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Based on record reviews and interviews, the hospital failed to ensure all practitioner's orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, vital signs, and other information necessary to monitor the patient's condition were contained in patients' medical records. This deficient practice was evidenced by failing to ensure all verbal orders were included in the medical record for 1 (#1) of 3 (#1, #2, #3) medical records reviewed from a total sample of 20.

Findings:

Review of Patient #1's medical record revealed an admission date of 09/09/2024. Review of the nurse's note dated 09/09/2024 at 11:30 a.m. by S4RN revealed in part, "patient left unit at this time via wheelchair accompanied by family. AMA (against medical advice) papers signed. Per statement from patient, family to transport patient to 'Hospital D' ER (emergency room). Chart and records sent with patient per instruction from S3MD. Per instruction from MD two IVs (intravenous) left in place and foley catheter left in place." Review of the physician orders failed to reveal a physician order to leave in place two IV accesses and a foley catheter at discharge.

In an interview on 10/15/2024 at 2:45 p.m. S1DON and S2RN verified there was no documentation of a physician order to leave in place two IVs and a foley catheter at discharge in Patient #1's medical record. S1DON stated the two IVs and foley catheter should not have been left in place at discharge.

In a phone interview on 10/15/2024 at 3:44 p.m. S4RN stated S3MD gave her a verbal order to leave in Patient #1's IVs and foley catheter at discharge.

Based on observations, record reviews and interviews, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by:

1.) the hospital failing to post EMTALA signage within the emergency department. (See findings tag A-2402);

2.) the hospital failing to place a psychiatric patient under a Physician's Emergency Certificate (PEC) and failing to have documented evidence of conducting safety rounds on a psychiatric patient for 1 of 1 (#8) patients who presented to the emergency department with a psychiatric condition from a total sample of 20 (See findings tag A-2407); and

3.) the hospital failing to have documented evidence of an accepting physician at the receiving hospital, failing to have documented evidence of a physician certificate of transfer, failing to have documented evidence of identifying the risks and benefits of the transfer, and failing to provide appropriate mode of transport to the receiving hospital (See findings tag A-2409).

Based on observation and interview, the hospital failed to ensure signs were posted conspicuously in places likely to be noticed by all individuals entering the emergency department specifying the rights of individuals under section 1867 of the Emergency Medical Treatment and Active Labor Act (EMTALA), with respect to examination and treatment for emergency medical conditions and women in labor, and to post conspicuously information indicating whether or not the hospital participated in the Medicaid program under a State plan approved under Title XIX. This deficient practice was evidenced by failing to post EMTALA signage within the emergency department.

Findings:

In an observation on 10/16/2024 at 11:41 a.m. - 12:04 p.m. of the emergency department accompanied by S1DON revealed there was no EMTALA signage posted anywhere within the emergency department.

In an interview on 10/16/2024 at 12:03 p.m. S1DON verified there was no EMTALA signage posted anywhere within the emergency department.

Based on record reviews and interview, the hospital failed to provide stabilizing treatment. This deficient practice was evidenced by: 1.) failing to place a psychiatric patient under a Physician's Emergency Certificate (PEC) and 2.) failing to have documented evidence of conducting safety rounds on a psychiatric patient for 1 of 1 (#8) patients who presented to the emergency department with a psychiatric condition from a total sample of 20.

Findings:

Review of Patient #8's ED visit record revealed Patient #8 presented to the emergency department on 09/21/2024 at 7:35 p.m. Review of the emergency department provider note dated 09/21/2024 revealed in part, Patient #8 was seen by S5MD at 7:50 p.m. "HPI (history of present illness): 13 year old female brought by mother for voicing suicidal ideations." "She has been dealing with bullying in school, and has made several voiced threats to hurt herself. She has been cutting herself on the hands recently. She threatened to jump off a 2 story building tonight." Further review revealed "Clinical Impression: Other: MDD (major depressive disorder) with SI (suicidal ideation)." "Disposition: Other: sent via private auto to 'Hospital C'. Disposition Notes: I called 'Hospital C', verified they have a bed. Spoke with patient's mother, who agrees to take her there voluntarily, as she did not want to do a PEC since her kids have been through a lot as adopted foster kids. I agreed with her as long as she takes her there directly. Mom agrees. Nurse called 'Hospital C' to verify and reserve bed."

Review of the nurse's notes dated 09/21/2024 revealed in part, "7:50 p.m. S5MD reports he spoke with 'Hospital C', they have a bed available, he reports mom agrees to take her for inpatient treatment." "9:00 p.m. Spoke with intake at 'Hospital C' notified patient has just left and is on her way transported per mother."

Further review of the record failed to reveal Patient #8 being placed under a PEC.

In a phone interview on 10/16/2024 at 11:33 a.m. S5MD stated he considered doing a PEC for Patient #8. He stated he discussed the situation with Patient #8's mother and decided not to PEC Patient #8. He stated she was a minor. He stated Patient #8's mother was willing to take Patient #8 to the psychiatric hospital.

Further review of the record failed to reveal documented evidence of conducting safety rounds on Patient #8 while in the ED.

Review of Patient #8's medical record from 'Hospital C' revealed an admission date of 09/21/2024 at 11:13 p.m. Review of the psychiatric evaluation dated 09/22/2024 at 10:07 a.m. revealed in part, Patient #8 was admitted to 'Hospital C' under a formal voluntary admission with a psychiatric diagnosis of major depressive disorder, single episode, severe without psychotic features.

Based on record reviews, the hospital failed to provide documented evidence to indicate an appropriate transfer was provided for 1 (#8) of 20 (#1-#20) patients who presented to the hospital's emergency department (ED) with an emergency medical condition. This deficient practice was evidenced by: 1.) failing to have documented evidence of an accepting physician at the receiving hospital; 2.) failing to have documented evidence of a physician certificate of transfer; 3.) failing to have documented evidence of identifying the risks and benefits of the transfer; and 4.) failing to provide appropriate mode of transport to the receiving hospital.

Findings:

Review of Patient #8's ED visit record revealed Patient #8 presented to the emergency department on 09/21/2024 at 7:35 p.m. Review of the emergency department provider note dated 09/21/2024 revealed in part, Patient #8 was seen by S5MD at 7:50 p.m. "HPI (history of present illness): 13 year old female brought by mother for voicing suicidal ideations." "She has been dealing with bullying in school, and has made several voiced threats to hurt herself. She has been cutting herself on the hands recently. She threatened to jump off a 2 story building tonight." Further review revealed "Clinical Impression: Other: MDD (major depressive disorder) with SI (suicidal ideation)." "Disposition: Other: sent via private auto to 'Hospital C'. Disposition Notes: I called 'Hospital C', verified they have a bed. Spoke with patient's mother, who agrees to take her there voluntarily, as she did not want to do a PEC (Physician's Emergency Certificate) since her kids have been through a lot as adopted foster kids. I agreed with her as long as she takes her there directly. Mom agrees. Nurse called 'Hospital C' to verify and reserve bed."

Review of the nurse's notes dated 09/21/2024 revealed in part, "7:50 p.m. S5MD reports he spoke with 'Hospital C', they have a bed available, he reports mom agrees to take her for inpatient treatment." "9:00 p.m. Spoke with intake at 'Hospital C' notified patient has just left and is on her way transported per mother."

Further review of the record failed to reveal documented evidence of an accepting physician at the receiving hospital, documented evidence of a physician certificate of transfer, documented evidence of identifying the risks and benefits of the transfer, and failing to provide appropriate mode of transport to the receiving hospital.

Review of Patient #8's medical record from 'Hospital C' revealed an admission date of 09/21/2024 at 11:13 p.m. Review of the psychiatric evaluation dated 09/22/2024 at 10:07 a.m. revealed in part, Patient #8 was admitted to 'Hospital C' under a formal voluntary admission with a psychiatric diagnosis of major depressive disorder, single episode, severe without psychotic features.