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Based on hospital policy review, medical record reviews, physician and staff interviews the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

1. Based on hospital policy review, medical record review, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 27 sampled DED patients who presented to the hospital for evaluation and treatment and was discharged (Patient #10). Additionally, the facility failed to ensure that an appropriate medical screening examination was provided as evidenced by failing to have a physician re-evaluate patient (#27) with persistent alcohol withdrawal symptoms prior to transfer.


~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A2406.


2. Based on hospital policy review, medical record reviews, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physician(s) failed to ensure an appropriate transfer by failing to sign a certification that the medical benefits at another medical facility outweigh the increased risks to the individual; failed to ensure the receiving facility had available space and qualified personnel for the treatment of the individual and had agreed to accept transfer of the individual; failed to send to the receiving facility copies of all medical records available at the time of the transfer; and failed to ensure the transfer was effected through qualified personnel and transportation equipment for 1 (Patient #10) of 27 sampled patients discharged with instructions to "Go Straight to (Hospital B) for Detox."

~ Cross refer to §489.24(e)(1)-(2) Appropriate Transfer, Tag A2409.

Based on hospital policy review, medical record review, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 27 sampled DED patients who presented to the hospital for evaluation and treatment and was discharged (Patient #10). Additionally, the facility failed to ensure that an appropriate medical screening examination was performed by an Emergency Department Physician prior to transferring patient #27 with persistent alcohol withdrawal symptoms.


Findings included:

Review on 01/15/2016 of current hospital policy "EMTALA", NSG-CLI #857, effective 12/17/2014, revealed "POLICY/PURPOSE Any person who comes to (Hospital A) requesting assistance for a potential emergency medical condition or emergency services will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists. ...IMPLEMENTATION ...D. MEDICAL SCREENING EXAMINATIONS 1. A medical screening exam is required when an individual: a. Seeks care at the hospital Emergency Department... 4. The requirements of a medical screening examination are as follows: a. The medical screening consists of an assessment and any ancillary tests or focused assessment based on the patient's chief complaint necessary to determine the presence or absence of an emergency medical condition. This may be a brief history and physical examination or may require complex ancillary studies and procedures such as (but not limited to) lab tests....EKG or radiology procedures. b. The medical screening examination is the process a provider must use to reach with reasonable clinical confidence whether an emergency condition does or does not exist. c. The medical screening must provide evaluation and stabilizing treatment within the scope of the hospital's abilities...

Review of current hospital policy "Standards of Patient Care Emergency Department", last revised 07/22/2014, revealed "I. ADMISSION: ...B. Emergency Severity Index: Triage Classification and Reassessment Guidelines ...3. Level III - Urgent: Condition poses a potential threat to life, limb or physiological function requiring early emergency intervention. ...Reassessment occurs at a minimum, every 3 hours or more often as condition warrants. Vitals within normal limits are repeated a minimum of every 3 hours, or more frequently as indicated. Unstable vital signs are repeated every 30 minutes until stable, then hourly x 1, and every 4 hours thereafter, or more frequently as condition warrants. ..."

1. Closed DED record review on 01/14/2016 for Patient #10, revealed a 33 year old male who presented ambulatory to Hospital A's DED via private transportation on 12/28/2015 at 1038. Review revealed the patient was triaged by a Registered Nurse (RN) at 1047. Review revealed a "Chief Complaint" of "Psychiatric Illness." Review of "Description of Symptoms" revealed "PT (patient) STATES HE WANTS TREATMENT FOR ALCOHOLISM. STATES HE DRANK TODAY. DENIES SI/HI (suicidal/homicidal ideation)." Review revealed vital signs (VS) were assessed as temperature (T) 98.7 degrees Fahrenheit (F); Pulse (P) 132 (high - range 60-100); Respirations (R) 18; blood pressure (BP) 169/102 (high - range 100/60-140/80); and Pulse Oxygen Saturation (SpO2) 95% on room air (RA). Pain was assessed as a "4" (numeric scale - 0 pain free to 10 worst pain). Review revealed a past medical history of chronic back pain. Record review revealed the patient's current home medication was Epinephrine [Epipen 2-Pak] for allergic reactions to bee venom. Review revealed the patient was triaged as "Priority 3 - Urgent." Review of nursing documentation at 1130 by RN #1 revealed "ED Psychiatric Assessment." Review revealed "Psychiatric Complaint" with "Is the patient under psychiatric care? No" and "Presents with Depression." Review revealed "Behavioral Health" with "Chief Complaint" of "Request Detox- Drinking 18 pack day. Sts (states) 'I need to get help. This drinking is killing me'. Review revealed "Depression" with "Depressive Symptoms" of "Worthlessness." Review revealed "Having thoughts of harming yourself or taking your life" with "No: 'drinking will kill me'." Review of "ED Primary Care Assessment" revealed "Mental Status Alert Oriented." Review revealed "Hx (history) Alcohol Use YES....18 pack day..."

Review of MSE documentation by PA #1 (Physicians' Assistant), revealed a MSE was conducted at 1139. Review revealed a "Chief Complaint: Psychiatric Illness" and "Stated Complaint: PSYCH EVAL." Review of HPI (history of present illness) revealed "PT PRESENTS FOR DETOX FROM ALCOHOL STATES DRINKS AN 18-PACK PER DAY FOR SEVERAL YEARS. BEEN DRINKING SINCE 19 Y/O (years old)." Review revealed "DRANK 18-PACK THIS AM (morning)." Review revealed "Relevant History: Reports: Alcoholism. Current Substance of Use: Reports: Alcohol (ETOH) ...Severity: None Associated Signs & Symptoms: Reports: None." Review of "ED Past Medical History" revealed "...Patient has no past medical history....Psychological History: Reports: Substance Use Disorder (ETOH)." Review revealed Review of Systems (ROS) was Negative. Review revealed: Constitutional: alert (awake), no apparent distress. Oriented to: time, person, and place. Last recorded vital signs: T98.7 F; P 132H; R 18; BP 169/102H; and Pulse Ox 95. HEENT (head, ears, eyes, nose, throat) - Head: normal (normocephalic). Eye Exam: normal (PERRL [pupils equal round reactive to light], EOMI [extraoccular movement intact], sclera white). Oropharynx: normal (pharynx: moist without exudate, gums - no swelling). Tympanic Membrane: normal. ...Nose: no symptoms reported (septum midline). Neck: normal (FROM [full range of motion], trachea at midline). Respiratory/Cardiovascular - Respiratory: normal - CTA [clear to auscultation] (BBS [bilateral breath sounds] clear to auscultation without adventitious sounds). Cardiovascular: normal (RRR [regular rate & rhythm] without murmur, gallop or rub). GI (Gastrointestinal) - Auscultation: normal (NABS [no abnormal bowel sounds). Palpation: normal (soft, No rebound or guarding, non-distended). Tenderness: non-tender. Murphy's Sign (abdominal assessment fo diagnosis of Gall Bladder disease): negative. Musculoskeletal - Back: normal (non-tender). Extremities: normal (normal tone, pulses 2+, no cyanosis or edema, FROM). Integumentary - Skin: normal, warm, and dry. Lymphatics: normal (no adenopathy). Neurologic - Memory Impaired: normal. Motor Function: normal (normal tone, pulses 2+, no cyanosis or edema, FROM). Cranial Nerve (CN): normal (CN II-XII intact sensation, strength 5/5). Cerebellar: normal. Mood Description: normal. Perception: normal. Review revealed, ED Alcohol/Sub (substance)/Withdrawal Exam documentation revealed, Neurologic - Oriented to: time, person, and place. Memory Impairment: normal. CN: normal. Motor Function Unable to Test or Normal: normal. Cerebellar Function: normal. Reflexes: normal. Thought: coherent. Affect: appropriate. Perception: normal. Insight: normal. Judgment: normal. Review revealed, Differential Diagnosis - Alcohol withdrawal syndrome, Intoxication Alcohol,
Substance abuse disorder.

Record review revealed no documentation of any physician's orders for treatments (i.e. medications, radiology, laboratory studies, etc.) or consults (psychiatric/mental health evaluation) ordered by PA #1 or Physician A.


1a. Closed medical record review on 01/15/2016 for Patient #10 revealed the patient presented ambulatory to the Hospital B's DED via private transportation on 12/28/2015 at 1401 (41 minutes Hospital after discharge from Hospital A's DED). Review revealed the patient's VS were obtained at 1313 and a urine specimen was obtained at 1325 by a Nursing Assistant. Review revealed initial VS were T 98.8 degrees F; P 110; R 18; BP 142/73; and SPO2 98% on RA. Pain was assessed as a "4/10" (numeric scale - 0 pain free to 10 worst pain). Review revealed the patient was triaged by an RN at 1400. Review of nursing documentation revealed "NURSING TRIAGE (Adult) pt went to (Hospital A) ED today and they sent him here." Review of HPI revealed "Headache - Onset a couple of days because he was banging his head on the wall ...(+) vomiting today ...(+) moderate headache. Back pain - Onset for years without injury. Pain described as sharp and non-radiating. ...Substance Abuse - alcohol abuse since he was 19. (+) patient requesting detox. Pt. [sic] (consumed) a case of beer since 7 am today. Brought to ED by self, (-) hx. of previous detox. Pt placed in a W/C (wheelchair)." Review revealed "PHYSICAL EXAM: GENERAL APPEARANCE: well nourished, alert, oriented x 3 (person, place, time), no acute distress, no obvious discomfort." Review revealed "TRIAGE SUICIDAL HOMICIDAL ASSESSMENT: Denies thoughts of hurting self or others. Review revealed the patient was assigned an acuity level 3 (1-5, with 1 least severe, 5 most severe). Review of an "ASSESSMENT BEHAVIORAL HEALTH" conducted by an RN at 1521 revealed, "pt states he went to (Hospital A) er (emergency room) and they told him to come here because they do not do detox there he also adm (admits) hitting his head against wall with no reasonably [sic] explanation of that [sic] he does seem impaired at this time, he is interested at [sic] in pt (inpatient) detox at this time. ...MENTAL STATUS: speech clear, oriented x4 (person, place, time, situation), normal affect, responds appropriately to questions. ...GENERAL APPEARANCE: no acute distress, no obvious discomfort. SUICIDAL HOMICIDAL ASSESSMENT: Denies thoughts of hurting self or others. All clothing and personal items removed, labeled, and locked in bin..." Review of nursing documentation at 1704 revealed ...M.D. at bedside. Pt c/o (complains of) back pain." Review revealed at 1759 the patient was administered Toradol (non-steroidal anti-inflammatory) 30 milligrams (mgs) IM (intramuscular) once for back pain of 7/10. Review revealed at 1805 the patient was administered Ativan (anti-anxiety medication) 2 mgs once by mouth. Review at 1850 revealed "DSP (disposition) ADMISSION - Patient prepared for transport to inpatient bed 504, admitted to service of....M.D. Admission orders were received. ...Transport to floor by ED Technician. ..."

Review of MSE documentation by Physician E revealed an MSE was conducted at 1652. Review of HPI revealed "33 year old male presents for psychiatric evaluation. Pt is [sic] request detox from ETOH. Pt states 'I am an ass hole when I am sober and happy when I am drinking.' States last alcohol consumption was at 0900 this am. Pt reports his wife and children have given him an ultimatum to detox. Reports having the shaks [sic] and hallucinations in the past but denies today. Reports a very mild headache. Pt admits to nonspecific SI and HI to 'no one in particular.' States 'I am just so angry.' Pt reports not sleeping all night." Review of ROS revealed "In addition to the systems reviewed below, all other systems reviewed are negative except for those included in history. ...MUSCULOSKELETAL ROS: ...(+) arthralgias ...PSYCHIATRIC ROS: ...(+) suicidal ideations....(+) homicidal ideations." Review of PE revealed "GENERAL APPEARANCE: well nourished, alert, cooperative, no obvious discomfort. ...EYES: PERRL, EOMI, conjunctiva clear. ...SKIN: warm, dry, good color, no rash. NEURO: motor intact, sensory intact. MENTAL STATUS: speech clear, oriented x3, normal affect, responds appropriately to questions. DIFFERENTIAL Dx (diagnosis): PSYCHIATRIC Dx: schizophrenia, personality disorder, drug abuse, depression, anxiety, alcohol abuse, adjustment reaction. ..." Review of a physician's note at 1703 revealed "Medical clearance complete. Patient is ready for transport to EDBH (Behavioral Health Unit). Pt has been medically cleared." Review of a physician's note at 1708 revealed "Pt admits to sig (significant) alcohol problem, causing relationship problems esp (especially) with spouse and children. His family intervened and urged him to seek help. Was seen initially at (Hospital A) and was actually directed to be seen at (Hospital B) 'for detox.'"

Review revealed the following labs were ordered on the patient and reviewed by the ED Provider: CBC (complete blood count) with Differential, CMP (comprehensive metabolic panel), ETOH Level, and a UDS (urine drug screen). Review of lab results revealed a blood ETOH level of 242 mg/dL (milligrams/deciliter) [normal range less than 11 mg/dl] obtained at 1420. Review of UDS results were negative at 1320. Review revealed the patient was voluntarily admitted to Hospital B's inpatient behavioral health unit.

Review of an inpatient admission History and Physical dictated 12/29/2015 at 2031 revealed an admission date of 12/28/2015. Review revealed "...According to medical record, blood alcohol level was very high at 242 mg/dL. ...DIAGNOSES: AXIS I 1. Alcohol dependency and withdrawal. 2. Mood Disorder, alcohol induced. ...TREATMENT PLAN: ...At time of admission....was initiated on routine alcohol, Valium (Benzodiazepine) detox protocol..."

Review of an inpatient discharge summary dictated 12/31/2015 at 1030 revealed the patient was admitted to the Behavioral Health unit on 12/28/2015. Review revealed "...admitted voluntarily for alcohol detox and mood stabilization. ...HOSPITAL COURSE: ...He was started on naltrexone (Opioid antagonist) and was placed on a Valium detox. He tolerated this detox fairly well and cleared up and made a commitment to continue treatments on outpatient basis... At the time of discharge, he has stable mood, goal directed thought process, has a normal cognition and no dangerousness to self or others. DISCHARGE DIAGNOSES: AXIS I: Alcohol dependence, alcohol-induced mood disorder. ..." The patient was discharged on 12/31/2015.




Telephone interview on 01/14/2016 at 1305 with PA #1 revealed he recalled Patient #10. Interview revealed he conducted the MSE on Patient #10 on 12/28/2015. Interview revealed as part of the MSE he reviewed the nurse's triage notes, talked with the patient, conducted a complete physical examination and assessed for signs and symptoms of alcohol withdrawal. Interview revealed the patient was tachycardic (elevated heart rate) and hypertensive (elevated blood pressure). Interview revealed alcohol use would increase the heart rate and elevate the blood pressure. Interview revealed the patient was also overweight, a heavy smoker, and heavy drinker. Interview revealed the patient did not exhibit any signs and symptoms of alcohol withdrawal. Interview revealed the patient's vital signs were not symptomatic of withdrawal. Interview revealed he "felt" no lab tests were warranted, therefore none were ordered. Interview revealed if the patient had been symptomatic of withdrawal he would have ordered labs. Interview revealed the patient reported drinking an 18 pack of beer prior to arrival to the ED. Interview revealed "there were signs of intoxication." Interview revealed he could not remember what they were. Interview revealed the patient was accompanied by another gentleman, his father or father-in-law. Interview revealed there was not a "detox" unit at Hospital A. Interview revealed the hospital used a contracted mental health agency (MHA #1) to perform mental health assessments and assist with bed placements and psychiatric transfers. Interview revealed he did not order a psychiatric mental health evaluation on the patient. Interview revealed if the patient had been symptomatic of alcohol withdrawal he would have admitted the patient to a medical bed and then transferred the patient to a detox facility. Interview revealed he "did not feel the patient had to go directly to a detox facility." Interview revealed he was made aware by MH staff that the patient did arrive at Hospital B and was seen in the ED and admitted to an inpatient detox unit. Interview revealed the patient "did not have an EMC. Interview revealed Physician A co-signed the patient's chart. Interview revealed Physician A did not evaluate the patient. Interview revealed he did not consult or discuss the patient's care with Physician A while the patient was in the ED. Interview revealed as a PA he can perform a MSE, treat, and discharge patients without an attending physician being consulted or laying hands on the patient. Interview revealed there is an attending physician on-duty at all times in the ED for consultation and supervision.

Telephone interview on 01/15/2016 at 1120 with Physician B, revealed he was Hospital A's DED Medical Director. Interview revealed he was familiar with the 12/28/2015 ED record for Patient #10. Interview revealed he had discussions with PA #1 about the case. Interview revealed Hospital A did not provide alcohol detoxification services. Interview revealed PA #1, "does not work here that often." Interview revealed the patient had been drinking heavily on the morning he arrived in the ED. Interview revealed the patient's heart rate and blood pressure were elevated. Interview revealed the patient's elevated vital signs were not associated with alcohol withdrawal symptoms. Interview revealed elevated blood pressures in an asymptomatic patient are normally not addressed in the ED setting. Interview revealed "the patient's increased heart rate could have been addressed." Interview revealed the patient's vital signs should have been reassessed prior to discharge. Interview revealed the patient "was nontoxic." Interview revealed he (Physician B) "thought" the patient was only given a list of detox facilities and Hospital B was his preference. Interview revealed the MSE by PA #1 was "adequate." Interview revealed "Could it have been done better? Absolutely." Interview revealed there was "no science behind doing blood work." Interview revealed blood work was normally obtained because certain State facilities required certain lab tests for admission. Interview revealed admission requirements vary for each individual facility. Interview revealed there was no history or symptoms to suggest alcohol withdrawal. Interview revealed the patient had "no EMC." The patient "was fine." Interview revealed the patient was "stable" when discharged.


Telephone interview on 01/14/2016 at 1415 with MH #1 (Mental Health Staff) revealed he recalled Patient #10. Interview revealed he was working on 12/28/2015 when he received a call from the PA requesting a list of detox referrals. Interview revealed the PA stated he did not want an assessment on the patient.

The facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital ' s emergency department including ancillary services (labs, complete psychiatric/mental health evaluation) routinely available to the emergency department to determine whether or not an emergency medical existed for patient #10 on 12/28/2015.


2. Hospital A, closed DED record review on 01/14/2016 for Patient #27 revealed a 53 year old male presented to the DED via Emergency Medical Services (EMS) ambulance on 11/24/2015 at 1244 with police escort after being found intoxicated. Patient #27 was triaged as " Emergent. " Review of DED triage documentation at 1244 revealed "...EMS reports pt is violent and assaulted EMS crew." Review of physician's documentation by Physician F dated 11/25/2015 at 1135 revealed "EMS reports patient stated SI (suicide ideations). Patient is non-cooperative for the most part - on my arrival patient is calm - telling me he is suicidal with a plan to shoot himself. States 'If I had a gun I'd be dead'. Record review revealed on 11/24/2015 at 1416 the patient's blood alcohol level was 0.34 (normal less than 10). The patient ' s Home medications were listed as: Disulfiram (medication used to treat chronic alcoholism) 250 mg (milligrams) by mouth daily; Lisinopril/Hydrochlorothiazide (medication used to treat high blood pressure) 10-12.5 mg; 1 tablet by mouth daily; and Sertraline (anti-depressant medication) HCL 100 mg by mouth daily. The ED physician documented the patient ' s final diagnosis as Alcohol Abuse, Alcohol Intoxication and Suicidal Ideation. Further review of the medical record revealed the patient ' s vital signs were abnormal: 11/24/2015: 12:44 p.m.-Blood Pressure 160/100 (normal Blood Pressure range- 100/60-140/80) Heart Rate: 111 (normal range heart rate 60-100); 2:55 p.m. Heart Rate: 117; 10:45 p.m. Heart Rate: 133; 11/25/2015: 5:17am- Blood Pressure-172/105; 7:37 am Heart Rate: 120, Blood pressure 155/97; 11:44 am - Heart rate 120 Blood Pressure 155/89; 12:18 p.m.- Heart Rate -126, Blood Pressure-162/92; 3:11 p.m. heart rate -110, Blood Pressure- 142/92; and 5:39 p.m.- Heart rate-102, Blood pressure 152.84.
The ED nurse documented on 11/25/2015 at 03:39 am the patient " c/o (complained) of shaking, Ativan 4mg po (by mouth) Clonidine 0.1 mg given as ordered ...11/25/2015 11:44 am ...anxious, tremors, restless, ...Ativan given ...11/25/2015 13:55 (1:55 pm) ...continues with minor tremors and restlessness ...11/25/2015 15:11 (3:11 pm) ...still trembling. Some anxiousness ...restless ...meds given ...11/25/2015 17:39 (5:39 PM)- ...still some tremors and restlessness. " Record review revealed the patient was last re-evaluated at bedside by a DED Physician's Assistant (PA #3) at 1135 (6 hours and 30 minutes prior to the patient's transfer from the DED) and was evaluated via Telepsychiatry (delivery of psychiatric assessment and care usually through videoconferencing) by a Psychiatric PA (PA #4) at 1305 (5 hours prior to the patient's transfer from the DED). Review of the record revealed that patient #27 ' s condition had demonstrated continued tachycardia, elevated blood pressure despite multiple doses of clonidine and being on an alcohol withdrawal protocol of Ativan. The ED nurse notes after the patient was accepted for transfer continued to document, " tremors, " " trembling, " " anxiousness, " and " restlessness. " Record review failed to reveal any available documentation of re-evaluation of Patient #27 ' s condition (persistent alcohol withdrawn symptoms) on 01/14/2016 by the on-duty ED physician (Physician F) prior to transfer. The facility failed to ensure that an appropriate medical screening examination was provided for patient #27 as evidenced by failing to have a physician re-evaluate patient (#27) with persistent alcohol withdrawal symptoms prior to transfer

Interview on 01/15/2016 at 1105 with Director #1 during medical record review revealed Patient #27's patient transfer form identified Physician D as the transferring physician. Interview revealed 11 00 was documented as the time and transfer accepted by receiving MD and time accepted transfer on the patient transfer form. Physician D was not on-duty when the patient was transferred out of the ED. Interview revealed Physician F was on-duty. Interview revealed no documentation of re-evaluation by Physician F prior to the patient's transfer. Interview revealed no documentation of re-evaluation by Physician F prior to the patient's transfer. Further Interview revealed "I do not disagree with the findings of the medical record review."

Based on hospital policy review, medical record reviews, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physician(s) failed to ensure an appropriate transfer by failing to sign a certification that the medical benefits at another medical facility outweigh the increased risks to the individual; failed to ensure the receiving facility had available space and qualified personnel for the treatment of the individual and had agreed to accept transfer of the individual; failed to send to the receiving facility copies of all medical records available at the time of the transfer; and failed to ensure the transfer was effected through qualified personnel and transportation equipment for 1 (Patient #10) of 27 sampled patients discharged with instructions to "Go Straight to (Hospital B) for Detox." .

Findings included:

Cross refer to tag A-2406 as it relates to failure to provide appropriate medical screening examination for Patient #10 who presented to the hospital ' s ED with an emergency medical condition.


Review on 01/15/2016 of current hospital policy "EMTALA", NSG-CLI #857, effective 12/17/2014, revealed "...IMPLEMENTATION ...F. TRANSFER OR REFERRAL OF EMERGENCY PATIENTS....TO ANOTHER FACILITY. 1. Transfer is considered in the following circumstances: a. When the hospital is unable to respond to the needs of the patient present with an emergency medical condition in a manner that would be in the patient's best interest, including, but not limited to....mental health referrals....conscious or unconscious patients with potential deteriorating status... b. When the hospital is unable to provide an appropriate bed for the patient; c. When the hospital is unable to provide an appropriate specialty physician to manage the patient's care... 2. The following items apply to the transfer of patients with stable conditions: a. Patient consent must be obtained prior to transferring patients with stable conditions. ...3. The following items apply to the transfer of patients with unstable conditions: b. ...ii. The examining physician certifies, in writing, that the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks of transfer to the patient.... iii. The physician's written certification shall be documented on the 'Patient Transfer Form', and shall include a summary of the risks and benefits of the transfer, as identified by the physician, upon which the certification is based. ...4. Documentation of the consent for or refusal of transfer shall be completed using the following guidelines: a. The patient's written consent to transfer shall be documented on the 'Patient Transfer Form'. ...5. Before transfer can occur, arrangements must be made with a physician at the receiving facility to accept the patient in transfer. a. The transferring physician is responsible for arranging for a physician at the receiving facility to provide appropriate care for the patient. The Emergency Department charge nurse or designee shall immediately contact the proposed receiving facility to determine if the receiving facility has available space and qualified personnel to treat the patient, and whether it is willing to accept the transfer. The name and title of the contact person at the other facility, and the time and outcome of the contact, shall be documented in the 'Patient Transfer Form'. ...6. When a receiving facility has agreed to accept the transfer of a patient, Emergency Department....personnel shall contact an appropriate emergency transport service. 7. Copies of the patient's medical record will be sent with the patient to the receiving facility. a. The following information must be sent to the receiving facility: Copies of all medical records available at the time of transfer relating to the patient's emergency medical condition. ...9. Requirements for transfer of all patients (stable or unstable conditions): a. After assessing the patient's condition the transferring physician shall determine the means of transfer: by ambulance, helicopter, or automobile. b. The patient shall not be transferred until the receiving hospital, physician, or facility has consented to accept the patient and the patient has been sufficiently stabilized for transfer. ...d. Immediately prior to transfer (i.e. within 15 minutes of transfer), the patient's condition and vital signs shall be documented in the medical record. ...h. The 'Patient Transfer Form' shall be signed by the patient if capable, next of kin, or legal guardian of minors or patients who are medically or mentally unable to do so. ..."

Review of current hospital policy "Standards of Patient Care Emergency Department", last revised 07/22/2014, revealed "IX. TRANSFER: ...2. After acceptance by the receiving facility, the primary nurse prepares appropriate paperwork and will have patient or family member sign Consent for Transfer. 3. The primary nurse calls report tot he receiving unit and documents the full name and credentials of the person accepting report. ...5. The primary nurse will take a final set of vital signs within 15 minutes of patient transport. ..."

1. Closed DED record review on 01/14/2016 for Patient #10, revealed a 33 year old male who presented ambulatory to Hospital A's DED (Transferring Hospital) via private transportation on 12/28/2015 at 1038. Review revealed, Additional Information - "I HAVE CONTACTED MENTAL HEALTH TO SEE IF A DETOX FACILITY HAS AN OPEN BED FOR THIS PT TO GO TO, I AM WAITING RETURN PHONE CALL. MENTAL HEALTH HAS FOUND A BED AND WE WILL SEND PT THERE BY FAMILY FOR DETOX TREATMENT." Decision Time to Discharge: 12:04. Review revealed, Departure - Disposition: Home. Condition: Good. Final Diagnosis: Alcohol Abuse. Instructions: Abuse of Alcohol (ED). Education/Counseling Given To: Patient. Education/Counseling Given Regarding: Diagnosis, Treatment, Prognosis, and Follow Up. Referrals: None, No Provider. Review revealed, Additional Instructions: "GO STRAIGHT TO (Hospital B) FOR DETOX." Review revealed the electronic signature of PA #1 at 12/28/2015 at 1207 and the electronic signature of Physician A at 12/28/2015 at 1644. Record review revealed no documentation of any physician's orders for treatments (i.e. medications, radiology, laboratory studies, etc.) or consults (psychiatric/mental health evaluation) ordered by PA #1 or Physician A.

Review of a copy of the discharge paperwork given to the patient by RN #1 revealed:
Patient Visit Information - You were seen today for: Alcohol Abuse
Patient Instructions Reviewed - Abuse of Alcohol (ED) received 12/28/2015 at 12:16. Care Plan Goals - Problem: Alcohol Abuse. Goals: Decreased symptoms/improved condition. Interventions: Follow discharge instructions. Contact physician if condition worsens or does not improve. Activity Restrictions or Additional Instructions
"GO STRAIGHT TO (Hospital B) FOR DETOX." Follow Up - None, No Provider. Follow-Up Plan: 1-2 days.

Review of a "Discharge Data (Signature Page) dated 12/28/2015 at 1216, revealed "Discharge Instructions Given" with "Instructions: Abuse of Alcohol (ED)." Review revealed "Medications & Follow UP" with "Referrals: None ...Additional text: GO STRAIGHT TO (Hospital B) FOR DETOX." Review revealed "I have read and understand the discharge and follow up instructions that have been given to me by my caregivers." Review revealed the hand written signature of Patient #10 on the signature line. Review revealed "Instructions given and reviewed by:" with the handwritten signature of RN #1 on the signature line, dated 12/28/2015 at 1220.

Continued review of nursing documentation revealed the patient was "Discharged" and given "Written/Verbal" discharge (D/C) instructions and patient specific education materials. Review revealed the patient "Verbalizes Understanding of D/C Instructions." Review revealed "Mode of Departure Walking." Record review failed to reveal reassessment of the patient's abnormal vital signs prior to discharge. Review revealed the patient was discharged from the DED at 1220.



Telephone interview on 01/14/2016 at 1305 with PA #1 revealed he recalled Patient #10. Interview revealed the hospital used a contracted mental health agency (MHA #1) to perform mental health assessments and assist with bed placements and psychiatric transfers. Interview revealed he did not order a psychiatric mental health evaluation on the patient. Interview revealed the MH staff called around each day to find out what psychiatric and detox beds are open and available in the area. Interview revealed "in this case" he called the MH staff to see what facility had an open detox bed for Patient #10. Interview revealed MH staff were aware of the open detox beds available in the area and came to the ED and spoke with the patient and gave the patient a list of outpatient referrals and detox facilities with open beds. Interview revealed the list was not documented in the patient's record. Interview revealed the patient was told the detox facilities would not hold beds open. Interview revealed the patient was "instructed to go straight to (Hospital B) or where ever he choose for detox. So a bed would still be available." Interview revealed the patient's discharge papers were "patient instructions and not facility instructions." Interview revealed "the intention was for the patient to be discharged and to follow-up with the detox facility of his choice as soon as possible and not to be a transfer." Interview revealed "we were not going to transfer the patient." Interview revealed if the patient had been symptomatic of alcohol withdrawal he would have admitted the patient to a medical bed and then transferred the patient to a detox facility. Interview revealed he "did not feel the patient had to go directly to a detox facility." Interview revealed he was made aware by MH staff that the patient did arrive at Hospital B and was seen in the ED and admitted to an inpatient detox unit. Interview revealed he did not complete a patient transfer form. Interview revealed he did not contact Hospital B to confirm bed availability and physician acceptance. Interview revealed he did not call and give report to Hospital B's ED physician. Interview revealed copies of the patient's medical record were not given to the patient. Interview revealed the patient received only his discharge instructions. Interview revealed the patient "did not have an EMC." Interview revealed the patient was "stable" upon discharge. Interview revealed the patient was accompanied by a family member. Interview revealed the patient's discharge instructions directed him to go straight to Hospital A because it was the patient's preference and he (PA #1) wanted to reiterate the need to go on to a detox facility because the facility would not hold a bed for him. Interview revealed Physician A co-signed the patient's chart. Interview revealed Physician A did not evaluate the patient. Interview revealed he did not consult or discuss the patient's care with Physician A while the patient was in the ED. Interview revealed as a PA he can perform a MSE, treat, and discharge patients without an attending physician being consulted or laying hands on the patient. Interview revealed there is an attending physician on-duty at all times in the ED for consultation and supervision.

Telephone interview on 01/15/2016 at 1120 with Physician B, revealed he was Hospital A's DED Medical Director. Interview revealed he was familiar with the 12/28/2015 ED record for Patient #10. Interview revealed he had discussions with PA #1 about the case. Interview revealed Hospital A did not provide alcohol detoxification services. Interview revealed PA #1, "does not work here that often." Interview revealed PA #1 "tried to go the extra step" for the patient. Interview revealed the patient's discharge instructions were "worded to go directly there, to encourage the patient to seek immediate care for alcohol abuse."


Interview on 01/14/2016 at 1340 with RN #1 revealed she worked in the Transitional Care Unit (TCU). Interview revealed she was floated to the ED on 12/28/2015 because the TCU was closed due to low census. Interview revealed she recalled Patient #10. Interview revealed the patient was alert, cooperative, and pleasant. Interview revealed the patient was "happy acting, joking around, talking loud and fast." Interview revealed she was the patient's primary care nurse who discharged the patient from the ED. Interview revealed she was "told everything was good to go" and the patient was ready for discharge. Interview revealed "(MH #1) was standing in the area with papers in hand." Interview revealed she recalled "someone said there were beds available at (Hospital B)." Interview revealed she printed the patient's discharge instructions. Interview revealed she reviewed the discharge instructions with the patient and gave copies to him. Interview revealed the discharge instructions instructed the patient to "Go Straight to (Hospital B) for detox." Interview revealed she asked him if he understood them and he verbalized an understanding and signed the signature page. Interview revealed another gentleman, his father-in-law, was with him. Interview revealed the patient left the ED ambulatory with the gentleman. Interview revealed she did not reassess the patient's vital signs upon discharge. Interview revealed "they should have been reassessed." Interview revealed the patient was "discharged" and "not a transfer." Interview revealed she did not call report to Hospital B's staff and did not give the patient a copy of his complete medical record or a patient transfer form.

Telephone interview on 01/14/2016 at 1415 with MH #1 (Mental Health Staff) revealed he recalled Patient #10. Interview revealed he was working on 12/28/2015 when he received a call from the PA requesting a list of detox referrals. Interview revealed the PA stated he did not want an assessment on the patient. Interview revealed he had called around to facilities earlier in the day and was aware of the available detox beds in the area. Interview revealed he went down to the ED and gave the list of referrals to Patient #10. Interview revealed he told the patient where some detox beds were open and available. Interview revealed "I gave him the names of (Facility #1), (Hospital B), and (Hospital D)." Interview revealed the patient stated his preference was "(Hospital B)." Interview revealed "the patient was to be discharged." Interview revealed he did not document the information given to the patient in the medical record. Interview revealed there was "no official order."

Interview on 01/15/2016 at 1105 with Director #1 during medical record review for Patient #10 revealed "I do not disagree with the findings of the medical record review." Interview revealed "it looks like a transfer, not a discharge."

The facility failed to ensure that their Transfer Policies and Procedures were followed for Patient #10 on 12/28/2015 as evidenced by failing to: a.) ensure a written certification for transfer was completed; b.) ensure that the transferring physician make arrangements before a transfer occurs with a physician at the receiving hospital to provide care appropriate care for the patient; c.) contact the receiving hospital to determine if the hospital had available space and qualified personnel to treat the patient; d.) contact an appropriate emergency transport service; and d.) Copies of the medical records will be sent with the patient to the receiving hospital.














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3. Hospital A, closed DED record review on 01/14/2016 for Patient #27 revealed a 53 year old male presented to the DED via Emergency Medical Services (EMS) ambulance on 11/24/2015 at 1244 with police escort after being found intoxicated. Review of DED triage documentation at 1244 revealed "...EMS reports pt is violent and assaulted EMS crew." Review of physician's documentation by Physician F dated 11/25/2015 at 1135 revealed "EMS reports patient stated SI (suicide ideations). Patient is non-cooperative for the most part - on my arrival patient is calm - telling me he is suicidal with a plan to shoot himself. States 'If I had a gun I'd be dead'. Record review revealed on 11/24/2015 at 1416 the patient's blood alcohol level was 0.34 (normal less than 10). Review revealed a diagnosis of "unspecified depressive d/o (disorder)." Review of telepsychiatry assessment dated 11/25/2015 at 1305 revealed "patient is unreliable to contract for safety of self and others due to impaired insight and judgement ....pt is currently under involuntary commitment." Review of service note from LCSW (licensed clinical social worker) dated 11/25/2015 at 1500 revealed receiving facility (Hospital B) accepted by physician at 1430 on 11/25/2015.

Review of a "Patient Transfer Form" (physician's certification) dated 11/24/2015, revealed "Physician Request For Patient Transfer" with a diagnosis of unspecified depressive disorder. Review revealed the "Transferring M.D." was Physician D. Review revealed the "Receiving Facility" was Hospital B. Review revealed the "Time Contacted" was 1100 (11/25/2015). Review revealed the "Time Accepted Transfer" was 1100 (11/25/2015). Review revealed the "Receiving M.D." was Physician G. Review revealed the "Time Transfer Accepted by Receiving M.D." was 1100 (11/25/2015). Review revealed on the eleventh (11th) line below the "Receiving M.D." line, after the risk and benefits portion, revealed "Signed (Transferring M.D.)" with the signature of Physician F on a line. Review revealed no date or time next to Physician F's signature. Review revealed the signature of Physician F did not match the handwriting on the "Transferring M.D.", "Receiving Facility", "Time Contacted", "Time Accepted Transfer", "Receiving M.D." and "Time Transfer Accepted by Receiving M.D." lines. Review revealed the handwriting on the lines appeared to match Physician D's handwriting. Record review revealed Patient #27 was transferred from the DED on 11/25/2015 at 1805 (7 hours and 5 minutes after Physician D contacted Physician G on 11/25/2015 at 1100). Review revealed the date and time of the physician's certification did not closely match the date and time of the transfer. Further record review revealed the patient was last re-evaluated at bedside by a DED Physician's Assistant (PA #3) at 1135 (6 hours and 30 minutes prior to the patient's transfer from the DED) and was evaluated via Telepsychiatry by a Psychiatric PA (PA #4) at 1305 (5 hours prior to the patient's transfer from the DED). Record review failed to reveal any available documentation of re-evaluation of the patient's condition by the on-duty physician (Physician F) prior to transfer.

Telephone interview on 01/15/2016 at 1050 with Physician F revealed she was on-duty when Patient #27 was transferred from the DED on 11/15/2015. Interview revealed psychiatric transfers take longer to find placement. Interview revealed the certification papers are usually signed when the patient is transferred. Interview revealed she had no communication with Mental Health staff. Interview revealed she had no communication with Hospital B's physicians or staff. Interview revealed she is unable to remember the time she signed the patient transfer form or patient specifics. Interview revealed she does not date or time when she signs the physician's certification (Patient Transfer Form).

Interview on 01/15/2016 at 1105 with Director #1 during medical record review revealed Patient #27's patient transfer form identified Physician D as the transferring physician. Interview revealed 1100 was documented as the time transfer accepted by receiving M.D. and time accepted transfer on the patient transfer form. Interview revealed the transfer form was signed by Physician F. Interview revealed there was not a blank line for the physician to write the date and time next to the transferring physician's signature line. Interview revealed the hand written signature of Physician F did not match the handwriting of Physician D's name and the documented times. Interview revealed the patient was transferred out of the ED on 11/26/2015 at 1800 (7 hours later). Interview revealed Physician D was not on-duty when the patient was transferred out of the ED. Interview revealed Physician F was on-duty. Interview revealed no documentation of re-evaluation by Physician F prior to the patient's transfer. Interview revealed there was no way to determine when Physician F signed the patient transfer form to ensure the date and time of the physician's certification closely matched the date and time of Patient #27's transfer. Further Interview revealed "I do not disagree with the findings of the medical record review."

NC00113355