HospitalInspections.org

Based on medical record review, medical staff By-laws, State Health Related Boards rules, Daily census report review, policies and procedures and interview, the hospital (Hospital #1) failed to ensure all patients presenting to the hospital's psychiatric Intake Assessment Department (IAD) or Emergency Department (ED) seeking treatment received an appropriate Medical Screening Examination (MSE), and patients with an emergency psychiatric medical condition received stabilizing treatment for 16 of 24 (Patients #1, 3, 4, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 18, 20, and 24) sampled patients; failed to provide treatment, care and services within the capability and capacity of the hospital for 12 of 13 (Patients #1, 3, 4, 7, 12, 13,14, 15, 16, 17, 18, and 20) sampled patients they had the capacity and capability to treat, and the facility failed to ensure the EMTALA Memorandum of Transfer forms were fully completed for 11 of 13 (Patients #3, 7, 10, 12, 13, 14, 15, 16, 17, 18, and 20) sampled patients who required transfer to another facility.

Refer to the findings in deficiencies A2406, A2407, and A2409.

Based on medical record reviews, medical staff bylaws, State Health Related Board rules, daily census report review, Senate Bill number 317, policy and procedure review and interviews, the hospital failed to ensure all patients presenting to the hospital's Psychiatric Intake Assessment Department (IAD) or Emergency Department (ED) seeking medical assistance were provided an appropriate medical screening examination within the hospital's capabilities to include ancillary services such as on call Psychiatrists, and Qualified Medical Personnel (QMPs) to determine whether or not an emergency psychiatric condition existed for 16 of 24 (Patients #1, 3, 4, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 18, 20, and 24) sampled patients. Additionally, the facility failed to ensure that psychiatric screening examinations were conducted by individuals who were determined qualified by the facility's medical staff's By-Laws General Rules and Regulations.

The findings included:

1. Review of Delta Medical Center's (Hospital #1 - an acute care hospital with a psychiatric unit) EMTALA (Emergency Treatment and Labor Act) policy revealed, "...Any individual who presents on the property of [Name of Hospital #1] and is in need of assistance for medical conditions will be provided an appropriate medical screening examination [MSE] within the capabilities of the Emergency Department to determine whether an emergency medical condition exists...
After the medical screening, if the Emergency Department Physician determines the individual has an emergency medical condition...the individual will be provided further examination and treatment necessary to stabilize the condition..."

2. Review of Hospital #1's Medical Screening Examination (MSE) policy approved 9/19/19 revealed, "Purpose: To provide a Medical Screening Examination (MSE) for patients that present to the Admissions Department at [name of hospital]...Policy Statement: In order to identify an emergency medical or psychiatric condition, patients present to the Admissions department seeking care will receive a medical screening exam by a Registered Nurse [RN], physician or Qualified Medical Professional...Procedure...Patient present to [name of hospital] admission department and checks-in...Admissions assessor will notify RN that an assessment is needed...RN obtains copy of blank MSE form and completes any demographic data...RN introduces self to patient and explains that he/she will be asking some health questions and performing a quick exam...RN performs MSE and documents on the MSE form...If no emergency medical condition or medical issue requiring outside assessment is found, the completed form is given to admission assessor for assessment completion...After the assessment is complete, the psychiatrist will be consulted regarding the patient's disposition...If the medical screening identifies a condition that requires further evaluation, the physician is notified by the nurse, using the SBAR (situation, background, assessment and recommendations)...The physician will determine the disposition of the patient...If the physician decides to transfer to an ED, the RN will...Call ambulance to transport patient to designated ED...Notify patient and complete transfer paperwork...Remain with patient until ambulance transport arrives...If patient has a [an] emergency medical condition, the physician will be notified and staff will call 911 for emergency transport to an Emergency Dept.[department] The RN must remain with the patient.
Non-admitted patients...Obtain a medical screening...Complete Assessment...The assessor/nurse reviews with the doctor to obtain recommendation...The patient is given the referrals and signs a form saying they have received referrals..."

3. Review of Hospital #1's policy title, Policy for continuum of Care: Revised July 2019, revealed, "Purpose: To establish guidelines for admissions to a Behavioral Health unit to assure that patients are appropriately admitted in a legal and comfortable manner...Policy Statement: Admissions to a Behavioral Health unit is indicated for adults suffering from an acute psychiatric condition(s) or from an acute exacerbation of a chronic condition. Such patients will also require intensive psychiatric intervention with different levels of medical treatment. The RN is responsible for overseeing the admission of all patients, including the supervision of delegated duties. According to Tennessee regulations, only a Registered Nurse can perform an initial nursing admission assessment...Procedure: All patients will receive a medical screening by a QMP [Quality Medical Professional] as designated by the bylaws and an intake assessment. These findings will be reviewed with a licensed provider to determine an appropriate level of treatment..."

4. Review of Hospital #1's policy titled "Care of the Suicidal Patient" revised July 2019 revealed, "Purpose: To establish guidelines for the treatment team to accurately and consistently assess the suicidal patient and to establish appropriate actions toward preventing the patient from self-harm behaviors...Policy Statement: Any patient who verbalizes ideations involving thoughts of self-harm or suicide will be placed on either Suicide Precautions (15 minute assessment and documentation) or 1:1 observation (staff member constantly with the patient not more than an arm's length away and documents at 15 minute intervals) or Q [every] 5 checks depending on the intensity of the suicidal thoughts and feelings."

5. Review of Hospital #1's medical staff Bylaws rules and regulations, Section 5 revealed, "...Hospital policies regarding patient care should be followed at all times...Patients are admitted to the hospital only on the decision of a LIP [Licensed Independent Practitioner] permitted by the state...All patients presenting to the Emergency Department for care will receive a medical screening exam...the patient will be seen by either an Emergency Department physician, on-call physician, the patient's private physician, or a qualified provider (ED nurse practitioner or ED physician assistant)..."

6. Review of Hospital #1's Exhibit A to the Medical Staff Bylaws revealed, "...Allied Health Professional (AHP) The following are recognized as Allied Health Professionals; Psychologist, Nurse Practitioners and Physician Assistants...Qualified Medical Professional (QMP) The following are recognized as qualified medical professionals: Physicians; Nurse Practitioner, Physician's Assistant Social Workers, Social Services Staff and Registered Nurses.
Qualified Mental Health Professionals (QMHP)...The following are recognized as Quality Mental Health Professionals: Psychiatrists, Psychologist, Psychiatric Nurse Practitioners, Psychiatric Registered Nurses, Social Workers and Social Services staff."

7. Review of the State Health Related Board Statutes for Master's in Science (MS), Licensed Master of Social Work (LMSW) and RN revealed "the scope of practices for these disciplines do not allow them to independently practice, treat patients and prescribe medical treatment for patients. Therefore, cannot be considered a Qualified Medical Professional (QMP) or Licensed Independent Practitioner (LIP) to perform a MSE."

8. Review of the Public Chapter number 12, Senate Bill number 317 revealed, "...This section does not preclude a qualified nurse from determine whether a patient presenting to a hospital has an emergency medical condition if the determination is pursuant to...A cooperative working relationship with a physician; and ...Protocols jointly developed by the hospital's medical and nursing leadership and adopted by the hospital's medical staff and governing body..."Qualified registered nurse" means a registered nurse who has been approved by the hospital's governing body, based on the recommendation of hospital nursing leadership, as possessing the skills and competency to make a determination of the existence of a specified emergency medical condition of a patient presenting to the hospital..."

9. When requested, Hospital #1 was unable to provide a cooperative relationship agreement with a physician, protocols jointly developed by the hospital's medical and nursing leadership and adopted by the hospital's medical staff and governing body, or the approval of a qualified registered nurse based on recommendations by nursing leadership in order for the registered nurses to determine if a patient presenting to the hospital has an emergency medical condition.

10. Medical record review revealed Patient #1 was a 44 year old male with a history of major depressive symptoms including auditory hallucinations. The patient did not have insurance.

Review of Hospital #1's (an acute care/Psychiatric hospital) psychiatric IAD EMTALA log revealed Patient #1 presented via car to the hospital's psychiatric IAD on 10/8/19 at 9:24 PM with the chief complaint of "psych" and had an "Emergency Medical Psych Condition". There was no documentation who determined the patient had an emergency psychiatric condition.

Review of Patient #1's EMTALA Medical Screening Examination dated 10/8/19 from 9:24 PM through 10:22 PM revealed RN #4 performed the examination on Patient #1. RN #4 documented the patient had several family members die and the patient stated he heard and saw dead people. Patient #1 also stated he drank 2 beers and a half pint of Vodka 3 hours before presenting to the IAD. The patient's breathalyzer (test the presence of alcohol in a patient) result at 11:11 PM was 0.167 (0.08 is legal limit). Under the assessment section titled Assessment Findings, RN #4 documented the patient met criteria for Emergent Medical Condition based on risk of imminent harm to self and others due to psych conditions.

On 10/8/19 beginning at 10:28 PM, Assessor #4, who had a Masters in Social Work, performed the psychiatric assessment/examination to determine if an emergency psychiatric condition existed and documented the patient had been drinking beer and liquor over the past few days and had not taken any medication. The Assessor documented the patient reported hearing voices talking to him, and was having delusional content and flight of ideas. The Assessor documented the patient had major depressive symptoms that were stress related. The Assessor documented the patient's suicide risk was "low risk". Under the assessment section titled Level of Care Recommendation, Assessor #4 documented the patient as having an "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight". There was no documentation a LIP, physician or Psychiatrist performed an MSE to determine if an emergency medical condition (EMC) existed.

Review of the 10/9/19 Crisis Assessment performed by a mobile crisis agency's Master in Social Work employee from 6:00 AM - 6:30 AM revealed, "...Pt [Patient #1] presented to Delta Medical Center (Hospital #1) on 10/8/19 due to hearing voices and being off his medications. Pt denies SI [Suicidal Ideations] and HI [Homicidal Ideations]. Pt denies prior suicide attempt...Pt reports feelings of hopelessness and depression...Pt reports alcohol abuse. Pt is homeless and unemployed...Pt is non compliant to medication...Pt currently is not a danger to self AEB [as evidenced by] pt denies SI and HI. However pt reports auditory hallucinations with commands and non medication compliance. Pt was offered inpatient tx [treatment] with pt accepting needed services. Pt's case was discussed with CSU [Crisis Stabilization Unit] Nurse at Hospital #3 (a Psychiatric hospital). Pt will disposition to [mobile crisis agency] Crisis Stabilization Unit."

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #1 was transferred at 10:58 AM on 10/9/19 to Hospital #3 (a Psychiatric hospital), admitted, stabilized and treated for diagnoses including Unspecified Bipolar and Related Disorder, Alcohol Use Disorder.

Review of Hospital #1's daily census report revealed the hospital had beds available on this date to admit, stabilize and treat Patient #1.

In an interview on 10/16/19 at 9:30 AM in Hospital #1's conference room, the Director of Intake Admissions verified Patient #1 was transferred to a crisis stabilization unit at Hospital #3 which is contracted by the State for patients with medicaid or no insurance. The Director stated, "...if a patient is unfunded, mobile crisis will see all of these, plus Tenn- Care [state medicaid] patients..." The Director stated in order to refer to [named Hospital #3] they [the patients] have to be seen by mobile crisis..."

11. Medical record review revealed Patient #3 was a 57 year old female with history of suicide with a plan to overdose with hallucinations telling her to harm herself. The patient had insurance.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #3 presented via car to the psychiatric IAD on 8/6/19 with the chief complaint of "psych" and had an "Emergency Medical Condition". There was no documentation who determined the patient had an emergency medical condition.

Review of Patient #3's EMTALA Medical Screening Examination conducted on 8/6/19 at 8:00 PM revealed RN #5 performed the examination. RN #5 documented the patient had a rash on both arms and was having suicidal ideations with a plan to overdose on mental health medications. Under the assessment section titled Assessment Findings, RN #5 documented the patient met criteria for Emergency Medical Condition based on physical findings.

On 8/6/19 at 7:45 PM Assessor #3, who had a Masters in Social Work degree, performed the psychiatric assessment to determine if an emergency psychiatric condition existed and documented, "...the patient reported her boyfriend put her out of the house after an argument...Patient reports being depressed, sad and hopeless."
Assessor #3 documented on the Columbia-Suicide Severity Rating Scale the patient's suicide risk assessment was at high risk. There was no documentation the physician was notified of the high risk suicide assessment.
Assessor #3 documented the Level of Care Recommendation for Patient #3 were, "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight and Potential danger to self or others." There was no documentation a physician, LIP or Psychiatrist performed an assessment to determine if an EMC existed, stabilization or treatment.

Patient #3 was transferred to Hospital #2's (an acute care hospital) emergency department for treatment of the patient's rash. There was no documentation on the EMTALA Transfer form of the receiving physician's name at Hospital #2 or a signature of transferring physician at Hospital #1. There was no documentation of the names of Hospital #1's staff acting under physician's orders. There was no documentation of stabilizing treatment for the patient's psychiatric emergency condition prior to being transferred to Hospital #2 to be treated for a rash.

12. Medical record review revealed Patient #4 was a 26 year old male with a history of mood swings and depression. The patient did not have insurance.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #4 presented via walk-in on 8/11/19 at 6:16 PM with the chief complaint of "psych" and had an "Emergency Medical Psych Condition". There was no documentation who determined the patient had an emergency psychiatric condition.

On 8/11/19 beginning at 6:25 PM Assessor #6, who had a Masters in Education of Community Counseling, performed the psychiatric assessment to determine if an emergency psychiatric condition existed and documented the patient came to the IAD with suicidal ideations and a plan to jump into an intersection. Assessor #6 documented Patient #4 denied hallucinations. The Assessor documented the patient stated he felt like he was going crazy. Assessor #6 documented the patient was tearful. On the suicide risk assessment the Assessor documented Patient #4 was a high suicide risk. There was no documentation the physician, LIP or Psychiatrists was notified of the high risk suicide assessment. Assessor #6 documented Patient #4 was a "Potential danger to self or others" and a need for acute inpatient. There was no documentation a physician, LIP or Psychiatrist performed a MSE to determine if an EMC existed, or provided stabilization or treatment.

On 8/11/19 at 6:45 PM RN #3 performed a medical screening examination of Patient #4 and documented the patient stated he felt he was becoming psychotic, but denied hearing voices. Under the assessment section titled Assessment Findings, RN #3 documented Patient #4 met criteria for an Emergent Medical Condition based on risk of imminent harm to self and others due to psych conditions.

On 8/11/19 from 7:52 PM - 8:15 PM a mobile crisis agency Master in Social Work employee performed an assessment of the patient and documented, "...Pt jumped into the intersection of highway into the onset of traffic placing his life in jeopardy...pt was discussing that his life had no balance or purpose...Pt reported that he wants an evaluation to help him understand why he feels so depressed and often suicidal..." The mobile crisis employee documented the patient met criteria for inpatient level of care and was not safe for home or community environment.

The patient was referred to Hospital #3 but no beds were immediately available. The patient remained in the IAD at Hospital #1 until 8/12/19 at 1:34 AM (7 hours and 18 minutes after arrival) at which time the patient was transferred to Hospital #3. There was no documentation Patient #4 had received stabilization and treatment for the emergency psychiatric condition while in Hospital #1's IAD waiting to be transferred to Hospital #3.

Review of Hospital #1's daily census report revealed the hospital had beds available on this date to admit, treat and stabilize Patient #4.

13. Medical record review revealed Patient #7 was a 57 year old male with a history of verbal and physical aggression. The patient resided in a care home and had made threats to kill staff. The patient had Medicare insurance.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #7 presented via car to the psychiatric IAD on 8/27/19 at 2:27 PM with the chief complaint of "psych" and had an "Emergency Psychiatric Medical Condition". There was no documentation who determined the patient had an emergency psychiatric condition.

Review of Patient #7's EMTALA Medical Screening Examination revealed the examination was conducted on 8/27/19 at 3:10 PM by RN #5. RN #5 documented the patient's behavior as unpredictable and the patient was speaking in a manner that was not based in reality. Under the assessment section titled Assessment Findings, RN #5 documented the patient met criteria for Emergent Medical Condition based on the risk of imminent harm to self or others due to psychiatric condition.

On 8/27/19 beginning at 6:45 PM, Assessor #2, who had a Masters of Science in Counseling, performed the psychiatric assessment to determine if an emergency psychiatric condition existed and documented, the patient refused to answer questions directly. The Assessor documented the patient was referred to Hospital #1 for inpatient treatment by his care home due to the patient was refusing medications, being verbally and physically aggressive and threatening staff. Assessor #2 documented the patient had homicidal ideations towards care home staff, non-compliance with medications, and manic and psychotic like behaviors; also the patient was experiencing grandiose delusions and was hard to redirect. The Assessor documented the patient refused to answer questions for the suicide risk assessment; and the Assessor's recommendations for Patient #7 were, "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight...Potential danger to self or others...Failure of less-intensive treatment... Less-intensive treatment not safe or feasible".
Assessor #2 documented the patient requested to be admitted to Hospital #4 (a Psychiatric hospital) for treatment. There was no documentation a physician, LIP or Psychiatrist performed a MSE in order to determine if the patient had an EMC requiring stabilization and/or treatment prior to being transferred to Hospital #4.

Review of Hospital #1's Physician Certification Statement revealed the form was completed and signed by Assessor #2 on the physician's signature line. On the line for the physician's printed name and credentials, Assessor #2 signed their name and credentials as a MS (Master in Science). The Assessor documented the patient's diagnosis was Schizophrenia.

Review of the form titled Memorandum of Transfer (EMTALA) revealed an area for the physician's signature to verify the patient's emergency medical condition had not been stabilized prior to transfer; as this area was left blank.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #7 was transferred by ambulance to Hospital #4 at 10:45 PM on 8/27/19.

There was no documentation the patient had received an appropriate psychiatric assessment performed by a QMP or stabilization treatment at Hospital #1 prior to being transferred to Hospital #4.

Review of Hospital #1's daily census report revealed the hospital had beds available on this date to treat and stabilize Patient #7.

14. Medical record review revealed Patient #8 was a 20 year old male with a history of paranoid schizophrenia. The patient had eloped from Hospital #1 on 8/29/19 after a 5 day hospitalization. The patient had insurance.

On 8/30/19 at 2:41 PM, Hospital #1's psychiatric IAD EMTALA log revealed Patient #8 presented via car to the psychiatric IAD with the chief complaint of "psych" and did not have an Emergency Psychiatric Medical Condition. There was no documentation who determined the patient did not have an emergency medical condition.

Review of the EMTALA Medical Screening Examination for Patient #8 on 8/30/19 at 3:40 revealed RN #1 performed the examination. The patient stated his fist hurt because he was hitting on the gate and had no place to go and had no medications. Under the assessment section titled Assessment Findings RN #1 documented the patient did not meet the criteria for an Emergency Medical Condition.

Review of the Intake Assessment dated 8/29/19 but signed on 8/30/19 at 3:40 PM. the Director of Intake, who has a Masters in Education, performed the psychiatric assessment to determine if an emergency psychiatric condition existed and documented "...the patient denied SI or HI (suicidal ideations or homicidal ideations), pt does admit to psychosis, he reports seeing images..." Under the assessment section titled Level of Care Recommendations the Director of Intake documented "outpatient/community referral."
The Director of Intake documented she completed a Columbia Suicide Risk Severity Rating Scale on Patient #8 on 8/30/19 at 15:30 and Assessor #3 (who had a Master in Social Work) completed one at 7:35 PM. Patient #8 was listed as a "low risk" suicide assessment. There was no documentation the physician was notified of the patient's presenting symptoms or a LIP or Psychiatrist performed an appropriate and ongoing MSE or assessment based on the patients presenting signs and symptoms to determine if an emergency psychiatric condition existed.

Review of the Physician Certification Statement for Non-Emergent Ambulance Services form dated 8/30/19 revealed the patient was being discharged from Hospital #1 to an Emergency Shelter. Assessor #3 (Masters in Social Work) documented the the medical necessity was due to the patient, "is mentally unstable, unable to operate vehicle." Assessor #3 checked the box the patient was a danger to self and others. On the physician signature line on the form, Assessor #3 signed her name as the physician.

In an interview in the administrative conference room on 10/17/19 at 1:05 PM, the Director of Intake stated, "I was in intake...[Patient #8] was probably refusing to leave...I did his assessment...[Patient #8] had smoked marijuana and wanted a sandwich...had no clinical need to be admitted. We gave him a referral to [name of an Emergency Shelter #1]. We may have called a cab to take him...If a patient is here for several hours, we have a water fountain, snacks and juice...We don't normally document if we fed the patients...I spoke to his psychiatrist who said he [Patient #8] was just malingering."

The patient was in Hospital #1's IAD for 8 hours and 15 minutes. There was no documentation a physician, LIP or Psychiatrists had assessed/examined the patient to determine if the patient had an EMC, provided stabilization and/or treatment although the patient was listed as "medically unstable and was a danger to self and others".

Review of Hospital #1's daily census report revealed on this date the hospital had beds available to admit, treat and stabilize Patient #8.

15. Medical record review revealed Patient #9 was a 32 year old female with history of auditory and visual hallucinations. She did not have insurance.

Review of Hospital #1"s psychiatric IAD EMTALA log revealed Patient #9 presented to the psychiatric IAD on 7/9/19 at 10:45 AM with the chief complaint of "Psych" and did not have an "Emergency Psychiatric Medical Condition." There was no documentation who determined the patient did not have an emergency medical condition.

On 7/9/19 at 11:00 AM Assessor #7 who had a Master's in Clinical Counseling performed the psychiatric assessment to determine if an emergency psychiatric condition existed and documented, "...the patient presented with auditory and visual hallucinations and depression..."
Under the assessment section titled Level of Care Recommendations, Assessor #7 documented the recommendations for the patient were, "Acute Inpatient: Less-intensive treatment not safe or feasible..."
Assessor #7 also wrote the recommendation for Patient #9 was "Intensive Outpatient Program (IOP)".

Review of the EMTALA Medical Screening Examination for Patient #9 revealed on 7/9/19 at 11:50 AM RN #1 performed the examination. RN #1 documented the patient had psychosis, auditory and visual hallucinations. Under the assessment section titled Assessment Findings the RN documented "Patient meets criteria for Emergent Medical Condition based on physical findings...Yes."

Review of the Post-Assessment Referral/Refusal of Treatment form for Patient #9 documented the patient did not meet criteria for inpatient or partial hospitalization and was referred to the Intensive Outpatient Program (IOP) at Hospital #1. The Intake Log documented she was discharged at 11:45 AM and instructed to come to Hospital #1's IOP. There was evidence on the discharge instructions of when Patient #9 was supposed to be back at Hospital #9's IOP.

There was no documentation a physician, LIP or Psychiatrist performed an appropriate and ongoing MSE, stabilization or treatment prior to there patient being discharged.

Review of Hospital #1's daily census report revealed the hospital had beds available on this day to admit, treat and stabilize Patient #9.

16. Medical record review revealed Patient #10 was a 55 year old female who presented with confusion, disorganized and bizarre behavior. She had insurance.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #10 presented to the psychiatric IAD on 7/8/19 at 10:35 PM with the chief complaint of "psych" and had an "Emergency Medical Psych Condition". There was no documentation who determined the patient had an emergency psychiatric condition.

Assessor #3, who had a Masters in Social Work, completed the form titled Treatment Referral Form which revealed Patient #10 was a walk-in to the hospital's psychiatric IAD. Assessor #3 documented the patient "was confused, disorganized, bizarre behavior, schizophrenia, patient thinks house is on fire..." There were no documentation the patient's blood pressure (BP), pulse rate, respiration rate or temperature were obtained at this time.

Review of the EMTALA Medical Screening Examination for Patient #10 revealed on 7/9/19 at 11:02 PM the patient's blood pressure (BP) was elevated at 221/132 (normal being 130/80) and the patient's pulse rate was elevated at 158 (normal being 54 -91).
At 11:08 PM the patient's BP remained elevated at 182/123 and the pulse rate remained elevated at 150.
At 11:19 PM the patient's BP remained elevated and Assessor #3 called for RN #8 to report the elevated BP to the RN. There was no documentation a physician was called regarding the patient's elevated BP or any treatment provided for the patient's continued elevated BP.
At 11:26 PM the patient's BP was elevated at 202/133 and the pulse rate was elevated at 146.
At 12:00 AM, RN #8 arrived in the psychiatric IAD to assess Patient #10's elevated BP. There was no documentation a physician was called at this time and notified of the continued elevate BP and pulse. There was no evidence of any treatment provided to the patient for the continued elevated BP and pulse.
At 12:03 AM the patient's BP was elevated at 237/162 and the patient's pulse rate was elevated at 162.
At 12:12 AM the patient's BP was elevated at 237/135, with an elevated pulse rate of 162.
There was no documentation a physician was notified of the patient's continued elevated BPs and pulse rates.
At 12:32 AM, RN #8 called Hospital #5 in order to transfer Patient #10. There was no documentation of physician orders or involvement with the patient's transfer.

Review of the form titled Memorandum of Transfer (EMTALA) was incomplete. The date, time and name of the receiving physician was not listed. The area on the form was marked as not applicable. There was no documentation of a physician signature or certification by the physician that the risks and benefits of the transfer were appropriate without stabilization or treatment prior to the transfer.

There were no other assessments documented for Patient #10 or stabilization or treatment provided to the patient as the patient remained in Hospital #1's IAD from 10:35 PM to 1:10 AM before being transferred to Hospital #5.

Patient #10 was transferred by ambulance to Hospital #5 on 7/9/19 at 1:10 AM. The patient's BP remained elevated at 201/139 at the time of transfer to Hospital #5. The facility failed to ensure that an appropriate medical screening examination was provided for Patient #10 who presented to the ED with a history of Schizophrenia, confusion and abnormal vital signs. The facility failed to utilize available ancillary services (Psychiatric Services and Physicians on staff, Laboratory studies and Diagnostics tests) to fully assess, stabilize, treat, and determine whether or not an EMC existed for patient #10 on 7/8/2019.

Patient #10 remained in Hospital #1's IAD for 2 hours and 35 minutes without being examined, stabilized or treated by a physician for the emergency medical condition of uncontrolled elevated BP and pulse rates.

17. Medical record review revealed Patient #12 was a 53 year old male with a history of Major Depressive Disorder. The patient had medicaid insurance.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #12 presented via ambulance to the psychiatric IAD on 7/15/19 at 9:07 PM with the chief complaint of "psych" and had an "Emergency Psychiatric Medical Condition". There was no documentation who determined the patient had an emergency psychiatric condition.

Review of the EMTALA Medical Screening Examination for Patient #12 revealed on 7/15/19 at 9:25 PM RN #6 performed the examination. RN #6 documented the patient was hearing voices telling him to do bad things. RN #6 documented the patient had threatened staff at an outpatient mental health clinic with a knife. RN #6 documented Patient #12 also reported he had an enlarged scrotum and was having trouble urinating.
RN #6 documented the patient's blood pressure was elevated at 182/103, met criteria for an Emergent Medical Condition based on physical findings and was at risk for imminent harm to self/other due to psychiatric conditions. RN #6 documented the physician was contacted and an order for Clonidine was given to treat the patient's elevated blood pressure. There was no documentation a physician, LIP or Psychiatrist assessed the patient in order to determine if the patient had an emergency medical condition related to the immediate concern of the patient's enlarged scrotum and his inability to urinate. There was no documentation that an appropriate medical screening examination was provided for the patient.

Review of a Physician Certification Statement for Non-Emergency Ambulance services form dat

Based on policy and procedure review, Emergency Department (ED) log detail, medical record review and interview, the hospital failed to ensure further evaluation and treatment was provided as required to stabilize an emergency medical condition, within the capabilities of the hospital and its staff for 16 of 24 (Patients #1, 3, 4, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 18, 20 and 24) sampled patients who presented to the ED seeking treatment.

The findings included:

1. Review of Hospital #1's EMTALA (Emergency Treatment and Labor Act) policy revealed, "...Any individual who presents on the property of [Name of Hospital #1] and is in need of assistance for medical conditions will be provided an appropriate medical screening examination [MSE] within the capabilities of the Emergency Department to determine whether an emergency medical condition exists...After the medical screening, if the Emergency Department Physician determines the individual has an emergency medical condition...the individual will be provided further examination and treatment necessary to stabilize the condition...
For the purpose of this policy, the term "Emergency Medical Condition" is defined as: A Medical Condition manifesting itself by acute symptoms of sufficient severity (including pain) that the absence of immediate medical attention could reasonably be expected to result in 1. Placing the health of the patient...in serious jeopardy... 2. Serious impairment to bodily functions...The term "to stabilize" means, with respect to an emergency medical condition as described above, that no deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer...the term "stabilize" means to prove immediate medical attention so that no deterioration of the condition is likely..."

2. Review of Hospital #1's policy titled Care of the Suicidal Patient revised July 2019 revealed, "... Purpose: To establish guidelines for the treatment team to accurately and consistently assess the suicidal patient and to establish appropriate actions toward preventing the patient from self-harm behaviors... Policy Statement: Any patient who verbalizes ideations involving thoughts of self-harm or suicide will be placed on either Suicide Precautions (15 minute assessment and documentation) or 1:1 observation (staff member constantly with the patient not more than an arm's length away and documents at 15 minute intervals) or Q 5 [minute] checks depending on the intensity of the suicidal thoughts and feelings..."

3. Medical record review revealed Patient #1 was a 44 year old male with a history of major depressive symptoms including auditory hallucinations.

Review of the psychiatric Intake Assessment Department (IAD)'s EMTALA log revealed Patient #1 presented via car to the psychiatric IAD on 10/8/19 at 9:24 PM with the chief complaint of "psych" and had an "Emergency Medical Psych Condition."

Review of Intake Assessment beginning at 10:28 PM documented, the patient had been drinking beer and liquor over the past few days, had not taken any medication and hearing voices. The patient experienced delusions and flight of ideas. The patient was at low-risk for suicide.

Patient #1's Intake Assessment revealed the patient had an acute psychiatric condition that required 24 hour skilled nursing/medical oversight.

Review of the 10/9/19 Crisis Assessment conducted from 6:00 AM - 6:30 AM revealed, the patient presented to Hospital #1 on 10/8/19 because he was hearing voices with commands and was off his medication. He denied wanting to hurt himself or others, and denied trying to hurt himself in the past. The patient reported he was depressed and felt hopeless. The patient stated he abused alcohol, was homeless and unemployed. The patient was offered inpatient tx [treatment], and he accepted this service. The plan was to transfer the patient to the Crisis Stabilization Unit (mobile crisis agency).

Review of the psychiatric IAD EMTALA log revealed Patient #1 was transferred from Hospital #1, which is an acute/psychiatric hospital, to Hospital #3, which is a psychiatric hospital, on 10/9/19 at 10:58 AM for treatment of an emergency medical psych condition. The transfer of Patient #1 from Hospital #1 to Hospital #3 was not a transfer to a higher level of care. The patient's admission diagnoses at Hospital #3 included, "Unspecified Bipolar and related disorder, Alcohol Use Disorder, Severe and Hypertension."

There was no documentation the patient received stabilization and treatment for an emergency psychiatric condition, within the capabilities of Hospital #1 and its staff, prior to being transferred to Hospital #3.

4. Medical record review revealed Patient #3 was a 57 year old female with a history of suicide with a plan to overdose and hallucinations telling her to harm herself.

Review of the psychiatric IAD EMTALA log revealed Patient #3 presented via car to Hospital #1's psychiatric IAD on 8/6/19 with the chief complaint of "psych" and had an "Emergency Medical Condition".

Review of the 8/6/19 Intake Assessment conducted at 7:45 PM documented Patient #3 reported her boyfriend kicked her out of the house after an argument. Patient#3 was depressed, sad and hopeless. The patient had a rash on both arms. The patient was a high-risk for suicide. There was no documentation the physician was notified Patient #3 was at a high risk for suicide. Patient #3's level of care recommendation was documented as an acute psychiatric condition requires 24 hour skilled nursing/medical oversight and Potential danger to self or others.

The patient was transferred to Hospital #2's emergency department for treatment of the rash on both arms. There was no documentation the patient received stabilization and treatment for an emergency psychiatric condition, within the capabilities of Hospital #1 and its staff, prior to being transferred to Hospital #2.

Medical record review of Hospital #2's emergency department admission revealed a diagnosis of, "Dermatitis, Major Depression and Medical Clearance for Psychiatric Admission."

5. Medical record review revealed Patient #4 was a 26 year old male with a history of mood swings and Depression.

Review of the psychiatric IAD EMTALA log revealed Patient #4 presented via walk-in on 8/11/19 at 6:16 PM with the chief complaint of "psych" and had an "Emergency Medical Psych Condition."

Review of the Intake Assessment dated 8/11/19 at 6:25 PM documented Patient #4 presented to the IAD with suicidal ideation and had a plan to jump into an intersection. The patient stated he felt like he was going crazy and was tearful. The patient was a high-risk for suicide. Patient #4 was a potential danger to self or others. Patient #4 was in need of acute inpatient treatment.

On 8/11/19 from 7:52 PM - 8:15 PM a mobile crisis agency Master in Social Work (MSW) employee performed an assessment which revealed the patient wants an evaluation to help him understand why he feels so depressed and wants to hurt himself.

The mobile crisis employee documented the patient met criteria for inpatient level of care and was not safe for home or community environment. The patient was referred to Hospital #3 but no beds were immediately available. The patient remained in the IAD at Hospital #1 until 8/12/19 at 1:34 AM (7 hours and 18 minutes after arrival) at which time the patient was transferred to Hospital #3.

There was no documentation the patient received stabilization and treatment for an emergency psychiatric condition, within the capabilities of Hospital #1 and its staff, prior to being transferred to Hospital #3 for inpatient treatment of a psychiatric condition. Admission diagnoses at Hospital #3 included: "Unspecified Attention Deficit/Hyperactivity Disorder, Unspecified Depressive Disorder, Bipolar Affective Disorder, Depressed, Mild or Moderate Severity, unspecified and Housing Problem."

6. Medical record review revealed Patient #7 was a 57 year old male with a history of verbal and physical aggression. The patient resided in a care home and had made threats to kill staff.

Review of the psychiatric IAD EMTALA log revealed Patient #7 presented via car to the psychiatric IAD on 8/27/19 at 2:27 PM with the chief complaint of "psych" and had an "Emergency Psychiatric Medical Condition."

On 8/27/19 at 6:45 PM a mobile crisis agency MSW employee performed an assessment which documented the patient refused to answer questions directly. Patient #7 was referred to Hospital #1 for inpatient treatment by his care home due to refusing medications, being verbally and physically aggressive and threatening staff. The patient experienced HI (homicidal ideations) towards care home staff was non-compliant with medications, and displayed manic and psychotic- like behaviors. The patient experienced delusions of grandeur and was difficult to direct. Recommendations for the patient was for an acute psychiatric condition requires 24 hour skilled nursing/medical oversight due to the potential to harm self or others. Less-intensive treatment not safe or feasible. It was requested the patient be admitted to Hospital #4 for inpatient treatment.

There was no documentation the patient received stabilization and treatment for an emergency psychiatric condition, within the capabilities of Hospital #1 and its staff, prior to being transferred to Hospital #4 for inpatient treatment of a psychiatric condition. The admission diagnoses at Hospital #4 included: "Schizophrenia, unspecified, Suicidal Ideations, Homicidal Ideations, Essential Hypertension and Non-compliance with Medications."

7. Medical record review revealed Patient #8 was a 20 year old male with a history of paranoid schizophrenia. The patient had eloped from Hospital #1 on 8/29/19 after a 5 day hospitalization.

On 8/30/19 at 2:41 PM, the psychiatric IAD EMTALA log revealed Patient #8 presented via car to the psychiatric IAD with the chief complaint of "psych" and did not have any Emergency Psychiatric Medical Condition.

Review of the EMTALA Medical Screening Examination for Patient #8 dated 8/30/19 at 3:40 revealed RN #1 performed the examination. RN #1 documented the patient complained his fists were hurting because he had been hitting them on the gate. The patient had no place to go and no medications. RN #1 documented the patient did not meet the criteria for an Emergency Medical Condition.

Review of the Intake Assessment dated 8/29/19 but signed on 8/30/19 at 3:40 PM revealed Director of Intake, who has a Masters in Education, performed the psychiatric assessment with the following findings: the patient denied SI or HI (suicidal ideations or homicidal ideations), admits to psychosis and reports seeing images. The Director of Intake's Level of Care Recommendations was "outpatient/community referral". The Director of Intake also documented the patient was a low-risk for suicide.

Review of the Physician Certification Statement for Non-Emergent Ambulance Services form dated 8/30/19 revealed the patient was being discharged from Hospital #1 to an Emergency Shelter. Assessor #3 (Masters in Social Work) documented the medical necessity was due to the patient, "is mentally unstable, unable to operate vehicle." Assessor #3 checked the box the patient was a danger to self and others. On the physician signature line on the form, Assessor #3 signed her name as the physician.

The patient was in the IAD for 8 hours and 15 minutes. There was no documentation the patient continued to receive assessment from a qualified medical provider to determine if an emergency condition existed, therefore, there was no documentation the hospital provided stabilization and treatment for Patient #8, within the capabilities of Hospital #1 and its staff, prior to being transferred to the emergency shelter.

In an interview in the administrative conference room on 10/17/19 at 1:05 PM, the Director of Intake stated, "I was in intake. He [Patient #8] was probably refusing to leave...I did his assessment, he [Patient #8] had smoked marijuana and wanted a sandwich. Had no clinical need to be admitted. We gave him a referral to [Emergency Shelter #1]. We may have called a cab to take him...If a patient is here for several hours, we have a water fountain, snacks and juice...We don't normally document if we fed the patients...I spoke to his psychiatrist who said he [Patient #8] was just malingering."

8. Medical record review revealed Patient #9 was a 32 year old female with history of auditory and visual hallucinations.

Review of the psychiatric IAD EMTALA log revealed Patient #9 presented to the psychiatric IAD on 7/9/19 at 10:45 AM with the chief complaint of "Psych" and did not have an "Emergency Psychiatric Medical Condition."

On 7/9/19 at 11:00 AM Assessor #7, who had a Master's in Clinical Counseling, performed the psychiatric assessment with the following findings: presented with auditory and visual hallucinations and depression. Assessor #7's Level of Care Recommendations were "Acute Inpatient: Less-intensive treatment not safe or feasible..." and the patient should go to an Intensive Outpatient Program (IOP).

Review of the EMTALA Medical Screening Examination for Patient #9 on 7/9/19 at 11:50 AM revealed RN #1 performed the examination. RN #1 documented the patient had psychosis, auditory and visual hallucinations. RN #1 also documented the patient met the criteria for Emergent Medical Condition based on physical findings.

Review of the Post-Assessment Referral/Refusal of Treatment form for Patient #9 documented the patient did not meet criteria for inpatient or partial hospitalization and was referred to the Intensive Outpatient Program (IOP) at Hospital #1. The Intake Log documented she was discharged at 11:45 AM.

There was no documentation the LIP or Psychiatrist performed an appropriate and ongoing MSE or assessment based on the patients presenting signs and symptoms to determine if an emergency psychiatric condition existed, therefore there was no documentation the patient received stabilization and treatment for an emergency psychiatric condition while in Hospital #1's IAD.

9. Medical record review revealed Patient #10 was a 55 year old female who presented with confusion and disorganized, bizarre behavior.

Review of the psychiatric IAD EMTALA log revealed Patient #10 presented to the psychiatric IAD on 7/8/19 at 10:35 PM with the chief complaint of "psych" and had an "Emergency Medical Psych Condition".

Assessor #3, who had a Masters in Social Work, completed the form titled Treatment Referral Form which revealed Patient #10 was a walk-in to the IAD and experienced confusion, disorganized, bizarre behavior, schizophrenia, and thinks house is on fire..." There were no documentation the patient's blood pressure (BP), pulse rate, respiration rate or temperature was obtained at this time.

Review of the EMTALA Medical Screening Examination for Patient #10 revealed on 7/9/19 at 11:02 PM the patient's blood pressure (BP) was elevated at 221/132 and the patient's pulse rate was elevated at 158. (The average blood pressure for a 55 year old female is 120-130/80, pulse rate 54-91.)
At 11:08 PM the patient's BP remained elevated at 182/123 and the pulse rate remained elevated at 150.
At 11:19 PM the patient's BP remained elevated and Assessor #3 called for RN #8 to report the elevated BP to the RN. There was no documentation a physician was called regarding the patient's elevated BP.
At 11:26 PM the patient's BP was elevated at 202/133 and the pulse rate was elevated at 146.
At 12:00 AM, RN #8 arrived in the IAD to assess Patient #10's elevated BP. There was no documentation a physician was called at this time.
At 12:03 AM the patient's BP was elevated at 237/162 and the patient's pulse rate was elevated at 162.
At 12:12 AM the patient's BP was elevated at 237/135, with an elevated pulse rate of 162.
There was no documentation a physician was notified of the patient's continued elevated BPs and pulse rates.
At 12:32 AM, RN #8 called Hospital #5 in order to transfer Patient #10. There was no documentation of physician orders or involvement with the patient transfer. There was no documentation the patient received stabilization and treatment for an emergency medical condition, within the capabilities of Hospital #1 and its staff, while at Hospital #1.

Review of the form titled Memorandum of Transfer (EMTALA) was incomplete. The date, time and name of the receiving physician was not listed. The area on the form was marked as not applicable. There was no documentation of a physician signature or certification by the physician that the risks and benefits of the transfer were appropriate without stabilization or treatment prior to the transfer.

There were no other assessments documented for Patient #10 or stabilization and treatment provided to the patient for an emergency medical condition, within the capabilities of Hospital #1 and its staff, prior to being transferred to Hospital #5.

Patient #10 was transferred by ambulance to Hospital #5 on 7/9/19 at 1:10 AM. The patient's BP remained elevated at the time of discharge at 201/139.

Patient #10 remained in the IAD at Hospital #1 for 2 hours and 35 minutes. There was no documentation the patient received stabilization and treatment for an emergency medical condition of uncontrolled elevated blood pressures and pulse rates. The patient's diagnoses at Hospital #5 included: "Urinary Tract Infection, Altered Mental Status, and Syncope and Collapse."

10. Medical record review revealed Patient #12 was a 53 year old male with a history of Major Depressive Disorder.

Review of the psychiatric IAD EMTALA log revealed Patient #12 presented via ambulance to the psychiatric IAD on 7/15/19 at 9:07 PM with the chief complaint of "psych" and had an "Emergency Psychiatric Medical Condition".

Review of the EMTALA Medical Screening Examination for Patient #12 revealed on 7/15/19 at 9:25 PM RN #6 performed the examination and documented the patient was hearing voices telling him to do bad things. RN #6 documented the patient had threatened staff at an outpatient mental health clinic with a knife. Patient #12 complained of having trouble urinating and an enlarged scrotum. The patient's blood pressure was elevated at 182/103. RN #6 documented the patient met the criteria for an Emergent Medical Condition based on physical findings and was at risk for imminent harm to self/other due to psychiatric conditions. RN #6 documented the physician was contacted and an order for Clonidine was given to treat the patient's elevated blood pressure. There was no documentation the patient received further treatment and stabilization for the emergency psychiatric and medical condition, within the capabilities of Hospital #1 and its staff.

Review of a Physician Certification Statement for Non-Emergency Ambulance services form dated 7/15/19 revealed the patient was being transferred to Hospital #5. Assessor #10, who had a Masters in Psychology, completed the form and documented the medical necessity was due to the patient could not urinate and his scrotum was swelling. Assessor #10 checked on the form that Patient #12 was a danger to self and others. Assessor #10 wrote her name on the line for the physician's name. There was no documentation a physician verified the information on the form. There was no documentation the patient received further treatment and stabilization for the emergency medical condition, within the capabilities of Hospital #1 and its staff.

Review of a Memorandum of Transfer EMTALA form revealed the following information was left blank: Receiving physician name, signature and name of transferring physician, type of vehicle used, facility transported to. The section to be completed and signed by a physician if the patient's emergency medical condition had not been stabilized prior to transfer, was left blank.

Review of the psychiatric IAD EMTALA log revealed Patient #12 was transferred by ambulance to Hospital #5 at 11:03 PM on 7/15/19 for medical treatment.

There was no documentation the patient received stabilization and treatment for an emergency medical condition, within the capabilities of Hospital #1 and its staff, while in Hospital #1's IAD and prior to being transferred to Hospital #5. Admission diagnoses at Hospital #5 included: "Urinary Tract Infection, Testicular Pain, Suicidal Ideations and Urinary Retention."

11. Medical record review revealed Patient #13 was a 48 year old male with a history of Schizophrenia.

Review of the psychiatric IAD EMTALA log revealed Patient #13 presented via ambulance to the psychiatric IAD on 9/25/19 at 5:20 PM with the chief complaint of "psych" and had an "Emergency Medical Psych Condition".

Review of the EMTALA Medical Screening Examination form for Patient #13 revealed on 9/25/19 at 5:15 PM RN #1 performed the examination. Patient #1 had suicidal ideations with a plan to make gangsters shoot him. The patient had visual hallucinations. RN #1 documented the patient's blood sugar (BS) was 455 (normal limits being 70 - 99 - a very high BS above 400 can be a medical emergency and should be treated immediately with intravenous fluids and insulin). RN #1 documented the patient had just eaten and did not call a physician, a LIP or notify anyone of the patient's abnormal elevated BS. There was no documentation the patient received stabilization and treatment for an emergency medical condition of elevated blood sugar, within the capabilities of Hospital #1 and its staff.

At 6:00 PM, Assessor #7, who had a Masters in Clinical Counseling, performed the psychiatric assessment with the following findings: patient has suicidal ideations of wanting to die and planned to make a gangster mad in the streets of [named city] so he can make him kill him.
Assessor #7 documented the patient recommendation as "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight" and "Potential danger to self or others". There was no documentation the patient received stabilization and treatment for an emergency medical condition of elevated blood sugar, within the capabilities of Hospital #1 and its staff.

At 6:30 PM, 1 hour and 15 minutes after arrival to the IAD seeking treatment, RN #1 re-checked the patient's BS and it was dangerously elevated at 512. RN #1 contacted Nurse Practitioner #1 who instructed RN #1 to transfer the patient to Hospital #2 due to abnormal blood sugar readings. There was no documentation the patient received stabilization and treatment for an emergency medical condition of elevated blood sugar, within the capabilities of Hospital #1 and its staff.

Review of the Physician Certification Statement revealed the form had the physician's printed name and credentials; however, the certification statement was completed and signed by Assessor #2, who had a Master of Science degree. Assessor #7 documented the patient's diagnosis was High Blood Sugar, Schizophrenia, and needs medical clearance.

Review of the form titled Memorandum of Transfer (EMTALA) revealed an area for the physician's signature to verify the patient's emergency medical condition had not been stabilized prior to transfer. The area was left blank.

Review of the psychiatric IAD EMTALA log revealed Patient #13 was discharged on 9/25/19 at 7:25 PM, 2 hours and 10 minutes after arrival to the IAD seeking treatment for an emergency medical and an emergency psychiatric condition. There was no documentation the patient received stabilization and treatment for an emergency medical condition, within the capabilities of Hospital #1 and its staff, while in Hospital #1's IAD and prior to being transferred to Hospital #2 by ambulance. The diagnoses at Hospital #2 included: "Acute Hyperglycemia and Suicidal Risk."

12. Medical record review revealed Patient #14 was a 42 year old male with a history of alcohol abuse. The patient had insurance but was homeless. The patient had been discharged from Hospital #1's inpatient psychiatric unit the morning of 9/24/19 at 10:25 AM with diagnosis of Major Depressive Disorder.

A. Review of the psychiatric IAD "EMTALA" log revealed Patient #14 presented via car to the psychiatric IAD on 9/24/19 at 5:40 PM with chief complaint of "psych" and had an "Emergency Medical Psych Condition".

Review of the "EMTALA MEDICAL SCREENING EXAMINATION" conducted on 9/24/19 at 5:40 PM revealed RN #1 performed the examination. RN #1 documented the patient had homicidal thoughts toward his ex-wife for keeping his daughter away from him and he drank 4-42 oz. beers today. The patient's breathalyzer was 0.484 (legal is 0.08). At 7:00 PM, RN #1 documented he had spoken to physician about breathalyzer levels. Received orders to push fluids and have mobile crisis to see pt.

Review of the 9/24/19 Intake Assessment conducted at 6:47 PM documented, "Patient reports 'being freaked out', at [Rehab Center #1] so he left, called a ride and started drinking..." Review of the "COLUMBIA-SUICIDE SEVERITY RATING SCALE" date 9/24/19 revealed the patient was at "moderate risk".

Review of the 9/24/19 Crisis Assessment performed via telehealth by mobile crisis agency Licensed Master Social Work, PhD. revealed, "...Patient is 42 year old White male who presents with history of Alcohol Use Disorder, Schizophrenia and Bipolar. Patient says he is seeking Alcohol Detox. He was discharged from [Hospital #1] this morning and sent to a facility in [named city] when he arrived there he became very paranoid and anxious, he said he could not stay there...Patient says all his diagnoses kicked in and just not stay up there alone...Justification for Disposition: Patient is seeking inpatient hospitalization for his alcohol problem. Patient was discharged from [Hospital #1] this morning and referred to a program in [named city]. He went and refused to stay for treatment. Patient is being referred for outpatient treatment or partial program at [Hospital #1] if they have beds. He will be provided list of programs and given service referral..."

Review of the Treatment Referral Form dated 9/24/19 at 9:15 PM documented, "...called director notified to reassess pt when his alcohol level is 0.08 or lower... [MD #3] reports that IOP is not an option because pt is homeless and does not have an address...9/25/19 1:30 BAL [blood alcohol level] 0.012, 3:35 BAL 0.045 [This time for the BAL's does not reflect if it is AM or PM] , 5:36 AM,BAL 0.007."

The patient was discharged at 10:30 AM. There was no documentation where the patient was discharged to, if he had been medically or psychologically cleared for discharge.

There was no documentation the patient received stabilization and treatment for an emergency medical psyche condition while in the hospital's IAD.

B. Review of the psychiatric IAD EMTALA log revealed Patient #14 returned to Hospital #1 on 9/25/19 at 8:41 PM with the chief complaint of "psych" and had an "Emergency Medical Psych Condition".

Assessor #3, who had a Master's in SW, documented at 9:33 AM Patient #14 was "d/c [discharged] to outpatient tx [treatment] from [Hospital #1] on 9/24/19 after voluntarily leaving his placement for residential treatment on 9/24/19 at [Rehab Center #1]. Patient slept outside of the Medical Outpatient Building on [Hospital #1's] premises and came to [Hospital #1's] intake as a walk-in stating he was suicidal with a plan to hang himself or cut his wrists."

Assessor #3, who had a Masters in SW, performed the psychiatric assessment to determine if an emergency psychiatric condition existed. Assessor #3 documented the patient was, "...suicidal w/a [with a] plan to either hang himself or cut his wrist..." and the patient reported, "I'm thinking about hurting somebody". The Assessor documented the patient presented with a "sad, flat, affect...is easily agitated...reports feelings of hopelessness..."
The suicide risk assessment was listed as "low" risk. There was no documentation a LIP or Psychiatrists performed an examination to determine if an emergency psychiatric condition exited.

Hospital #1 staff (form was not signed or dated) documented the patient was at a low- risk for suicide.

RN #5 on 9/25/19 at 7:45 AM documented the patient was a low risk for suicide. Assessor #3's (Masters in SW) Level of Care Recommendations documented the patient was a potential danger to self or others.

Review of the Memorandum of Transfer (EMTALA) form revealed Assessor #3 (Masters in SW) signed as the transferring physician. RN #1 documented he contacted Hospital #4 as the receiving hospital. There was no documentation who the physician was at the receiving hospital. There was no documentation of a physician order to transfer the patient. Review of the area for the physician's signature was left blank.

The Physician Certificate of Transfer form stated Patient #14 needed "care not available at [named Hospital #1]. Assessor #3, Masters in SW, signed in the area titled "Transferring Physician/Registered Nurse."

Review of the IAD EMTALA log revealed Patient #14 was discharged on 9/25/19 at 11:32 PM and departed the hospital by "ambulance." The EMTALA log documented the patient's disposition as "transferred." There was no documentation the patient received stabilization and treatment for an emergency medical condition, within the capabilities of Hospital #1 and its staff, while in Hospital #1's IAD. Review of Hospital #4's medical record revealed the patient was admitted with the diagnosis, "Major Depressive Disorder, recurrent."

13. Medical record review revealed Patient #15 was a 64 year old male with a history of recurrent Major Depressive Disorder with severe "psych."

Review of the psychiatric IAD EMTALA log revealed Patient #15 presented via car to the psychiatric IAD on 9/24/19 at 2:20 PM with the chief complaint of "psych" and had an "Emergency Medical Psych Condition."

Review of the EMTALA Medical Screening Examination for Patient #15 revealed on 9/24/19 at 3:50 PM RN #1 performed the examination to determine if an emergency medical or emergency psychiatric condition existed.. RN #1 documented the patient was having suicidal thoughts about overdosing, and last used heroin the day before. The patient's BS was elevated at 535. The RN documented the patient met the criteria for Emergent Medical Condition based on risk of imminent harm to self and others due to a psychiatric condition. There was no documentation the patient received stabilization and treatment for an emergency medical condition, within the capabilities of Hospital #1 and its staff.

Review of a Physician Certification Transfer form dated 9/24/19 at 3:20 PM revealed Patient #15 was to be transferred to Hospital #2. RN #1 completed and signed the transfer form.

Review of the psychiatric IAD EMTALA log revealed Patient #15 was transferred by ambulance at 3:55 PM on 9/24/19 to Hospital #2. There was no documentation the patient received stabilization and treatment for an emergency medical condition, within the capabilities of Hospital #1 and its staff, prior to being transferred to Hospital #2.

Review of Hospital #2's "Patient Education & [and] Visit Summary" form dated 9/24/19 at 4:27 PM revealed Patient #15's presenting complaint at Hospital #2 was "...very high blood sugar sent here for med [medical] clearance...Discharge Diagnoses: Acute Hyperglycemia and Depression with suicidal Ideation."

14. Medical record review revealed Patient #16 was a 43 year old male residing in a care facility with history of combative, refusing medications, elopement and fighting staff.

Review of the psychiatric IAD "EMTALA" log revealed Patient #16 presented via ambulance to the psychiatric IAD on 9/18/19 at 2:30 PM with chief complaint of "Psych" and had an "Emergency Medical Psych Condition." There was no documentation who determined the patient had an Emergency medical psych condition.

Review of the 9/18/19 Intake Assessment conducted at 5:24 PM documented, "Per care home staff patient is combative, refuses meds, tries to elope and fights staff. Patient has extremely slurred speech, making him a poor historian. Patient presents with poor incomprehensible speech. Patient has difficulty speaking. Patient is hard to redirect per care home staff..." Under the assessment section titled "Level of Care Recommendations" the Assessor documented the patient as "Acute Inpatient: Acute psychiatric condition requires 24 hour skilled nursing/medical oversight and Potential danger to self or others..."

The patient w

Based on facility policy review, facility document review, medical record review, and interview the facility failed to ensure patients presenting to the hospital's Psychiatric Intake Assessment Department (IAD) or Emergency Department (ED) seeking medical assistance with identified emergency psychiatric conditions received the care and services at Delta Medical Center (Hospital #1) who had the capacity and capability to treat and stabilize patients for 12 of 13 (Patient #1, 3, 4, 7, 12, 13, 14, 15, 16, 17, 18, and 20) sampled patients who presented to Hospital #1 seeking treatment, and the facility failed to ensure the Emergency Medical Treatment and Labor Act (EMTALA) Memorandum of Transfer forms were fully completed for 11 of 13 (Patient #3, 7, 10, 12, 13, 14, 15, 16, 17, 18, and 20) patients who were transfer to another facility.

The findings included:

1. Review of Delta Medical Center's (Hospital #1) (an acute care hospital with a psychiatric unit) EMTALA (Emergency Treatment and Labor Act) policy revealed, "...Any individual who presents on the property of [Name of Hospital #1] and is in need of assistance for medical conditions will be provided an appropriate medical screening examination [MSE] within the capabilities of the Emergency Department to determine whether an emergency medical condition exists...After the medical screening, if the Emergency Department Physician determines the individual has an emergency medical condition...the individual will be provided further examination and treatment necessary to stabilize the condition...The Specialty Physician will also evaluate if DMC [Hospital #1] has the trained staff and equipment to provide appropriate care for this patient...Admission to the hospital will be determined by the ED [Emergency Department] Physician and Specialty Physician On Call...If Delta Medical Center is not able to provide the level of care the patient requires, it is the responsibility of the hospital and physician to: 1. Provide medical care to stabilize the patient for transport so that, within a reasonable medical probability, the individual's condition will not likely deteriorate materially as a result of the transfer from [Hospital #1] to another facility...5. Document on the patient's record: a. The need for transfer, risks, and benefits of transfer b. Accepting physician and facility c. Responsibility during transfer d. Time of contact of the facility and physician e. Name of accepting physician and vital signs at time of transfer f. Report was given to accepting facility 6. Complete and sign the following forms...Patient Transfer form...A Physician Certification must be signed by the transferring physician stating...That based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks to the patients...A summary of the most apparent risks, benefits, and alternative upon which the certification is based...

2. Review of Hospital #1's Medical Screening Examination (MSE) policy approved 9/19/19 revealed, "Purpose: To provide a Medical Screening Examination (MSE) for patients that present to the Admissions Department at [name of hospital]...Policy Statement: In order to identify an emergency medical or psychiatric condition, patients present to the Admissions department seeking care will receive a medical screening exam by a Registered Nurse [RN], physician or Qualified Medical Professional...Procedure...Patient present to [name of hospital] admission department and checks-in...RN performs MSE and documents on the MSE form...If no emergency medical condition or medical issue requiring outside assessment is found, the completed form is given to admission assessor for assessment completion...After the assessment is complete, the psychiatrist will be consulted regarding the patient's disposition...If the medical screening identifies a condition that requires further evaluation, the physician is notified by the nurse, using the SBAR (situation, background, assessment and recommendations)...The physician will determine the disposition of the patient...If the physician decides to transfer to an ED, the RN will...Call ambulance to transport patient to designated ED...Notify patient and complete transfer paperwork...Remain with patient until ambulance transport arrives...If patient has a [an] emergency medical condition, the physician will be notified and staff will call 911 for emergency transport to an Emergency Dept.[department] The RN must remain with the patient..."

3. Medical record review revealed Patient #1 was a 44 year old male with a history of major depressive symptoms including auditory hallucinations. The patient did not have insurance.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #1 presented via car to the hospital's psychiatric IAD on 10/8/19 at 9:24 PM with the chief complaint of "psych" and had an "Emergency Medical Psych Condition".

Review of Patient #1's EMTALA Medical Screening Examination dated 10/8/19 from 9:24 PM through 10:22 PM revealed the patient met criteria for Emergent Medical Condition based on risk of imminent harm to self and others due to psychiatric conditions.

Review of the psychiatric assessment dated 10/8/19 at 10:28 PM revealed, Patient #1 had an "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight".

Review of the 10/9/19 Crisis Assessment performed by a mobile crisis agency's employee from 6:00 AM - 6:30 AM revealed, the patient reported feelings of hopelessness, depression, had a history of alcohol abuse, and was currently unemployed and homeless. The patient was offered inpatient treatment at the Crisis Stabilization Unit at another hospital which was Hospital #3 (a Psychiatric Hospital). There was no documentation the patient was offered psychiatric treatment and services at Hospital #1.

Review of Hospital #1's daily census report revealed the hospital had the capability and the beds available on this date to admit, stabilize and treat Patient #1. Hospital #1 failed to utilize its ancillary, psychiatric and physician services to treat and stabilize Patient #1.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #1 was transferred at 10:58 AM on 10/9/19 to Hospital #3 (a Psychiatric hospital); even though Hospital #1's daily census report reveled the hospital had the capacity to treat and stabilize the patient.

In an interview on 10/16/19 at 9:30 AM in Hospital #1's conference room, the Director of Intake Admissions verified Patient #1 was transferred to a crisis stabilization unit at Hospital #3 which is contracted by the State for patients with medicaid or no insurance. The Director stated, "...if a patient is unfunded, mobile crisis will see all of these, plus Tenn- Care [state medicaid] patients..." The Director stated in order to refer to [named Hospital #3] they [the patients] have to be seen by mobile crisis..."

4. Medical record review revealed Patient #3 was a 57 year old female with history of suicide with a plan to overdose with hallucinations telling her to harm herself.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #3 presented via car to the psychiatric IAD on 8/6/19 with the chief complaint of "psych" and had an "Emergency Medical Condition".

Review of Patient #3's EMTALA Medical Screening Examination conducted on 8/6/19 at 8:00 PM revealed the patient had a rash on both arms and was having suicidal ideations with a plan to overdose on mental health medications and the patient met criteria for Emergency Medical Condition based on physical findings.

Review of the psychiatric assessment dated 8/6/19 at 7:45 PM revealed, Patient #3 had an "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight and Potential danger to self or others."

There was no documentation a psychiatrist or LIP provided psychiatric stabilization and treatment prior to the patient being transferred. There was no documentation the hospital provided treatment for the patient's rash although the hospital is certified as an acute care hospital. There was no documentation the patient was aware of the risk and benefits of the transfer.

Patient #3 was transferred to Hospital #2's (an acute care hospital) emergency department for treatment of the patient's rash. There was no documentation on the EMTALA Transfer form of the receiving physician's name at Hospital #2 or a signature of transferring physician at Hospital #1. There was no documentation of the names of Hospital #1's staff acting under physician's orders. The hospital failed to utilize its ancillary, psychiatric and physician services to treat and stabilize Patient #3.

5. Medical record review revealed Patient #4 was a 26 year old male with a history of mood swings and depression. The patient did not have insurance.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #4 presented via walk-in on 8/11/19 at 6:16 PM with the chief complaint of "psych" and had an "Emergency Medical Psych Condition".

Review of the psychiatric assessment dated 8/11/19 at 6:24 PM revealed Patient #4 was a "Potential danger to self or others" and required acute inpatient treatment.

Review of Patient #4's EMTALA Medical Screening Examination conducted on 8/11/19 at 6:45 PM revealed, Patient #4 met criteria for an Emergent Medical Condition based on risk of imminent harm to self and others due to psych conditions.

Review of the 8/11/19 Crisis Assessment performed by a mobile crisis agency's employee from 7:52 PM - 8:15 PM revealed the patient met criteria for inpatient level of care and was not safe for home or community environment.

Review of Hospital #1's daily census report revealed the hospital had the capability and the beds available on this date to admit, treat and stabilize Patient #4. There was no documentation the physician, LIP or Psychiatrists was notified of the high risk suicide assessment. Assessor #6 documented Patient #4 was a "Potential danger to self or others" and a need for acute inpatient. There was no documentation the a physician, LIP or Psychiatrist performed a MSE to determine if an EMC existed, or provided stabilization or treatment. There was no documentation the patient was made aware of the risks and benefits associated with the transfer. There was no documentation the hospital utilized its ancillary, psychiatric and physicians services to treat and stabilize Patient #4.

The patient was referred to Hospital #3 but no beds were immediately available. This referral was inappropriate since Hospital #1 had beds and psychiatric services available to treat Patient #4. The patient remained at Hospital #1 untreated in the IAD unit until 8/12/19 at 1:34 AM (7 hours and 18 minutes after arrival) at which time the patient was transferred to Hospital #3. There was no documentation Hospital #1 provided stabilization and treatment to Patient #4 when the hospital had the psychiatric services, staff and beds available to treat and stabilize Patient #4.

6. Medical record review revealed Patient #7 was a 57 year old male with a history of verbal and physical aggression. The patient resided in a care home and had made threats to kill staff. The patient had Medicare insurance.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #7 presented via car to the psychiatric IAD on 8/27/19 at 2:27 PM with the chief complaint of "psych" and had an "Emergency Psychiatric Medical Condition".

Review of Patient #7's EMTALA Medical Screening Examination dated 8/27/19 at 3:10 PM revealed the patient met criteria for Emergent Medical Condition based on the risk of imminent harm to self or others due to psychiatric condition.

Review of the psychiatric assessment dated 8/27/19 at 6:45 PM revealed, the patient had homicidal ideations towards care home staff and was hard to redirect. Patient #7 had an "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight...Potential danger to self or others..."

Assessor #2 documented the patient requested to be admitted to Hospital #4 (a Psychiatric hospital) for treatment. There was no documentation this request was made in writing or that the patient was made aware of the risks and benefits of the transfer. There was no documentation a physician, LIP or Psychiatrist performed a MSE in order to determine if the patient had an EMC requiring stabilization and/or treatment prior to being transferred to Hospital #4, or if the patient was competent and understood treatment was available at Hospital #1.

Review of Hospital #1's daily census report revealed the hospital had the capability and the beds available on this date to admit, treat and stabilize Patient #7. The hospital failed to utilize its ancillary, psychiatric and physician services to treat and stabilize Patient #7.

Review of Hospital #1's Physician Certification Statement revealed the form was completed and signed by Assessor #2 on the physician's signature line. On the line for the physician's printed name and credentials, Assessor #2 signed their name and credentials as a MS (Master in Science). The Assessor documented the patient's diagnosis was Schizophrenia.

Review of the form titled Memorandum of Transfer (EMTALA) revealed an area for the physician's signature to verify the patient's emergency medical condition had not been stabilized prior to transfer; this area was left blank.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #7 was transferred by ambulance to Hospital #4 at 10:45 PM on 8/27/19. There was no documentation to determine this transfer was appropriate.

7. Medical record review revealed Patient #10 was a 55 year old female who presented with confusion, disorganized and bizarre behavior. She had insurance.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #10 presented to the psychiatric IAD on 7/8/19 at 10:35 PM with the chief complaint of "psych" and had an "Emergency Medical Psych Condition".

Review of the EMTALA Medical Screening Examination for Patient #10 revealed on 7/9/19 at 11:02 PM the patient's blood pressure (BP) was elevated at 221/132 (normal being 130/80) and the patient's pulse rate was elevated at 158 (normal being 54 -91).
At 11:08 PM the patient's BP remained elevated at 182/123 and the pulse rate remained elevated at 150.
At 11:19 PM the patient's BP remained elevated and Assessor #3 called for RN #8 to report the elevated BP to the RN. There was no documentation a physician was called regarding the patient's elevated BP or any treatment provided for the patient's continued elevated BP..
At 11:26 PM the patient's BP was elevated at 202/133 and the pulse rate was elevated at 146.
At 12:00 AM, RN #8 arrived in the psychiatric IAD to assess Patient #10's elevated BP. There was no documentation a physician was called at this time and notified of the continued elevate BP and pulse. There was no evidence of any treatment provided to the patient for the continued elevated BP and pulse.
At 12:03 AM the patient's BP was elevated at 237/162 and the patient's pulse rate was elevated at 162.
At 12:12 AM the patient's BP was elevated at 237/135, with an elevated pulse rate of 162.

There was no documentation a physician or LIP was notified of the patient's continued elevated BPs and pulse rates or stabilization and treatment for the elevated BP.

At 12:32 AM, RN #8 called Hospital #5 in order to transfer Patient #10. There was no documentation of physician orders or involvement with the patient's transfer. The date, time and name of the receiving physician was not listed. The area on the form was marked as not applicable. There was no documentation of a physician signature or certification by the physician that the risks and benefits of the transfer were appropriate without stabilization or treatment prior to the transfer.

Patient #10 was transferred by ambulance to Hospital #5 on 7/9/19 at 1:10 AM. The patient's BP remained elevated at 201/139 at the time of transfer to Hospital #5. The facility failed to ensure that an appropriate medical screening examination was provided for Patient #10 who presented to the ED with a history of Schizophrenia, confusion and abnormal vital signs.

Patient #10 remained in Hospital #1's IAD for 2 hours and 35 minutes without being examined, stabilized or treated by a physician for the emergency medical condition of uncontrolled elevated BP and pulse rates.

Hospital #1 failed to utilize available ancillary services (Psychiatric Services and Physicians on staff, Laboratory studies and Diagnostics tests) to fully assess, stabilize, treat, and determine whether or not an EMC existed for Patient #10 on 7/8/2019.

8. Medical record review revealed Patient #12 was a 53 year old male with a history of Major Depressive Disorder.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #12 presented via ambulance to the psychiatric IAD on 7/15/19 at 9:07 PM with the chief complaint of "psych" and had an "Emergency Psychiatric Medical Condition".

Review of the EMTALA Medical Screening Examination for Patient #12 on 7/15/19 at 9:25 PM revealed the patient was hearing voices telling him to do bad things and reported he had an enlarged scrotum and was having trouble urinating.

Review of a Physician Certification Statement for Non-Emergency Ambulance services form dated 7/15/19 revealed the patient was being transferred to Hospital #5 (an Acute Care Hospital). Assessor #10, who had a Masters in Psychology, completed the form and documented the medical necessity was due to the patient could not urinate and his scrotum was swollen. Assessor #10 checked on the form that Patient #12 was a danger to self and others. There was no documentation a physician verified the information on the form. There was no physician order to transfer the patient. Assessor #10 wrote her name on the line for the physician's name.

Review of Hospital #1's daily census report revealed the hospital had the capability and the beds available on this date to admit, treat and stabilize Patient #12. There was no documentation Hospital #1 utilized its ancillary, psychiatric and physician services to treat and stabilize Patient #12.

Review of a Memorandum of Transfer EMTALA form revealed the following information was left blank: Receiving physician name, signature and name of transferring physician, type of vehicle used, facility transported to. The section to be completed and signed by a physician if the patient's emergency medical condition had not been stabilized prior to transfer, was left blank.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #12 was transferred by ambulance to Hospital #5 (Acute Care Hospital) at 11:03 PM on 7/15/19 for medical treatment. There was no documentation of physician involvement in the transfer of Patient #12. Hospital #1 is an acute care hospital. There was no documentation of the reasons why the hospital failed to use its ancillary, and physician services to treat and stabilize the patient or if the patient was aware of the risks and benefits of the transfer.

9. Medical record review revealed Patient #13 was a 48 year old male with a history of Schizophrenia. The patient had medicaid insurance.

Review of Hospital #1`s psychiatric IAD EMTALA log revealed Patient #13 presented via ambulance to the psychiatric IAD on 9/25/19 at 5:20 PM with the chief complaint of "psych" and had an "Emergency Medical Psych Condition".

Review of the EMTALA Medical Screening Examination form for Patient #13 on 9/25/19 at 5:15 PM revealed the patient's blood sugar (BS) was 455 (normal limits being 70 - 99 - a very high BS above 400 can be a medical emergency and should be treated immediately with intravenous fluids and insulin). RN #1 documented the patient had just eaten and did not call a physician, a LIP or notify anyone of the patient's abnormal elevated BS of 455.

Review of the psychiatric assessment dated 9/25/19 at 6:00 PM, revealed Patient #13 had an "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight" and "Potential danger to self or others".

At 6:30 PM, 1 hour and 15 minutes after arrival to the IAD seeking treatment, RN #1 re-checked the patient's BS and it was dangerously elevated at 512. RN #1 contacted Nurse Practitioner #1 who instructed RN #1 to transfer the patient to Hospital #2 (an Acute Care Hospital) due to abnormal blood sugar readings.

Review of the Physician Certification Statement revealed the form was completed and signed by Assessor #2, who had a Master of Science degree, on the physician's signature line. On the line for the physician's printed name and credentials, Assessor #2 signed their name and credentials as a MS (Master in Science). The Assessor documented the patient's diagnosis was High Blood Sugar, Schizophrenia, and needs medical clearance. There was no documentation on the form of physician, LIP, or Psychiatric verification and approval of the transfer. .

Review of the form titled Memorandum of Transfer (EMTALA) revealed an area for the physician's signature to verify the patient's emergency medical condition had not been stabilized prior to transfer; the area was left blank. There was no documentation a physician was involved in the patient's transfer, or a physician contacted the receiving hospital. There was no documentation who the accepting physician was at the receiving hospital.

Review of the psychiatric IAD EMTALA log revealed Patient #13 was transferred to Hospital #2 on 9/25/19 at 7:25 PM. There was no documentation Hospital #1 had utilized its ancillary and physician services to treat and stabilize Patient #13.

10. Medical record review revealed Patient #14 was a 42 year old male with a history of alcohol abuse. The patient had insurance but was homeless. The patient had been discharged from Hospital #1's inpatient psychiatric unit the morning of 9/24/19 at 10:25 AM with diagnosis of Major Depressive Disorder.

A. Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #14 presented via car to the psychiatric IAD on 9/24/19 at 5:40 PM with chief complaint of "psych" and had an "Emergency Medical Psych Condition."

Review of the EMTALA Medical Screening Examination dated 9/24/19 at 5:40 PM revealed the patient met the criteria for Emergency Medical Condition based on risk of imminent harm to self/other due to psych conditions and risk related to intoxication.

Review of the psychiatric assessment dated 9/24/19 at 6:47 PM, revealed the "Patient reports 'being freaked out', at [Rehab Center #1] so he left, called a ride and started drinking..."

Review of the 9/24/19 Crisis Assessment performed via telehealth at 8:30 PM by a mobile crisis agency Licensed Master Social Work revealed, "...Patient is seeking inpatient hospitalization for his alcohol problem...Patient is being referred for outpatient treatment or partial program at [Hospital #1] if they have beds. He will be provided a list of programs and given service referral..."

Review of the Treatment Referral Form dated 9/24/19 at 9:15 PM revealed Assessor #2 documented, "...called director notified to reassess pt [patient] when his alcohol level is 0.08 or lower... [Physician #3] reports that IOP [intensive outpatient program] is not an option because pt is homeless and does not have an address..."

Review of the IAD EMTALA log revealed Patient #14 was discharged on 9/25/19 at 10:30 AM and departed the hospital by "car". The EMTALA log documented the patient's disposition as "referral".

Hospital #1 failed to utilize its ancillary, psychiatric and physician services to treat and stabilize Patient #14.

B. Review of Hospital #1's (acute care/psychiatric hospital) psychiatric IAD EMTALA log revealed Patient #14 returned to Hospital #1 on 9/25/19 approximately 10 hours later at 8:41 PM with the chief complaint of "psych" and had an "Emergency Medical Psych Condition".

Assessor #3, who had a Master's in Social Work (SW), documented at 9:33 PM Patient #14 was discharged from Hospital #1 on 9/24/19 and was sent to Rehab Center #1 for further treatment. The patient left the rehab center and returned to Hospital #1 claiming he was suicidal with a plan to cut his wrist or hang himself.

Review of the psychiatric assessment dated 9/25/19 at 9:33 PM revealed the patient was "...suicidal w/a [with a] plan to either hang himself or cut his wrist..." and the patient reported, "I'm thinking about hurting somebody".

Review of the Columbia-Suicide Severity Rating Scale signed by RN #5 on 9/25/19 at 07:45 AM revealed the patient was a "Potential danger to self or others."

Review of the Memorandum of Transfer (EMTALA) form revealed Assessor #3 signed as the transferring physician. RN #1 documented he contacted Hospital #4 (a Psychiatric hospital) as the receiving hospital. There was no documentation who the physician was at the receiving hospital. There was no documentation of a physician order to transfer the patient. Review of the area for the physician's signature was left blank.

The Physician Certificate of Transfer form stated Patient #14 needed "care not available at [named Hospital #1]. Assessor #3, Masters in SW, signed in the area titled "Transferring Physician/Registered Nurse".

Review of Hospital #1's daily census report revealed on this date the hospital had capability and beds available to stabilize and treat Patient #14. There was no documentation Hospital #1 utilized its ancillary, and psychiatric services to treat and stabilize Patient #14.

Review of the IAD EMTALA log revealed Patient #14 was transferred on 9/25/19 at 11:32 PM and departed the hospital by "ambulance."

11. Medical record review revealed Patient #15 was a 64 year old male with a history of recurrent Major Depressive Disorder with severe "psych".

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #15 presented via car to the psychiatric IAD on 9/24/19 at 2:20 PM with the chief complaint of "psych" and had an "Emergency Medical Psych Condition".

Review of the EMTALA Medical Screening Examination for Patient #15 on 9/24/19 at 3:50 PM revealed the patient's BS was elevated at 535 and the patient met the criteria for Emergent Medical Condition based on risk of imminent harm to self and others due to a psychiatric condition.

Review of a Physician Certification Transfer form dated 9/24/19 at 3:20 PM revealed Patient #15 was to be transferred to Hospital #2 (an Acute Care Hospital). The Transfer form was completed and signed by RN #1. There was no documentation who the receiving physician was at Hospital #2.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #15 was transferred by ambulance at 3:55 PM on 9/24/19 to Hospital #2. There was no documentation of a physician's order to transfer. There was no documentation Hospital #1 utilized its ancillary, psychiatric and physician/LIP services to treat and stabilize Patient
#15.

12. Medical record review revealed Patient #16 was a 43 year old male residing in a care facility with history of combative behaviors, refusing medications, elopement and fighting staff.

Review of Hospital #1's psychiatric IAD "EMTALA" log revealed Patient #16 presented via ambulance to the psychiatric IAD on 9/18/19 at 14:30 (2:30 PM) with chief complaint of "Psych" and had an "Emergency Medical Psych Condition".

Review of the "EMTALA MEDICAL SCREENING EXAMINATION" conducted on 9/18/19 at 2:40 PM revealed the patient did not meet the criteria for Emergency Medical Condition based on unknown and non-verbal patient.

Review of the psychiatric assessment dated 9/18/19 at 5:24 PM, revealed the patient had an "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight and Potential danger to self or others..."

Review of the form titled Memorandum of Transfer (EMTALA) revealed an area for the physician's signature to verify the patient's emergency medical condition had not been stabilized prior to transfer; the area was left blank. There was no documentation of the receiving hospital, name of the contact person accepting the transfer, or the name of the receiving physician. Assessor #2, who had a Master of Science in Counseling, signed as the transferring physician.

Patient #16 was transferred back to the skilled nursing facility where he resided on 11:15 PM on 9/18/19; therefore the Memorandum of Transfer form was not required to be completed. There was no documentation Hospital #1 utilized its ancillary, physician and psychiatric services to treat and stabilize Patient #16.

13. Medical record review revealed Patient #17 was a 49 year old male with a history of Schizophrenia. Patient #17 was referred to Hospital #1 (acute care/psychiatric hospital) by Hospital #4 (psychiatric hospital) due to a bed shortage at Hospital #4. Patient #17 had Medicare and Medicaid insurance.

Review of Hospital #1's psychiatric IAD "EMTALA" log revealed Patient #17 presented via ambulance at 4:36 PM on 9/17/19 with the chief complaint of "psych" and had an "Emergency Medical Psych Condition".

Review of the psychiatric assessment dated 9/17/19 at 5:35 PM, revealed the patient had an "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight...Potential danger to self or others..."

Review of the Physician Certification Statement for Non-Emergency Ambulance services revealed the form was completed and signed by Assessor #2 (Master of Science Counseling) on the physician's signature line. On the line for the physician's printed name and credentials, Assessor #2 signed their name and credentials as a MS (Master in Science). Assessor #2 documented the patient's diagnosis was Schizophrenia.

Review of the form titled Memorandum of Transfer (EMTALA) revealed an area for the physician's signature to verify the patient's emergency medical condition had not been stabilized prior to transfer; the area was left blank.

Review of Hospital #1's psychiatric IAD "EMTALA" log revealed Patient #17 was transferred by ambulance to Hospital #6 (a Psychiatric hospital) on 9/17/19 at 8:33 PM due to refusing services at Hospital #1. There was no documentation the patient had refused services at Hospital #1. There was no documentation the patient was aware of the risks and benefits of the transfer.

Review of Hospital #1's daily census report revealed on this date the hospital had capability and the beds available to treat and stabilize Patient #17. There was no documentation Hospital #1 utilized its ancillary, physician and psychiatric services to treat and stabilize Patient #17.

14. Medical record review revealed Patient #18 was a 46 year old male with a history of alcohol abuse. The patient did not have mental health insurance.

Review of Hospital #1's IAD EMTALA log revealed Patient #18 presented via car to the psychiatric IAD on 9/17/19 at 6:00 PM with the chief complaint chemical dependency and Psych and had an Emergency Medical Psych Condition.

Review of the EMTALA Medical Screening Examination conducted on 9/17/19 at 6:36 PM revealed the patient met the criteria for Emergency Medical Condition based on risk related to intoxication.

Review of the psychiatric assessment dated 9/17/19 at 7:45 PM revealed the patient "is seeking detox...meets criteria for dual diagnosis."

Review of the Physician Certification Statement for Non-Emergency Ambulance Services form revealed the form was completed and signed by Assessor #2 (Masters in Science of Counseling) on the physician's signature line. On the line for the physician's printed name and credentials, Assessor #2 signed their name and credentials as a MS (Master in Science). Assessor #2 documented the patient's diagnosis was Alcohol use disorder.

Review of the form titled Memorandum of Transfer (EMTALA) revealed an area for the physician's signature to verify the patient's emergency medical condition had not been stabilized prior to transfer; the area was left blank. Assessor #2 signed her name and credentials in the area for the signature of transferring physician.

Review of the 9/17/19 Crisis Assessment performed by a mobile crisis agency Licensed Master Social Work via telehealth revealed Patient #18 was referred to the Crisis Stabilization Unit at Hospital #3 (a Psychiatric hospital).

The patient was transferred at 12:10 AM via ambulance to Hospital #3.

Review of Hospital #1's daily census report revealed on this date, the hospital had