfer her to this Pediatric Hospital and were told there were no beds. Was told to drive patient to this Pediatric Hospital on 9/26/2016 at 2:43 AM. The MD documented in the Medical Decision Making section revealed that the patient's previous record was reviewed. Reviewed visit from the facility where Urinalysis, urine pregnancy test, CBC and chemistry tests were all negative. Further review revealed that procedures, Consults, and ED Department course was discussed with the family including the plan for the patient's ED treatment and plan for further evaluation. The patient's disposition was listed as "Admitted in Fair Condition." The patient's clinical impression was listed as, "This patient has an emergency medical condition." Patient #2's diagnoses were listed as Suicidal Ideation and Depression. Patient #2 was medically cleared for admission to a psychiatric unit. On 9/26/2016 at 5:28 AM Patient #2 was transferred from the ED to the Adolescent inpatient psychiatric unit.

Review of the policy titled, "Florida Transfer of Patients-Emergent Policy", most recently reviewed 12/20/2016 documents:

E. The transfer of an unstable patient with an emergency medical condition shall be carried out in accordance with the following procedure:
1. The hospital shall, with its capability, provide medical treatment, which minimizes the risks to the patient's health and, in the case of a woman who is having contractions, the health of the unborn child.
2. A representative of the receiving facility must have confirmed that:
a. The receiving facility has available space and qualified personnel to treat the patient, and
b. The receiving facility has agreed to accept the transfer of the patient and to provide appropriate medical treatment.
c. The hospital shall send the receiving facility copies of all pertinent medical records available at the time of transfer, including:
i. History
ii. Records related to the patient's emergency care
iii. Observations of signs and symptoms
iv. Preliminary diagnoses
v. Results of diagnostic studies available at time of transfer
vi. Treatment provided
vii. Results of any tests
viii. Copy of the informed, written request or certification and consent to transfer
ix. Transfer Order
d. The transfer shall be effected through qualified personnel and transportation equipment as determined by the physician including the use of necessary and medically appropriate life support measures during the transfer
e. The Nursing Supervisor and the Administrator on call must be notified prior to transfer to another facility for any reason.

3. All medically necessary transfers shall be made to the geographically closest hospital with the service capability, unless another prior arrangement is in place or the geographically closest hospital is at service capacity.
4. Documentation of current transfer arrangements with other hospitals and physicians will be in place.


The facility failed to ensure that their own Policy and procedure was carried out as evidenced by discharging an unstable patient with an identified emergency psychiatric condition, to the care of a family member.