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Based on interview, record review, and review of facility policies, it was determined that the facility failed to ensure eight (8) of twenty (20) sampled patients (Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, and Patient #9) who presented to the facility's (Facility #1) Emergency Department (ED) with an Emergency Medical Condition were transferred to another hospital for stabilizing medical treatment that could not be provided by Facility #1 (refer to C2407).

In addition, based on interviews, record reviews, and review of facility policies it was determined the facility failed to appropriately transfer one (1) of twenty (20) patients (Patient #1) (refer to C2409).

Based on interview, record review, and review of a facility policy, it was determined the facility failed to ensure eight (8) of twenty (20) sampled patients (Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, and Patient #9) who presented to the facility's (Facility #1) Emergency Department (ED) with an Emergency Medical Condition were transferred to another hospital for stabilizing medical treatment that could not be provided by the facility. Patients #2, #3, #4, #5, #6, #7, #8, and #9 presented to the facility with suicidal ideation/attempted suicide; two of the eight patients (Patients #3 and #4) had a Mental Inquest Warrant (MIW) (a court order for an individual to be involuntarily admitted for psychiatric treatment) prior to arrival, and the facility obtained an MIW for three of the eight patients (Patients #5, #6, and #9). Facility physicians completed a Medical Screening Exam for each patient and documented that the patients were "medically" stable and were being transferred to a psychiatric hospital/unit for an evaluation/treatment of their behavioral health condition. However, despite having an MIW for five patients and despite the physician's documentation that the patients were being transferred to a psychiatric hospital/unit, a review of the patients' discharge documentation revealed the patients were "transferred" to a Community Mental Health Center (CMHC) (an outpatient facility that provides mental health services) for evaluation/treatment. The facility failed to ensure an appropriate transfer was arranged for the patients to ensure that the patients received stabilizing medical treatment for their behavioral health emergency medical condition.

The findings include:

Review of the facility's policy titled "Admission, Assessment and Discharge Criteria," revised October 2013, revealed the facility would identify patients that required immediate treatment, would provide ongoing assessment, and would ensure accurate disposition of the ED patient. Continued review of the policy revealed a medical screening exam (MSE) would be completed on all patients who presented to the ED for treatment. Further review of the policy revealed a patient was considered stable for discharge when, within reasonable clinical confidence, it was determined that the patient had reached the point where his/her continued care, including diagnostic workup and/or treatment, would be performed as an outpatient or later as an inpatient, provided that the patient was given a plan of appropriate follow-up care with the discharge instructions. For psychiatric conditions, the patient was considered to be stable when he/she was no longer considered to be a threat to injuring himself/herself or others.

1. Review of the medical record for Patient #2 revealed the patient presented to the ED via Emergency Medical Services (EMS) on 03/11/18 at 11:05 AM with complaints of "withdrawal." Further review of the record revealed nursing staff triaged Patient #2 at 11:05 AM and the patient stated "depression, anxiety and pain" were his/her complaints. Nursing staff documented that Patient #2 presented with alcohol intoxication with an "intentional overdose" and had a history of Schizophrenia and Post Traumatic Stress Disorder. Further review revealed the facility conducted a Suicide Risk Screen on 03/11/18 at 11:05 AM that stated the patient had a history of suicide attempts with no present thoughts of harm to self.

A review of the physician's assessment dated 03/11/18 at 11:22 AM, revealed Patient #2 had alcohol intoxication and depression, but the patient was discharged on 03/11/18 at 12:40 PM with instructions to follow up with his/her primary care provider and take medications as prescribed.

Further review of medical records revealed Patient #2 returned to the ED on 03/11/18 at 2:45 PM via EMS, approximately two hours after the patient was discharged, with an "overdose." Nursing staff triaged Patient #2 at 2:45 PM and documented "per EMS, [Patient #2] drank a bottle of Benadryl." Nursing staff documented that Patient #2 had an intentional overdose at 2:00 PM on 03/11/18 by Benadryl. At 2:40 PM on 03/11/18, the facility completed a Suicide Assessment and determined the patient had a "specific plan" for suicide and had commented, "I don't want to go through the pain." Staff also documented that Patient #2 had paranoid ideations with auditory hallucinations.

A review of Physician #2's assessment dated 03/11/18 at 2:36 PM revealed the physician ordered laboratory studies (alcohol level was 105), intravenous (IV) fluids, and medications to treat nausea (Zofran) and increase stomach emptying (Reglan). The physician documented that the patient was seen earlier for depression and alcohol dependence and then "apparently went home and drank [a] bottle of Benadryl in effort to kill self." The physician's primary impression was suicidal ideation and alcohol abuse. The physician documented that Patient #2 was "medically" stable and cleared for evaluation/transfer to a psychiatric hospital or unit.

Continued review of Patient #2's medical record revealed staff also documented that the patient's "disposition" was a psychiatric hospital/unit due to suicidal ideation with follow-up instructions to follow up with the CMHC and to follow directions given at the CMHC.

However, review of Patient #2's discharge information revealed nursing staff documented that Law Enforcement "transferred" Patient #2 to a Community Mental Health Center (CMHC) for an "evaluation" for "psych" on 03/11/18 at 5:49 PM. According to the discharge information, the patient was not transferred to a psychiatric hospital/unit as stated in the patient's medical screening documentation. In addition, there was no documented evidence that the patient's transfer was arranged to ensure the patient received stabilizing medical treatment to treat the patient's suicidal ideation/attempt.

An interview with Physician #2 was attempted; however, the physician was not available.

2.(a) Review of the medical record for Patient #3 revealed the patient arrived at the facility on 01/02/18 at 11:16 AM, with Law Enforcement for "clearance for a psych [psychiatric] facility [Facility #2]." According to the patient's record, the patient was seen at a CMHC, where a Mental Inquest Warrant was obtained, and the patient was transferred to the ED. The police officer reported that the patient had been hallucinating. Nursing staff documented that the patient was awake, alert, and oriented to person and place but not date.

At 11:23 AM on 01/02/18, staff documented in the review of systems that Patient #3 had "no symptoms" or "no reported complaints," and had a history of psychiatric drug abuse, marijuana abuse, and methamphetamine abuse. Staff documented on 01/02/18 at 11:25 AM that a suicide assessment was "not applicable."

A review of Physician #2's assessment dated 01/02/18 at 11:32 AM revealed Patient #3's mother initiated the evaluation process. The physician documented that the patient was anxious, confused, had impaired concentration, delusions, paranoia, and visual hallucinations, and was psychotic. The patient also had a history of Bipolar Disorder, polysubstance abuse anxiety, emotional lability, hallucinations, marijuana abuse, methamphetamine abuse, mood changes, and prescription drug abuse. The physician documented that the patient was transferred to "psych" per the Sheriff's Department "stable/cleared." The physician also completed a prescription that stated, "medically stable and cleared for psychiatric eval [evaluation] and transfer."

However, even though Patient #3 had already been evaluated at the CMHC and an MIW had already been obtained for an inpatient psychiatric admission, nursing staff documented that a deputy Sheriff "transferred" the patient back to the CMHC on 01/02/18 at 12:32 PM. There was no documented evidence that the facility provided or arranged for a transfer of the patient to a medical facility for stabilizing treatment of the patient's condition.

2.(b) Continued review of medical records revealed Patient #3 presented to the facility's Emergency Department (ED) again approximately one month later via Emergency Medical Services (EMS) on 02/18/18 at 8:15 PM stating, "I want to die." The facility triaged Patient #3 at 8:18 PM, and documented that the patient "is tired of everything," "hasn't slept for days," and "wants to die." The patient stated he/she was seen at the CMHC and had an appointment the next day. Nursing staff documented that the patient was "drowsy," but the patient stated he/she had only taken prescribed medications. Further review revealed nursing staff conducted a suicide assessment at 8:22 PM on 02/18/18 and documented that the patient's plan was "I don't know; I'll figure something out."

A review of the physician's screening dated 02/18/18 at 8:29 PM revealed the physician documented that Patient #3 "came barreling through the doors demanding help" and "states I want to die." The physician documented that the patient was chronically suicidal but had no actual ideation or attempt, and had Anxiety, Depression, emotional lability, hallucination, methamphetamine abuse, mood changes, and prescription drug abuse. The physician stated Patient #3 was "stable for psych eval [psychiatric evaluation]" and was transferred to a "psych hospital or unit."

However, a review of nursing documentation revealed Law Enforcement "transferred" Patient #3 on 02/18/18 at 10:09 PM to the CMHC for an "eval [evaluation]," and there was no evidence the facility provided or arranged for a transfer for stabilizing treatment of the patient's mental health condition.

3. Review of the medical record for Patient #4 revealed the patient arrived at the facility on 03/09/18 at 7:08 PM and was triaged at 7:11 PM. According to the triage assessment, the patient was accompanied by Law Enforcement and had been treated at a CMHC prior to arrival. The documentation stated the CMHC sent the patient to the ED for medical clearance for a psychiatric hospital admission (at Facility #2). Further review revealed the facility completed a suicide assessment and Suicide Risk Screening on 03/09/18 at 7:18 PM that revealed Patient #4 had attempted suicide by "shooting" 4 grams of meth in his/her left arm. The assessment revealed the patient was having suicidal thoughts and planned to commit suicide by "shooting up with meth." Further review of the assessment revealed the patient had attempted suicide in the past and also had a history of anxiety, depression, and drug use.

A review of Patient #4's physician assessment (Physician #2) dated 03/09/18 at 7:23 PM revealed the patient was sent to the ED from a CMHC for "drug clearance" due to a history of drug abuse/overdose and suicidal ideation. The physician documented that the patient had a history of drug abuse, anxiety/depression, and suicidal ideation. Further review of the physician's documentation revealed the patient was "medically stable and cleared" for an evaluation/transfer for psychiatric treatment and was transferred to a psychiatric hospital/unit for suicidal ideation and substance abuse. The physician also completed a prescription that stated Patient #4 was "medically stable and cleared for psychiatric evaluation."

Further review of Patient #4's Summary Report revealed the patient was transferred to a psychiatric hospital/unit on 03/09/18 at 10:46 PM, with a note that stated, "Good luck with your stay at [Facility #2, a psychiatric hospital]." However, even though Patient #4 had already been evaluated at the CMHC and an MIW had already been obtained for an inpatient psychiatric admission, nursing staff documented that the patient was discharged, police "transferred" the patient back to the CMHC. There was no documented evidence that the facility provided or arranged for a transfer of the patient to a medical facility for stabilizing treatment of the patient's condition.

4. Review of the medical record for Patient #5, an adolescent patient, revealed the patient presented to the ED on 02/22/18 with his/her mother due to "having suicidal thoughts." Patient #5 was triaged at 3:02 PM and a suicide assessment was conducted at 3:11 PM on 02/22/18. The assessment revealed the patient had suicidal thoughts for years. According to the assessment, the patient's suicidal plan was "thought about several things, but has not acted on them." The patient stated he/she had thought about shooting him/herself, but had no access to a gun.

A review of Physician #3's assessment of Patient #5 on 02/22/18 at 3:37 PM, revealed the patient had suicidal thoughts for several years that were worse that day. The physician documented that the patient had a history of anxiety and suicidal ideation, and the patient appeared to be in "mild distress."

Further review of Patient #5's Patient Summary Report revealed on 02/22/18 at 5:15 PM, the facility contacted Police Dispatch to reach the county attorney for a Mental Inquest Warrant.

Continued review of Physician #3's assessment revealed the physician documented that the patient was "medically cleared" and was being transported to a psychiatric hospital/unit by the Sheriff's Office for suicidal ideation. A review of Patient #5's "disposition" also revealed the patient was transferred to a psychiatric hospital/unit on 02/22/18 at 5:45 PM. However, further review of the Patient Summary Report revealed nursing staff documented that Law Enforcement arrived at 5:25 PM on 02/22/18 "for citation and to transport patient" to the CMHC. According to the summary report, the patient was discharged on 02/22/18 at 5:46 PM with police who planned to transfer the patient to the CMHC. There was no evidence the facility arranged for Patient #5's transfer to a psychiatric hospital/unit for stabilizing medical treatment.

5. Review of the medical record for Patient #6 revealed the patient presented to the ED on 02/15/18 at 6:25 PM via Emergency Medical Services (EMS) with "sores all over body." Patient #6's triage assessment revealed the patient stated he/she had sores on the bottom of the left foot, leg, and head; fever; and diarrhea. The patient reported he/she woke up every day with new sores all over the body and had been out of his/her medications for one week.

Continued review of Patient #6's Patient Summary Report dated 02/15/18 at 7:55 PM, revealed the patient stated he/she was homeless. The report revealed the facility contacted Adult Protective Services and Police Dispatch, but was unsuccessful in finding shelter for Patient #6.

Review of a Suicide Assessment dated 02/15/18 at 9:00 PM, revealed Patient #6 stated he/she had "nowhere to go and was going to walk into traffic." Patient #6 agreed to go to Facility #3, an acute care hospital with a behavioral health unit. The facility documented that they contacted Facility #3 and was waiting for a return call. However, at 10:05 PM, Facility #3 stated they could not accept the patient transfer and the facility contacted Law Enforcement to obtain a Mental Inquest Warrant.

A review of the physician assessment for Patient #6 dated 02/15/18 at 7:22 PM, revealed Physician #3 documented that the patient had gotten bed bug bites since moving to a friend's house, the patient's friend took his/her medications, and the patient stated he/she was suicidal. The physician documented that the patient had an elevated blood sugar level and was positive for methamphetamines and marijuana. The physician's primary impression was suicidal ideation and insect bites. The physician documented that Patient #6 was "medically cleared for evaluation and treatment at a behavioral health facility" for suicidal ideation and was being transported by police. Further review revealed the physician also wrote a prescription that stated the patient was "medically cleared for evaluation and treatment at a behavioral health facility."

Further review of Patient #6's medical record revealed the patient's "disposition" on 02/15/18 at 11:00 AM was "transferred" to a psychiatric hospital/unit with instructions to follow up with his/her family physician in two to three days and to return to the ED if symptoms became worse. However, Patient #6's "discharge" documentation revealed the patient left in police custody with a Mental Inquest Warrant and there was no evidence the facility arranged for the transfer of Patient #6 to ensure the patient received stabilizing treatment.

6. Review of the medical record for Patient #7 revealed the patient presented to the ED on 02/13/18 at 11:22 PM, accompanied by police officers. A review of the patient's triage assessment on 02/13/18 at 11:25 PM revealed Patient #7 smelled of alcohol and stated he/she wanted to kill him/herself. The patient stated he/she planned to stab himself and have police "finish [him/her] off." The patient also stated he/she had used intravenous methamphetamine.

A review of a Suicide Assessment completed at 11:32 PM and a Suicide Risk Screen completed at 11:34 PM on 02/13/18 revealed Patient #6 continued to state that he/she was going to stab him/herself and have the police "finish it." According to police, when they arrived at the patient's home the patient had a knife to his/her throat. The assessment further revealed Patient #7 had just been released from Facility #2, a psychiatric hospital, earlier that day.

A review of Patient #7's physician assessment (Physician #2) dated 02/13/18 at 11:34 PM, revealed the patient was suicidal and had put a knife to his/her throat. The physician further documented that Patient #7 had overdosed the week before and was sent to a CMHC, and then to Facility #2. Further review revealed the patient was being seen that day for medical clearance prior to a psychiatric transfer. The physician documented that the patient was laughing and in good spirits now. Patient #7 had a history of alcohol abuse, intravenous drug abuse, methamphetamine abuse, suicidal ideation, emotional lability, and depression. Further review revealed Patient #7 was "medically" clear for a psychiatric evaluation and transfer, and was transferred to a psychiatric hospital/unit due to a suicidal attempt and alcohol abuse.

A review of Patient #7's medical record revealed staff documented that the patient's "disposition" was a psychiatric hospital/unit on 02/14/18 at 12:20 AM, with additional instructions to "go to [a CMHC] with police for evaluation." A review of "discharge" documentation revealed Patient #7 was transferred to a CMHC with police. However, there was no documented evidence that the facility arranged for the discharge to ensure the patient received stabilizing medical treatment.

7. Review of the medical record for Patient #8 revealed the patient presented to the Emergency Department on 01/27/18 accompanied by police with suicidal ideation. Review of the patient's triage assessment completed on 01/27/18 at 11:23 PM, revealed the patient's neighbor called police because the patient was "in the yard acting crazy." The police stated that when they arrived the patient asked police to shoot him/her in the head. The patient reported he/she drank nine bottles of beer.

Review of a Suicide Assessment completed for Patient #8 at 11:26 PM on 01/27/18 and a Suicide Risk Assessment completed at 11:27 PM revealed the patient was not currently having thoughts of self-harm.

Review of Patient #8's blood alcohol levels revealed on 01/27/18 at 11:43 PM the patient's blood alcohol level was 258, on 01/28/18 at 2:00 AM the level was 210, at 4:11 AM it was 169, and at 7:05 AM it was 120.

A review of Physician #4's assessment dated 01/27/18 at 11:46 PM revealed the patient became intoxicated, went to a neighbor's house acting belligerently, and asked police to shoot him/her in the head prior to arrival at the ED. The physician documented that the primary impression was alcohol intoxication and the patient would be released into police custody for transfer to the CMHC due to suicidal ideation.

Further review of Patient #8's medical record revealed the physician wrote a prescription dated 01/28/18, that the patient was "medically" cleared for an evaluation at the CMHC. However, it was documented in the physician assessment that Patient #8 was transferred to a psychiatric hospital/unit. In addition, staff also documented that the patient's "disposition" was a transfer to a psychiatric hospital/unit, with additional instructions to go to the CMHC for evaluation. The facility documented that the patient was "transferred" to the CMHC on 01/28/18 at 7:33 AM via police custody; however, there was no evidence that the facility arranged for the patient's transfer to ensure Patient #8 received stabilizing medical treatment.

8. Review of the medical record for Patient #9 revealed the patient presented to the ED on 12/02/17 via Emergency Medical Services (EMS) due to an overdose. Review of the patient's triage assessment at 2:03 PM on 12/02/17 revealed the patient was found in a driveway, leaning into a car window, sleeping. The assessment revealed the patient's speech was slurred; fell asleep when not stimulated; and had equal, but pinpoint pupils. The patient stated he/she had taken Neurontin (a medication used to prevent and control seizures and treats nerve pain that shares characteristics of medications associated with misuse and addiction), a fentanyl "lollipop" (a prescription opioid pain medication in the form of a lollipop to be used for the treatment of breakthrough pain in cancer patients), and chewed a 100 milligram fentanyl patch (the opioid medication can also be absorbed from a patch on the skin to treat pain). The patient's significant other also reported the patient had taken Xanax. According to the patient, he/she had taken the medications over several hours because he/she was in pain, and did not have suicidal or homicidal tendencies. A review of an Overdose Assessment completed at 2:22 PM on 12/02/17, revealed the patient intentionally overdosed on fentanyl, Neurontin, and Xanax.

Further review of Patient #9's medical record revealed the facility administered Narcan (a medication used to treat an overdose in an emergency situation) at 2:03 PM on 12/02/17. Further review revealed at 2:40 PM on 12/02/17, nursing staff documented that Patient #9 was awake and alert after the Narcan, but was combative and wanted to leave the facility. A fentanyl patch was seen inside the patient's mouth and was removed and discarded. According to the nursing documentation, Patient #9 made a statement while staff was present that he/she was going to go home and "blow [his/her] brains out."

A review of Physician #4's assessment of Patient #9 on 12/02/17 at 2:38 PM, revealed the patient's girlfriend found the patient intoxicated in his/her vehicle, and the patient had apparently been chewing on a fentanyl patch and had taken Neurontin. The physician's report revealed Patient #9 denied suicidal ideation. However, the physician stated because the patient had threatened "blowing [his/her] head off," the physician completed documentation to obtain an MIW and Patient #9 was being transferred to a psychiatric hospital/unit.

Continued review of Patient #9's medical record revealed at 2:50 PM on 12/02/17, police were at the facility to initiate an MIW due to the patient's suicidal comment. At 3:01 PM, nursing staff documented that the patient was calm and the patient stated he/she had made the comment out of anger and would not commit suicide; however, staff explained that since the patient made the comment, he/she would have to be evaluated at the CMHC and they would determine whether the patient was suicidal and in need of treatment. Further review of Patient #9's Patient Summary Report dated 12/02/17 at 3:20 PM revealed an MIW was signed for Patient #9 and Law Enforcement was present.

Review of Patient #9's Departure Information dated 12/02/17 at 3:57 PM, revealed the patient was transferred to a psychiatric hospital/unit. However, a review of the patient's "discharge" information revealed the patient was discharged with a Sheriff's deputy to be "transferred" to a CMHC, even though an MIW had been obtained. Regardless, there was no evidence the facility arranged for the patient's transfer to ensure the patient received stabilizing medical treatment for the patient's suicidal ideation.

Interviews with Registered Nurse (RN) #1 on 03/15/18 at 10:37 AM, RN #2 on 03/15/18 at 11:00 AM, and RN #3 on 03/15/18 at 12:10 PM revealed they worked as nurses in the ED. The RNs stated that when a patient presented with a psychiatric medical condition the patient was "transferred" to an outpatient facility, a CMHC, for an evaluation because the facility (Facility #1) did not have staff capable of evaluating/treating patients with suicidal ideation. Continued interviews revealed that normal procedure was to triage the patient, "medically clear" the patient, and then refer them to the outpatient community mental health center for an evaluation. However, the RNs stated they did not arrange for the patients' transfer or complete "transfer" paperwork for the patients because police officers "transferred" them to the outpatient facility.

Interview with the Chief Nursing Officer (CNO) on 03/13/18 at 12:03 PM revealed the facility only had the capability to complete a drug screen and a "medical workup" for patients who presented with a behavioral health concern, but did not have the means to provide a behavioral health assessment or treatment. The CNO stated that when a patient presented with a behavioral health emergency, the facility's procedure was to contact Law Enforcement who transferred the patient to the local CMHC for an evaluation. According to the CNO, police could not transport the patient unless they were under arrest, so prior to transfer, the patient was placed under arrest. The CNO further stated that the CMHC arranged transportation from there if the patient needed to be admitted to a psychiatric hospital/unit. The CNO stated the facility did not contact the CMHC and arrange for the patient to be transferred, and stated that technically the patient was being discharged from the facility when they were "transferred" to the CMHC.

Interview with the ED Medical Director on 03/15/18 at 12:47 PM revealed he had concerns about the way Facility #1 handled "transfers" of suicidal patients; however, there was no evidence action had been taken to address the concerns. The Medical Director stated that the facility usually just "medically" cleared patients with psychiatric diagnoses, and then referred them to the local community mental health center for evaluation.

Based on interviews, record reviews, and review of facility policies it was determined the facility failed to appropriately transfer one (1) of twenty (20) patients (Patient #1). On 03/05/18, the facility (Facility #1) transferred Patient #1 to Facility #2 (a psychiatric hospital) for stabilizing medical treatment. However, the facility failed to ensure the physician certified that the medical benefits expected from Patient #1's transfer to another medical facility outweighed the risks, with a summary of the risks and benefits upon which the transfer was based. The facility also failed to ensure Patient #1's medical records related to the emergency condition were provided to the receiving hospital (Facility #2).

The findings include:

Review of the policy titled, "Transfer of Patient to Another Acute Care Facility," dated December 2012, revealed patients that required more extensive care than provided at the facility would receive a medical screening and be stabilized to the extent possible prior to transfer to another facility that offered the required services. The policy stated the physician transferring the patient must complete arrangements with the receiving physician through direct communication before the patient left the facility. Continued review of the policy revealed the facility must complete the "Inter-Agency Patient Transfer Form," and provide the receiving facility with appropriate copies of the patient's medical record, including a copy of the patient's Advance Directives if available, Patient Transfer Form with the Consent for Transfer, and the original Inter-Agency Patient Transfer Form.

Review of the medical record revealed Patient #1 presented to the facility on 03/05/18 at 3:48 AM, with Suicidal Ideation and Alcohol Abuse, accompanied by Law Enforcement. A review of Patient #1's triage assessment dated 03/05/18 at 3:50 AM, revealed Law Enforcement presented with the patient for "medical clearance" prior to being admitted to an inpatient psychiatric hospital (Facility #2) due to suicidal ideation. The patient also stated he/she had not taken his/her blood pressure medication. Further review revealed at 3:57 AM on 03/05/18, the patient's blood pressure was 182/111 (normal is below 120/80).

An interview with Registered Nurse (RN) #2 on 03/15/18 at 11:00 AM, revealed the patient had been seen at an outpatient Community Mental Health Center (CMHC) prior to arrival at the Emergency Department (ED). The CMHC arranged for the patient to be transferred to Facility #2; however, Facility #2 wanted the patient to be assessed prior to the transfer to ensure the patient was medically stable.

Continued review of Patient #1's medical record revealed the facility conducted a Suicide Assessment at 4:15 AM on 03/05/18, and indicated that Patient #1 stated that he/she was "no longer suicidal."

Review of the physician's report dated 03/05/18 at 4:37 AM, revealed Patient #1 was "very intoxicated," had sent a picture to his/her brother with a gun to his/her head, and was at the ED for medical clearance. According to the assessment, the patient drank daily and drank to excess on this night, but had no history of suicidal/homicidal ideation. The physician's report revealed the patient was intoxicated, but was medically cleared and stable. According to the physician's report, Patient #1 was transferred to a psychiatric hospital/unit.

Further review of Patient #1's medical record revealed on 03/05/18 at 4:48 AM, staff faxed the patient's summary report and physician report to Facility #2 at their request. At 5:35 AM on 03/05/18, RN #2 documented that she had attempted to fax information to Facility #2 multiple times; however, Facility #2 had not received the information. According to the documentation, RN #2 asked Facility #2's charge nurse about giving a physician to physician verbal report regarding Patient #1; however, Facility #2's physician refused to accept a verbal report and stated that if Facility #1 sent the patient without a faxed report, it would be an EMTALA violation. However, a review of a nursing note dated 03/05/18 at 6:13 AM revealed Facility #2 accepted the transfer of Patient #1, and the patient was discharged to "home" with Law Enforcement officers at 6:14 AM on 03/05/18.

Further review of Patient #1's medical record revealed Physician #2 documented on a prescription pad that the patient was "medically stable and cleared for a psychiatric evaluation." However, there was no documented evidence in the medical record that the physician certified the transfer and completed a Patient Transfer Form (Inter-Agency Referral), Consent to Transfer, or Physician's Certificate of Transfer (which includes the risks and benefits of the transfer), according to the facility's policy. There was no documented evidence that the facility provided Facility #2 with Patient #1's medical record related to the patient's emergency medical condition.

An interview with Physician #2 was attempted. The physician was not available for interview, but provided a written response regarding the care of Patient #1 on 03/05/18. According to the physician, Patient #1's ED visit was for "medical clearance" only. The physician's written response stated the patient was brought to the ED by the local Community Mental Health Center and Law Enforcement and was "their patient, their responsibility, and under their control" due to a Mental Inquest Warrant. The written response further stated that the Community Mental Health Center had already contacted Facility #2. According to Physician #2's documentation, Patient #1 was transferred via Law Enforcement when Facility #2 accepted verbal report.

Interview with RN #2 on 03/15/18 at 11:00 AM revealed she recalled caring for Patient #1 and she stated she did not complete the appropriate transfer paperwork as required. RN #2 stated that because Law Enforcement and a social worker from the Community Mental Health Center had secured a bed for Patient #1 at Facility #2, she did not think Facility #1 had to complete paperwork for Patient #1's transfer.