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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in §489.24, related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS:

1. The facility failed to meet the following requirements under the EMTALA regulation:

Tag A2405 - Emergency Room Log - Based on interview and document review, the facility failed to maintain a complete obstetrical emergency log which tracked the care provided to patients who came to the OB department. Specifically, OB staff did not document the names and disposition of patients seeking assistance.

Tag A2406 - Medical Screening Exam - The facility failed to provide an appropriate Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Active Labor Act (EMTALA) regulation. Specifically, the hospital allowed a patient's spouse to transport the patient, who required continued evaluation for an unstabilized emergency medical condition (EMC), with the expectation the patient would be transported via private vehicle without medical oversight, to the hospital's main emergency department. This failure potentially contributed to a negative patient outcome due to a delay in emergent care.

Tag A2407 - Stabilizing Treatment - The facility failed to appropriately stabilize and resolve a patient's Emergency Medical Condition (EMC) within its capacity before the patient (Patient #8) was transferred via private vehicle from the offsite provider based dedicated emergency department (ED) to the hospital's main emergency department. Specifically, the hospital allowed a patient's spouse to transport the patient who required further psychiatric evaluation for an unstablized EMC to the hospital's main ED. This failure potentially contributed to a negative patient outcome due to a delay in emergent care.

Tag A2409 - Appropriate Transfer - The facility failed to provide an appropriate transfer through qualified personnel and transportation. Specifically, the hospital allowed a patient's spouse to transport the patient, who required psychiatric evaluation and treatment for an unstabilized emergency medical condition (EMC), with the expectation the patient would be transported via private vehicle without medical oversight from the off campus provider based emergency department (ED) to the hospital's main ED. This failure potentially contributed to a negative patient outcome due to inappropriate transfer of a patient with an unstabilized EMC.

Based on interview and document review, the facility failed to maintain a complete obstetrical (OB) emergency log which tracked the care provided to patients who came to the OB department. Specifically, OB staff did not document the names and disposition of patients seeking assistance.

FINDINGS:

POLICY

According to the policy, WIS: Medical Screening Examination in the Obstetrical Department and Process for RN Validation as Qualified Medical Personnel, an obstetrical patient log will be maintained reflecting all patients that seek emergency medical services including evaluation of labor status and disposition including admit, transfer and or transport, patient refusal of treatment or patient discharge.

According to the policy, EMTALA: Medical Screening Examination and Stabilizing Treatment, the Central Log are the hospital logs reflecting all patients who are on campus seeking Emergency Medical Services, including those maintained by the Emergency Department, the obstetrical department and the psychiatric intake office. Hospital logs are part of and incorporated into the Central log. An obstetrical patient log will be maintained reflecting all patients that seek emergency medical services including evaluation of labor status and disposition including admit, transfer and or transport, patient refusal of treatment or patient discharge.

1. The facility failed to maintain a complete obstetrical emergency log of patients who presented to the OB unit, including disposition, admit, transfer, patient refusal of treatment or patient discharge.

a) Review of the OB logs dated 05/01/16 through 10/25/16 revealed the following:

-On 05/25/16 at 6:24 a.m., Patient I presented to the OB department with a chief complaint of Spontaneous Rupture of Membranes (SROM). There was no evidence on the log indicating the if the patient was discharged, admitted, or transferred.

-On 08/30/16, OB staff documented the word "twins" in the area of the log where a patient's name was required. The arrival time documented was 2:39 p.m. There was no evidence identifying the individual or individuals who presented to the OB department. Furthermore, staff did not document the reason the individual was seeking emergent care.

-On 09/13/16 at 2:02 p.m., Patient G presented to the OB department with vaginal pressure. There was no evidence showing if the patient was discharged, transferred, or admitted.

-On 09/15/16 at 10:20 a.m., Patient F presented with a chief complaint of spotting. There was no documented disposition.

-On 10/02/16 at 5:30 p.m., Patient D presented with a chief complaint of methamphetamine use. There was no documented disposition of the patient.

-On 10/08/16 at 2:00 p.m., Patient B presented to the OB unit with a chief complaint of nausea, vomiting and headache. There was no documented disposition.

b) On 10/27/16 at 2:18 p.m., an interview was conducted with OB Registered Nurse #6 (RN) who was a charge nurse and worked in the department for approximately 4 years. S/he stated s/he worked in triage as well. RN #6 stated the triage nurse was responsible for maintaining the OB logs. S/he stated the purpose of the log was to keep track of how many patients were seen in triage, ensure the care that was provided matched the complaint and and were also used to keep track of patient care if the patient was seen previously. RN #6 stated the log was a reference tool and it should always be filled out.

After review of the incomplete logs, RN #6 stated if the patient was not identified on the log, you would not know who presented, staff would have to try to identify the patient by discharge dates. RN #6 stated training was provided on the use of the log, then stated s/he was unaware if the facility had a policy about the log.

c) On 10/28/16 at 9:01 a.m., an interview was conducted with the Director of OB (Director #8) who stated s/he did not know if the OB logs had been monitored. Director #8 stated s/he expected all areas on the log to be completed in the entirety. Director #8 stated the log was used to meet the EMTALA requirements and keep track of individuals who presented to the unit and their disposition. Director #8 stated the logs allowed the facility to go back and evaluate care based on the information collected on the logs. S/he stated an action plan needed to be developed to ensure the logs were monitored moving forward.

Based on interviews and document review, the facility failed to provide an appropriate Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Active Labor Act (EMTALA) regulation. Specifically, the hospital allowed a patient's spouse to transport the patient, who required continued evaluation for an unstabilized emergency medical condition (EMC), with the expectation the patient would be transported via private vehicle without medical oversight, to the hospital's main emergency department.

This failure potentially contributed to a negative patient outcome due to a delay in emergent care.

FINDINGS:

POLICY

According to the policy, EMTALA: Medical Screening Examination and Stabilizing Treatment, an Emergency Medical Condition or EMC: is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain and/or a Psychiatric Emergency) such that the absence of immediate medical attention could reasonable be expected to result in: placing the individual in serious jeopardy. A psychiatric Emergency are those situations where a patient is a danger to himself or others by reason of aggressive conduct to inability to perceive or appreciate danger. Stabilizing treatment is the treatment necessary to stabilize an EMC.

According to the policy, Safety Precautions: Suicide, Danger to Self, Non-Behavioral Settings for Adults, Children, and Adolescents, a Columbia Suicide Severity Rating Scale is the screening tool approved by the Behavioral Health for use in the non-behavioral setting. Patients should be screened upon the initial presentation to the setting using the Columbia Screening Tool.

1. The facility failed to adequately provide an appropriate MSE for a patient who presented to the facility's offsite dedicated Emergency Department (ED) for a psychiatric emergency.

a) On 10/27/16 at 12:09 p.m., an interview was conducted with the Senior Manager (Manager #4) for the Assessment and Referral Team (ART) and Employee #3 who worked in the ART department. Both were Licensed Professional Counselors (LPC). Employee #3 stated his/her role and responsibility was to provide psychiatric crisis assessments in the ED and consult when patients were suicidal, homicidal, and psychotic.

Employee #3 stated a psychotic patient could potentially have a diagnosis of schizophrenia, schizoaffective, and bipolar with psychotic features. Employee #3 stated if a patient had auditory and visual hallucinations, they may not have a sense of reality. The role of the ART department was to determine if the patient met criteria for inpatient psychiatric admission and to ensure the patient was safe.

Employee #3 stated staff would initially assess the patient by observation and watch their behavior. S/he stated staff would ask questions such as: are you hearing voices right now, are you seeing things other people are not seeing. Manager #4 stated usually if a patient was psychotic, they could not tolerate a 45 minute interview, you had to observe the patient's actions. Employee #3 stated generally, the patients were unable to provide the needed information, so the LPC had to gather the information from friends and family.

Both Manager #4 and Employee #3 stated psychotic behavior was considered an emergency. According to the employees, the psychotic patient could be alert, oriented, cooperative and calm. The patient could be psychotic even if the patient denied suicidal ideation (SI) and homicidal ideation (HI). Manager #4 stated psychosis often times included paranoia. The person could be too paranoid to tell someone what was going on with them and if they heard voices, the voices may be telling the person not to share what was happening with others.

Manager #4 stated if the behavior was new, it was important to figure out the cause of the behavior. S/he stated psychotic patients were unsafe and could not make decisions for themselves. Manager #4 stated visual hallucinations, could be caused by a serious medical reaction or medication reaction. S/he stated auditory hallucinations were common and could include command instructions which could tell the person to harm themselves or someone else, they were self deprecatory and that's what made psychosis dangerous.

Manager #4 stated if a patient's reason for psychosis was not medical, the emergency would not be over technically until the patient was transferred to an acute facility for psychiatric care.

Manager #4 stated the ART staff did not consult at the hospital's offsite ED. S/he stated the rooms at the offsite ED were not safe for psychiatric patients and this was the reason the patients were brought over to the main ED. The physician at the main ED would order the ART consult to evaluate the patient in need.

b) Medical record review revealed Patient #8 presented to the facility's offsite dedicated ED on 08/29/16 at 5:21 a.m., with a chief complaint of psychotic episodes and paranoid and delusional thoughts.

At 5:29 a.m., Physician #1 initiated provider care. According to the physician's note, Patient #8 presented with a psychotic event. The patient's spouse stated, at approximately 1:00 a.m., the patient was observed kneeling on the edge of the bed reacting to things that the spouse could not see and the patient was screaming "they are going to get me". The spouse stated the patient began to swing from the ceiling fan and ripped down the shower rod and ran from the house. The spouse stated, s/he was able to catch the patient and convinced the patient to be evaluated in the ED.

Physician #1 documented the patient denied drug use, denied SI or HI and the patient stated s/he was acting out. However, the Physician also documented the patient did not appear to be sincere about this. Physician #1 further documented, the spouse stated the patient was staring into space when s/he tried to talk with the patient and the patient never had behavior like this in the past. Physician #1 noted the course and duration of the patient's symptoms were episodic, the character of the patient's symptoms was psychosis and the degree of onset was severe.

Physician #1's review of systems indicated the psychiatric symptoms were psychosis and the degree of psychosis at present was none, the risk factors consisted of none, therapy today was none, and associated symptoms were none.

Physician #1's reexamination and reevaluation of the patient revealed the patient was slightly antsy, but continued to be cooperative.

According to the physician's documented medical decision making, Patient #8's differential diagnosis was acute psychosis. The patient was calm and cooperative at the time, denied SI or HI, and the patient stated s/he recalled feeling out of control, but the patient was hesitant to elaborate further. The physician documented s/he discussed the medical clearance and transfer to the Main ED for a psychiatric evaluation with the patient and his/her spouse.

On 08/29/16 at 6:30 a.m., Physician #1 entered a discharge order to be started. The order documented was discharge to home now with instructions.

In contrast, Registered Nurse (RN) #2 documented on the ED EMTALA transfer form, on 08/29/16 at 6:26 a.m., the patient was to transfer to the Main ED with family by private vehicle for further psychiatric evaluation by ART. This conflicted with the original discharge to home ordered entered by the physician.

At 6:45 a.m., ED Discharge Instructions were provided and signed by the patient. The discharge instructions indicated the patient was to go immediately to the Main ED for further evaluation. The documented check out time was 6:47 a.m.

Patient #8 and his/her spouse did not go to the hospital's Main ED as instructed for a psychiatric evaluation of his/her emergency medical condition.

According to the county coroner request for records provided with Patient #8's medical record; the patient expired at 11:05 a.m., 4 hours and 17 minutes after the patient left the facility's offsite ED.

c) Patient #8 was the only patient out of 7 reviewed who did not receive an ART evaluation for his/her psychiatric emergency. Patient #8 did not arrive at the Main ED as instructed by the offsite location staff. According to the Quality Meeting Minutes, dated 09/16/16, the facility indicated the patient's death was a suicide.

Review of an additional 7 medical records for patients (Patients #6, #8, #9, #12, #16, #18, and #20) who presented to the offsite ED between 07/01/16 through 10/22/16 with psychiatric symptoms, showed 6 of 7 patients (all patients other than Patient #8) were transferred by ambulance to the Main ED and received a psychiatric evaluation by the ART department.

d) On 10/27/16 at 2:55 p.m., an interview was conducted with the Chief Medical Officer (Physician #5). Physician #5 stated s/he reviewed Patient #8's medical record with the ED Medical Director after the facility found out the patient expired. Physician #5 stated although s/he did not believe psychosis represented an emergency, the patient did need to see a mental health professional. Physician #5 stated the ART department was relied on for their skill set and expertise in evaluating psychotic patients.

e) On 10/27/16 at 4:11 p.m., an interview was conducted with Physician #1 who was responsible for the care of Patient #8. S/he stated the patient did not report any delusions or any psychotic features. Physician #1 stated the delusions were reported by the patient's spouse. However, Physician #1 then stated s/he felt it was important to get the patient evaluated sooner rather than later. Physician #1 stated Patient #8's spouse did not want the patient to be transported via ambulance.

There was no evidence in Patient #8's medical record showing the physician offered ambulance transport to the Main ED. Further, there was no documentation of the spouse's refusal.

According to the policy, psychiatric emergencies were those situations where a patient was a danger to himself or others by reason of aggressive conduct to inability to perceive or appreciate danger.

There was no evidence Patient #8 was evaluated in a similar manner as stated by the ART department, Manager #4 and Employee #3, who were interviewed on 10/27/16 at 12:09 p.m.

Based on interviews and document review, the facility failed to appropriately stabilize and resolve a patient's Emergency Medical Condition (EMC) within its capacity before the patient (Patient #8) was transferred via private vehicle from the offsite provider based dedicated emergency department (ED) to the hospital's main emergency department.

Specifically, the hospital allowed a patient's spouse to transport the patient who required further psychiatric evaluation for an unstablized EMC to the hospital's main ED.

This failure potentially contributed to a negative patient outcome due to a delay in emergent care.

FINDINGS:

POLICY

According to the policy, EMTALA: Medical Screening Examination and Stabilizing Treatment, an Emergency Medical Condition or EMC: is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain and/or a Psychiatric Emergency) such that the absence of immediate medical attention could reasonable be expected to result in: placing the individual in serious jeopardy. A psychiatric Emergency are those situations where a patient is a danger to himself or others by reason of aggressive conduct to inability to perceive or appreciate danger. Stabilizing treatment is the treatment necessary to stabilize an EMC.

According to the policy, Safety Precautions: Suicide, Danger to Self, Non-Behavioral Settings for Adults, Children, and Adolescents, a Columbia Suicide Severity Rating Scale is the screening tool approved by the Behavioral Health for use in the non-behavioral setting. Patients should be screened upon the initial presentation to the setting using the Columbia Screening Tool.

1. The facility failed to ensure Patient #8 was stable pursuant to EMTALA regulations, which included resolution of the EMC that caused the individual to seek emergency treatment at the facility's offsite dedicated ED, prior to allowing the patient's spouse to transport the patient to the main hospital's ED via private vehicle.

a) On 10/27/16 at 12:09 p.m., an interview was conducted with the Senior Manager (Manager #4) for the Assessment and Referral Team (ART) and Employee #3 who worked in the ART department. Both were Licensed Professional Counselors (LPC). Employee #3 stated his/her role and responsibility was to provide psychiatric crisis assessments in the ED and consult when patients were suicidal, homicidal, and psychotic. The role of the ART department was to ensure the patients were safe.

Manager #4 and Employee #3 stated psychotic behavior was considered an emergency. According to the employees, the psychotic patient could be alert, oriented, cooperative and calm. The patient could be psychotic even if the patient denied suicidal ideation (SI) and homicidal ideation (HI). Manager #4 stated psychosis often times included paranoia. The person could be too paranoid to tell someone what was going on with them and if they heard voices, the voices may be telling the person not to share what was happening with others.

Manager #4 stated if a patient's reason for psychosis was not medical, the emergency would not be over technically until the patient was transferred to an acute facility for psychiatric care.

Manager #4 stated the ART staff did not consult at the hospital's offsite ED.

b) Medical record review revealed Patient #8 presented to the facility's offsite dedicated ED on 08/29/16 at 5:21 a.m., with a chief complaint of psychotic episodes and paranoid and delusional thoughts.

At 5:29 a.m., Physician #1 initiated provider care. According to the physician's note, Patient #8 presented with a psychotic event. The patient's spouse stated, at approximately 1:00 a.m., the patient was observed kneeling on the edge of the bed reacting to things that the spouse could not see and the patient was screaming "they are going to get me". The spouse stated the patient began to swing from the ceiling fan and ripped down the shower rod and ran from the house. The spouse stated, s/he was able to catch the patient and convinced the patient to be evaluated in the ED.

Physician #1 documented the patient denied drug use, denied SI or HI and the patient stated s/he was acting out. However, the Physician also documented the patient did not appear to be sincere about this. Physician #1 further documented, the spouse stated the patient was staring into space when s/he tried to talk with the patient and the patient never had behavior like this in the past. Physician #1 noted the course and duration of the patient's symptoms were episodic,the character of the patient's symptoms was psychosis and the degree of onset was severe.

Physician #1's review of systems indicated the psychiatric symptoms were psychosis and the degree of psychosis at present was none, the risk factors consisted of none, therapy today was none, and associated symptoms were none.

Physician #1's reexamination and reevaluation of the patient revealed the patient was slightly antsy, but continued to be cooperative.

According to the physician's documented medical decision making, Patient #8's differential diagnosis was acute psychosis. The patient was calm and cooperative at the time, denied SI or HI, and the patient stated s/he recalled feeling out of control, but the patient was hesitant to elaborate further. The physician documented s/he discussed the medical clearance and transfer to the Main ED for a psychiatric evaluation with the patient and his/her spouse.

On 08/29/16 at 6:30 a.m., Physician #1 entered a discharge order to be started. The order documented was discharge to home now with instructions.

In contrast, Registered Nurse (RN) #2 documented on the ED EMTALA transfer form, on 08/29/16 at 6:26 a.m., the patient was to transfer to the Main ED with family by private vehicle for further psychiatric evaluation by ART. This conflicted with the original discharge to home ordered entered by the physician.

At 6:45 a.m., ED Discharge Instructions were provided and signed by the patient. The discharge instructions indicated the patient was to go immediately to the Main ED for further evaluation. The documented check out time was 6:47 a.m.

Patient #8 and his/her spouse did not go to the hospital's Main ED as instructed for a psychiatric evaluation and continued treatment of his/her emergency medical condition.

According to the county coroner request for records provided with Patient #8's medical record; the patient expired at 11:05 a.m., 4 hours and 17 minutes after the patient left the facility's offsite ED.

c) Patient #8 was the only patient out of 7 reviewed who did not receive an ART evaluation for his/her psychiatric emergency. Patient #8 did not arrive at the Main ED as instructed by the offsite location staff. According to the Quality Meeting Minutes, dated 09/16/16, the facility indicated the patient's death was a suicide.

Review of an additional 7 medical records for patients (Patients #6, #8, #9, #12, #16, #18, and #20) who presented to the offsite ED between 07/01/16 through 10/22/16 with psychiatric symptoms, showed 6 of 7 patients (all patients other than Patient #8) were transferred by ambulance to the Main ED and received a psychiatric evaluation by the ART department. Five of the 7 patients were admitted or transferred to another facility for further psychiatric treatment.

The facility failed to ensure Patient #8 was treated consistently with other individuals who presented to the ED with psychiatric emergent medical conditions.

d) On 10/27/16 at 2:55 p.m., an interview was conducted with the Chief Medical Officer (Physician #5). Physician #5 stated s/he reviewed Patient #8's medical record with the ED Medical Director after the facility found out the patient expired. Physician #5 stated although s/he did not believe psychosis represented an emergency, the patient did need to see a mental health professional. Physician #5 stated the ART department was relied on for their skill set and expertise in evaluating psychotic patients.

e) On 10/27/16 at 4:11 p.m., an interview was conducted with Physician #1 who was responsible for the care of Patient #8. S/he stated the patient did not report any delusions or any psychotic features. Physician #1 stated the delusions were reported by the patient's spouse. However, Physician #1 then stated s/he felt it was important to get the patient evaluated sooner rather than later.

According to the policy, psychiatric emergencies were those situations where a patient was a danger to himself or others by reason of aggressive conduct to inability to perceive or appreciate danger. Stabilizing treatment was the treatment necessary to stabilize an EMC.

There was no evidence Patient #8 was evaluated in a similar manner as stated by the ART department, Manager #4 and Employee #3, who were interviewed on 10/27/16 at 12:09 p.m.

f) On 10/27/16 at 2:12 p.m., an interview was conducted with the Chief Operating Officer (COO #9), the Director of Clinical Performance Assessment and Improvement (Director #10), and the Regulatory Consultant (Consultant #11). Director #10 stated the facility immediately implemented guidelines after Patient #8 expired which required all patients at the offsite ED requiring further behavioral health evaluation to be transported via ambulance to the Main ED.

Based on interviews and document review, the facility failed to provide an appropriate transfer through qualified personnel and transportation. Specifically, the hospital allowed a patient's spouse to transport the patient, who required psychiatric evaluation and treatment for an unstabilized emergency medical condition (EMC), with the expectation the patient would be transported via private vehicle without medical oversight from the off campus provider based dedicated emergency department (ED) to the hospital's main ED.

This failure potentially contributed to a negative patient outcome due to inappropriate transfer of a patient with an unstabilized EMC.

FINDINGS:

POLICY

According to the policy, EMTALA: Medical Screening Examination and Stabilizing Treatment, an Emergency Medical Condition or EMC: is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain and/or a Psychiatric Emergency) such that the absence of immediate medical attention could reasonable be expected to result in: placing the individual in serious jeopardy. A psychiatric Emergency are those situations where a patient is a danger to himself or others by reason of aggressive conduct to inability to perceive or appreciate danger. Stabilizing treatment is the treatment necessary to stabilize an EMC.

According to the policy, Safety Precautions: Suicide, Danger to Self, Non-Behavioral Settings for Adults, Children, and Adolescents, a Columbia Suicide Severity Rating Scale is the screening tool approved by the Behavioral Health for use in the non-behavioral setting. Patients should be screened upon the initial presentation to the setting using the Columbia Screening Tool.

1. The facility failed to ensure a patient's transfer (Patient #8) from their offsite dedicated ED to their main hospital's ED was initiated through qualified personnel and transportation in order to ensure the patient safely arrived and received the necessary psychiatric evaluation to stabilize his/her EMC.

a) On 10/27/16 at 12:09 p.m., an interview was conducted with the Senior Manager (Manager #4) for the Assessment and Referral Team (ART) and Employee #3 who worked in the ART department. Both were Licensed Professional Counselors (LPC). Employee #3 stated his/her role and responsibility was to provide psychiatric crisis assessments in the ED and consult when patients were suicidal, homicidal, and psychotic.

Employee #3 stated a psychotic patient could potentially have a diagnosis of schizophrenia, schizoaffective, and bipolar with psychotic features. Employee #3 stated if a patient had auditory and visual hallucinations, they may not have a sense of reality. The role of the ART department was to determine if the patient met criteria for inpatient psychiatric admission and to ensure the patient was safe.

Employee #3 stated staff would initially assess the patient by observation and watch their behavior. S/he stated staff would ask questions such as: are you hearing voices right now, are you seeing things other people are not seeing. Manager #4 stated usually if a patient was psychotic, they could not tolerate a 45 minute interview, you had to observe the patient's actions. Employee #3 stated generally, the patients were unable to provide the needed information, so the LPC had to gather the information from friends and family.

Both Manager #4 and Employee #3 stated psychotic behavior was considered an emergency. According to the employees, the psychotic patient could be alert, oriented, cooperative and calm. The patient could be psychotic even if the patient denied suicidal ideation (SI) and homicidal ideation (HI). Manager #4 stated psychosis often times included paranoia. The person could be too paranoid to tell someone what was going on with them and if they heard voices, the voices may be telling the person not to share what was happening with others.

Manager #4 stated if the behavior was new, it was important to figure out the cause of the behavior. S/he stated psychotic patients were unsafe and could not make decisions for themselves. Manager #4 stated visual hallucinations, could be caused by a serious medical reaction or medication reaction. S/he stated auditory hallucinations were common and could include command instructions which could tell the person to harm themselves or someone else, they were self deprecatory and that's what made psychosis dangerous.

Manager #4 stated if a patient's reason for psychosis was not medical, the emergency would not be over technically until the patient was transferred to an acute facility for psychiatric care.

Manager #4 stated the ART staff did not consult at the hospital's offsite ED. S/he stated the rooms at the offsite ED were not safe for psychiatric patients and this was the reason the patients were brought over to the main ED. The physician at the main ED would order the ART consult to evaluate the patient in need.

b) Medical record review revealed Patient #8 presented to the facility's offsite dedicated ED on 08/29/16 at 5:21 a.m., with a chief complaint of psychotic episodes and paranoid and delusional thoughts.

At 5:29 a.m., Physician #1 initiated provider care. According to the physician's note, Patient #8 presented with a psychotic event. The patient's spouse stated, at approximately 1:00 a.m., the patient was observed kneeling on the edge of the bed reacting to things that the spouse could not see and the patient was screaming "they are going to get me". The spouse stated the patient began to swing from the ceiling fan and ripped down the shower rod and ran from the house. The spouse stated, s/he was able to catch the patient and convinced the patient to be evaluated in the ED.

Physician #1 documented the patient denied drug use, denied SI or HI and the patient stated s/he was acting out. However, the Physician also documented the patient did not appear to be sincere about this. Physician #1 further documented, the spouse stated the patient was staring into space when s/he tried to talk with the patient and the patient never had behavior like this in the past. Physician #1 noted the course and duration of the patient's symptoms were episodic,the character of the patient's symptoms was psychosis and the degree of onset was severe.

Physician #1's review of systems indicated the psychiatric symptoms were psychosis and the degree of psychosis at present was none, the risk factors consisted of none, therapy today was none, and associated symptoms were none.

Physician #1's reexamination and reevaluation of the patient revealed the patient was slightly antsy, but continued to be cooperative.

According to the physician's documented medical decision making, Patient #8's differential diagnosis was acute psychosis. The patient was calm and cooperative at the time, denied SI or HI, and the patient stated s/he recalled feeling out of control, but the patient was hesitant to elaborate further. The physician documented s/he discussed the medical clearance and transfer to the Main ED for a psychiatric evaluation with the patient and his/her spouse

On 08/29/16 at 6:30 a.m., Physician #1 entered a discharge order to be started. The order documented was discharge to home now with instructions.

In contrast, Registered Nurse (RN) #2 documented on the ED EMTALA transfer form, on 08/29/16 at 6:26 a.m., the patient was to transfer to the Main ED with family by private vehicle for further psychiatric evaluation by ART. This conflicted with the original discharge to home ordered entered by the physician.

At 6:45 a.m., ED Discharge Instructions were provided and signed by the patient. The discharge instructions indicated the patient was to go immediately to the Main ED for further evaluation. The documented check out time was 6:47 a.m.

Patient #8 and his/her spouse did not go to the hospital's Main ED as instructed for a psychiatric evaluation and continued treatment of his/her unstabilized emergency medical condition.

According to the county coroner request for records provided with Patient #8's medical record; the patient expired at 11:05 a.m., 4 hours and 17 minutes after the patient left the facility's offsite ED.

c) Patient #8 was the only patient out of 7 reviewed who did not receive an ART evaluation for his/her psychiatric emergency. Patient #8 did not arrive at the Main ED as instructed by the offsite location staff. According to the Quality Meeting Minutes, dated 09/16/16, the facility indicated the patient's death was a suicide.

Review of an additional 7 medical records for patients (Patients #6, #8, #9, #12, #16, #18, and #20) who presented to the offsite ED between 07/01/16 through 10/22/16 with psychiatric symptoms, showed 6 of 7 patients (all patients other than Patient #8) were transferred by ambulance to the Main ED and received a psychiatric evaluation by the ART department.

d) On 10/27/16 at 2:55 p.m., an interview was conducted with the Chief Medical Officer (Physician #5). Physician #5 stated s/he reviewed Patient #8's medical record with the ED Medical Director after the facility found out the patient expired. Physician #5 stated although s/he did not believe psychosis represented an emergency, the patient did need to see a mental health professional. Physician #5 stated the ART department was relied on for their skill set and expertise in evaluating psychotic patients.

e) On 10/27/16 at 4:11 p.m., an interview was conducted with Physician #1 who was responsible for the care of Patient #8. S/he stated the patient did not report any delusions or any psychotic features. Physician #1 stated the delusions were reported by the patient's spouse. However, Physician #1 then stated s/he felt it was important to get the patient evaluated sooner rather than later. Physician #1 stated Patient #8's spouse did not want the patient to be transported via ambulance.

There was no evidence in Patient #8's medical record showing the physician offered ambulance transport to the Main ED. Further, there was no documentation of the spouse's refusal.

f) On 10/27/16 at 2:12 p.m., an interview was conducted with the Chief Operating Officer (COO #9), the Director of Clinical Performance Assessment and Improvement (Director #10), and the Regulatory Consultant (Consultant #11). Director #10 stated the facility immediately implemented guidelines after Patient #8 expired which required all patients at the offsite ED requiring further behavioral health evaluation to be transported via ambulance to the Main ED.