HospitalInspections.org

Based on the hospital's Emergency Medical Treatment and Labor Act (EMTALA) policies, medical record review 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 MSE, and patients with an emergency psychiatric medical condition received stabilizing treatment for 8 of 20 (Patients #1, #2, #7, #10, #11, #12, #13, and #17) sampled patients, and the facility failed to provide a Physician Certification For Transfer for 3 of 7 (Patient #7, #13 and #17) sampled patients transferred from Hospital #1's Intake Assessment Department.

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

Based on review of medical records, medical staff bylaws, Emergency Department Logs, daily census reports, ambulance run trip reports, State Health Related Board rules, 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 (MSE) 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 8 of 20 (Patients #1, 2, 7, 10, 11, 12, 13, and 17) 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 bylaws General Rules and Regulations.

The findings included:

1. Review of Hospital #1's (an acute care/Psychiatric hospital) EMTALA (Emergency Treatment and Labor Act) policy revealed, "...Any individual who presents on the property of [Delta Medical Center -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 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 1 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..." Section 5 revealed, "...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 Amended and Restated Governing Board Bylaws revealed, "...Allied Health Professionals or "AHP" means an individual, other than an allopathic physician, osteopathic physician, clinical psychologist, podiatrist, nurse practitioner, or dentist, who is permitted by law and the Medical Staff to provide patient care services within the scope of their license, certificate, or other legal credentials in accordance with individually granted Clinical Privileges. Allied Health Professionals are not members of the Medical Staff...Licensed Independent Practitioner or "LIP" means any individual permitted by law and by the Hospital, in accordance with the limits established by the Governing Board and the Medical Staff, to provide patient care and services at the Hospital without direct supervision, but within the scope of the individuals' license and consistent with individually granted Clinical Privileges..."

The facility's amended and restated Governing Body Bylaws failed to state which Allied Health Professionals were determined qualified by the Governing Body to conduct medical screening examinations.

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 determining 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 as an emergency medical condition.

10. Medical record review revealed Patient #1 was a 52 year old male with a history of suicidal ideations and hallucinations. The patient had insurance, but had no days remaining on his plan to pay for services. The patient was also homeless.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #1 presented via car to the psychiatric IAD on 10/31/19 at 4:20 PM with 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 the EMTALA MSE form dated 10/31/19 at 4:20 PM revealed Registered Nurse (RN) #1 performed the examination to determine if an emergency medical condition existed. RN #1 documented Patient #1 had suicidal ideations without a plan, had been hearing voices and seeing things, had not been taking his medications, and had been smoking crack cocaine. Under the assessment section titled Assessment Findings on the MSE, RN #1 documented the patient met the criteria for Emergency Medical Condition based on risk of imminent harm to self/others due to psych conditions.

At 8:20 PM, a total of 4 hours after the MSE was completed, Assessor #1, who had a Masters in Social Work degree, performed the psychiatric IAD assessment to determine if an emergency psychiatric condition existed and documented, "The patient presents with suicidal ideations, he reports feeling sad, depressed, confused, frustrated. Patient reports hallucinations hearing voices and a history of alcohol/drug use..." The Level of Care Recommendations section revealed Patient #1 had an "Acute psychiatric condition requires 24 hour skilled nursing/medical oversight..."

Review of the Columbia-Suicide Severity Rating Scale dated 10/31/19 and completed by Assessor #1 revealed the patient was at "low risk" for suicide.

Review of the 10/31/19 Crisis Assessment performed via telehealth at 10:40 PM by a mobile crisis agency's Master of Science employee revealed, "...Patient presents as danger to self and others AEB [as evidenced by] SI [suicidal ideations] and psychosis. Patient stated he has been off his meds for about 2 weeks. Patient was not able to remain at [Hospital #1(an acute care/Psychiatric hospital)] due to patient having no Medicare days left. No one was able to contact for safety of patient. Therefore, due to acuity, patient was referred to [Hospital #3 - a psychiatric hospital] Referral is pending...Voluntary Admission: No..."

Review of the Medical Clearance Form completed by the mobile crisis agency on 11/1/19 at 12:58 AM revealed "...Cocaine use...Please send patient for med clearance. Obtain Labs...H & P [history and physical]..."

Review of the Memorandum of Transfer (EMTALA) form revealed RN #2 signed as the transferring physician per telephone orders. RN #2 documented she contacted Hospital #2 (an acute care hospital) as the receiving hospital on 11/2/19 at 8:25 AM. There was no documentation who the physician was at the receiving hospital. Under the section titled, "section to be completed if patient's emergency medical condition has not been stabilized prior to transfer" revealed, "...Patient needs admittance to [Hospital #3 - a psychiatric hospital)] for psychiatric care for command auditory hallucinations to harm himself. He is required to get medical clearance that is not provided at [Hospital #1 - an acute care/Psychiatric hospital] including labs and diagnostics..." signed by RN #2 for Physician #1.

Review of the Physician Certificate of Transfer form stated Patient #1 "...needs medical clearance not provided by sending facility in order to be admitted to [Hospital #3 -a psychiatric hospital] for psychiatric care..." RN #2 signed in the area titled Transferring Physician/Registered Nurse.

Review of the IAD EMTALA log revealed Patient #1 was discharged on 11/1/19 at 9:10 AM. The mode of departure was not documented. The EMTALA log documented the patient's disposition as "transferred for medical."

The patient was in Hospital #1's (an acute care/Psychiatric hospital) IAD receiving area for every 5 minutes observations from 4:20 PM on 10/31/19 until 9:10 AM on 11/1/19, a total of 16 hours and 50 minutes. During this time there was no documentation the patient had received an appropriate psychiatric screening examination by a qualified LIP or Psychiatrist, treatment or stabilization prior to being transferred.

Review of Ambulance Service #1's run report revealed they responded to Hospital #1 (an acute care/Psychiatric hospital) on 11/1/19 at 9:10 AM to transport the patient to Hospital #2 (an acute care hospital). Hospital #2 conducted an appropriate MSE, diagnosed the patient with Acute psychosis and discharged the patient back to Hospital #1.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #1 returned to Hospital #1 on 11/1/19 at 1:27 PM via ambulance with 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 Hospital #1's IAD notes dated 11/1/19 revealed Patient #1 returned to the hospital at 1:30 PM. Hospital #1 contacted Hospital #3 and requested the patient to be transferred to their care. At 4:30 PM, Patient #1 remained at Hospital #1 and had still not had any treatment for the diagnosis of Acute psychosis.

An un-timed nurse's note dated 11/1/19 revealed Physician #2 was notified Patient #1 remained in the IAD and the nurse documented, "...he [Physician #2] still does not want to accept pt [patient] due to pt reaching therapeutic maximum benefit...Pt malingering [the intentional production of false or grossly exaggerated physical or psychologic symptoms], homeless..." There was no documentation Physician #2 had performed a MSE to make this determination.

A nurse's note dated 11/1/19 at 5:00 PM and 5:30 PM revealed the nurse contacted Hospital #3 again requesting Patient #1's transfer and was notified by Hospital #3 the physician was "busy." Patient #1 examined remained in Hospital #1's IAD until 10:20 PM, a total of 8 hours and 45 minutes without receiving an appropriate MSE, stabilization or treatment for the diagnosis of Acute Psychosis.

Review of the Physician Certificate of Transfer form stated Patient #1 needed "treatment not offered at present facility." RN #1 signed in the area titled "Transferring Physician/Registered Nurse. Review of Ambulance Service #1's run report revealed they responded to Hospital #1 on 11/1/19 at 10:03 PM to transport the patient to Hospital #3.

Review of the IAD EMTALA log revealed Patient #1 was discharged on 11/1/19 at 10:27 PM and departed the hospital by "ambulance." The EMTALA log documented the patient's disposition as "Transferred."

Review of Hospital #1's daily census report revealed the hospital had beds available on both 10/31/19 and 11/1/19 to admit, stabilized and treat Patient #1.

In an interview on 11/6/19 at 1:47 PM in the conference room, the Director of Intake reported Physician #2 didn't want to admit Patient #1 because he thought he was malingering. She continued and reported the mobile crisis team was consulted because the patient had no insurance and they thought he needed to be admitted for treatment at Hospital #3 (a psychiatric hospital). She stated Hospital #3 required all patients to be medically cleared, so the patient was sent to Hospital #2 (acute care/psychiatric hospital) for medical clearance. The Director of Intake was asked if they refused to admit him due to his lack of medical insurance coverage and she stated, "No, his doctor felt he had reached his maximum therapeutic benefits here and wanted to try a different facility."
The Director of Intake was asked what took so long for the patient to be transferred and the Director stated, " [named Hospital #3 a psychiatric hospital] kept asking us for more information before they would accept him."

In a telephone interview on 11/7/19 at 2:00 PM, Physician #2 was asked what he could recall regarding Patient #1 and the physician stated, "He [Patient #1] came over here [Hospital #1 IAD EMTALA unit] and we called mobile crisis. They recommended he go to [Hospital #3 a psychiatric hospital]. They [Hospital #3] were asking for paper work and get him medically cleared...they still wouldn't accept him and kept asking for more and more information. They finally accepted him."
Physician #2 was asked if he refused to admit the patient for any reason and the physician stated, "We kept trying to communicate with [Hospital #3], it was an unnecessary delay."
Physician #2 was asked if he ever refused to accept patients when they were out of coverage days on Medicare and the physician stated, "No, we ask mobile crisis to evaluate them and they refer them to [Hospital #3]."

11. Medical record review revealed Patient #2 was a 64 year old male with a history of alcohol abuse. The patient had insurance.

Review of Hospital #1's (an acute care/Psychiatric hospital) psychiatric IAD EMTALA log revealed Patient #2 presented via car to the psychiatric IAD on 10/22/19 at 2:40 PM with chief complaint of "CD [chemical dependency]" and had an "Emergency Medical Psych Condition." There was no documentation who determined the patient had an emergency psychiatric condition.

Review of the EMTALA MSE form dated 10/22/19 at 3:15 PM revealed RN #1 performed the examination to determine if an emergency medical condition existed. RN #1 documented Patient #2 was there because of his alcohol abuse and reported he drank 1 to 1 ½ pints of vodka daily. Under the assessment section titled Assessment Findings on the MSE, RN #1 documented the patient met the criteria for Emergency Medical Condition based on risk of imminent harm to self/others due to psych conditions.

On 10/22/19 at 5:00 PM, RN #3 performed the psychiatric IAD assessment to determine if an emergency psychiatric condition existed and documented the patient came to the IAD with complaints of alcohol abuse and severe depression. RN #3 documented Patient #2 needed surgery for a medical condition but was informed he had to detox from alcohol in order to have the surgery. The patient denied suicidal or homicidal ideations.

Review of the Columbia-Suicide Severity Rating Scale dated 10/22/19 and completed by RN #3 revealed the patient was at "low risk" for suicide.

Review of the notes written on page 2 of the EMTALA MSE form dated 10/22/19 at 7:25 PM revealed RN #1 documented, "Received order from [Physician #2] to send pt [patient] for medical clearance..." RN #1 documented the ambulance service was on the scene to transport Patient #2 to Hospital #2 (an acute care hospital) at 8:37 PM.

Review of the Memorandum of Transfer (EMTALA) form 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.

The Physician Certificate of Transfer form stated Patient #2 needed "care not available at [Hospital #1]. RN #1 signed in the area titled "Transferring Physician/Registered Nurse.

Review of the IAD EMTALA log revealed Patient #2 was discharged on 10/22/19 at 8:42 PM and departed the hospital by "ambulance." The EMTALA log documented the patient's disposition as "Transferred." Review of Ambulance Service #1's run report revealed they responded to Hospital #1 (an acute care/Psychiatric hospital) on 10/22/19 at 8:37 PM to transport the patient to Hospital #2 (an acute care/Psychiatric hospital) for "alcohol abuse."

The patient was in Hospital #1's IAD receiving area from 3:25 PM until 8:35 PM on 10/22/19, a total of 5 hours and 10 minutes. During this time there was no documentation the patient had received an appropriate psychiatric screening examination by a qualified LIP or Psychiatrist, treatment or stabilization prior to being transferred.

Review of Hospital #1's daily census report revealed the hospital had beds available on 10/22/19 to admit, stabilized and treat Patient #2.

12. Medical record review revealed Patient #7 was a 44 year old male with a history of paranoid behavior, delusions, and hallucinations. The patient did not have insurance.

Review of Hospital #1's (an acute care/Psychiatric hospital) psychiatric IAD EMTALA log revealed Patient #7 presented via car to the psychiatric IAD on 10/26/19 at 2:49 PM with chief complaint of "psych" and did not have an "Emergency Medical Psych Condition." There was no documentation who determined the patient did not have an emergency psychiatric condition.

On 10/26/19 at 2:55 PM, Assessor #4, who has a Masters in Community Counseling, performed the psychiatric IAD assessment to determine if an emergency psychiatric condition existed and documented the patient came to the IAD requesting "blood work because someone injected him with something..." The Assessor documented the patient denied suicidal/homicidal ideations, was non-compliant with his medications, and was having auditory hallucinations. The Assessor documented Patient #7 had a "Grave disability with severe deterioration in functioning." Assessor #4 documented Physician #3 was contacted at 3:08 PM with recommendations to refer Patient #7 to the mobile crisis agency. The Assessor documented at 4:29 PM Physician #3 recommended for patient to be seen at Hospital #3 (a psychiatric hospital). There was no documentation the physician or LIP performed a MSE to determine if an emergency condition existed.

Review of the EMTALA MSE form dated 10/26/19 at 4:10 PM revealed RN #4 performed the examination to determine if an emergency medical condition existed. RN #4 documented Patient #7 was cooperative, confused, and reported "sometime I hear voices." Under the assessment section titled Assessment Findings on the MSE, RN #4 documented the patient did not meet the criteria for an Emergency Medical Condition.

Review of the Columbia-Suicide Severity Rating Scale dated 10/26/19 and completed by Assessor #4 revealed the patient was at "low risk" for suicide.

Review of the 10/26/19 Crisis Assessment performed via telehealth at 5:18 PM by a mobile crisis agency's Licensed Master of Social Work employee revealed, "...Client [Patient #7] reports hearing voices and seeing people..." The section titled Justification of Disposition revealed Patient #7 "meets criteria for inpatient level of care. Client reports that people are playing mind games...experiencing symptoms of paranoia and anxiety...audio and visual hallucinations...Voluntary Admission: No..."

Review of the IAD EMTALA log revealed Patient #7 was discharged on 10/26/19 at 9:51 PM and departed Hospital #1 by "ambulance." The EMTALA log documented the patient's disposition as "Referred." The patient was in Hospital #1's IAD from 2:50 PM until 11:00 PM on 10/26/19, a total of 8 hours and 10 minutes. There was no documentation the patient had experienced any issues or behaviors while in Hospital #1's IAD.

Review of Ambulance Service #2's trip report revealed the ambulance service had responded to Hospital #1's IAD on 10/26/19 at 9:43 PM and found Patient #7 sitting on the floor in the lobby with hospital staff, first responders and police officers surrounding the patient. The paramedic documented on the trip report, "...There was broken glass all along the floor and blood. Pt [Patient #7] allegedly used a fire extinguisher and other objects to threaten staff members and break glass partitions..." The paramedic further documented had police arrived on the scene and the patient was tazed and tackled and had suffered lacerations to his forearms, right knee and his forehead. The paramedic documented upon the ambulance personnel's arrival, Patient #7 was in handcuffs. The paramedic documented Patient #7, along with a police officer, was transported to Hospital #4's (an acute care hospital) emergency department for evaluation and treatment.

During this time there was no documentation the patient had received an appropriate psychiatric screening examination by a qualified LIP or Psychiatrist, treatment or stabilization prior to being transferred.

When questioned about the incident with Patient #7 and the lack of documentation in the patient's medical record about the incident, the Chief Sustainability Officer provided an incident report dated 10/26/19 at 8:30 PM and was tilted, "Non-patient incident report". Review of the report revealed, "...Patient psychotic. Attacked staff with fire extinguisher, spraying multiple employees in the face and damaging property. Police and Fire responded and patient taken by ambulance to hospital [Hospital #4]..."

The was no documentation of the incident or combative behaviors noted in Patient #7's medical record.
RN #4 documented the patient did not meet the criteria for an Emergency Medical Condition. The Assessor had documented Patient #7 as, "Grave disability with severe deterioration in functioning." There was no evidence a physician, or LIP performed a medical/psychiatric examination to determine if an emergency condition existed. Patient #7 remained in Hospital #1's IAD area for 8 hours and 10 minutes without stabilization or treatment. Patient #7 experienced a psychotic episode on the premises of Hospital #1. After the patient experienced the psychotic episode, there was still no documentation a physician or LIP examined and treated Patient #7.

There was no Memorandum of Transfer (EMTALA) form or Physician Certificate of Transfer form completed by Hospital #1 to transfer to Hospital #3. There was no documentation of the accepting physician at Hospital #4.

Review of Hospital #4's (an acute care hospital) emergency documentation dated 10/26/19 at 10:35 PM revealed, police informed hospital staff that Patient #7 was at Hospital #1 (an acute care/Psychiatric hospital) when he became upset and started spraying the nurse with a fire extinguisher, then broke the glass in the area with a table leg, and police were called to the scene. Upon police arrival, Patient #7 tried to run, and was subsequently stunned with a taser (a weapon firing barbs attached by wires to batteries, causing temporary paralysis) and restrained by the police, landed on the ground in the glass resulting in lacerations to his knees and forehead. The patient was treated, diagnosed with Altered Mental Status and laceration abrasions and was transported to Hospital #3 (a psychiatric hospital) by the police.

Review of Hospital #1's daily census report revealed the hospital had beds available on 10/26/19 to admit, stabilized and treat Patient #7.

In an interview on 11/7/19 at 12:27 PM in the conference room, the Director of Intake reported Patient #7 was not appropriate for Hospital #1 (an acute care/Psychiatric hospital) because of his behaviors. She reported the patient "ripped a fire extinguisher off the wall."

In an interview on 11/7/19 at 4:00 PM in the conference room, RN #4 reported Patient #7 was too aggressive to remain at Hospital #1 and no doctors would accept him for admission. He further reported Patient #7 ripped a fire extinguisher out of the wall and left the facility at 11:00 PM to go to Hospital #3.

Patient #7's visit to the psychiatric IAD at Hospital #1 resulted in the patient not receiving an appropriate and ongoing MSE by a QMP, and not receiving treatment and stabilization which resulted in Patient #7 experiencing a psychotic episode, receiving lacerations, and being tazed by the local police department.

13. Medical record review revealed Patient #10 was a 37 year old female with a history of opioid abuse and alcohol dependence. The patient had insurance.

Review of Hospital #1's psychiatric IAD EMTALA log revealed Patient #10 presented via car to the hospital's psychiatric IAD on 10/28/19 at 8:33 PM with the chief complaint of "CD [chemical dependence]" 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 MSE dated 10/28/19 at 7:45 PM revealed RN #1 performed the examination on Patient #10. RN #1 documented the patient stated she had been using cocaine and heroin 1 gram or more each day. Under the assessment section titled Assessment Findings, RN #1 documented the patient met criteria for Emergent Medical Condition based on risk of imminent harm to self and others due to psych conditions.

On 10/28/19 beginning at 3:13 PM, Assessor #2, who had a Master of Science in Psychology, performed an psychiatric IAD assessment to determine if an emergency psychiatric condition existed and documented the patient referred herself for treatment stating she has been unable to stop using heroin and cocaine. The Assessor documented the patient was depressed and had lost 30 pounds in the last 3 months. The Assessor documented the patient's suicide risk was "low risk". Under the assessment section titled Level of Care Recommendation Assessor #2 documented, "[Patient #10] 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 or treatment and stabilization provided.

On 10/29/19 at 11:30 AM Patient #10 signed herself out of the hospital against medical advice (AMA). Patient #10 stated she was not ready for residential treatment and preferred outpatient treatment.

On 10/29/19 at 1:25 PM Patient #10 presented back to the psychiatric IAD at Hospital #1 with the chief complaint of "CD [chemical dependence]" and had an "Emergency Medical Psych Condition". There was no documentation who determined the patient had an emergency psychiatric condition.

Review of Patient #10's EMTALA MSE dated 10/29/19 at 3:30 PM revealed RN #1 performed the examination on Patient #10. RN #1 documented the patient stated she needed to complete her treatment. Patient stated she used about "1/10th of heroin" while she was out of the hospital. Under the assessment section titled Assessment Findings, RN #1 documented the patient met criteria for Emergent Medical Condition based on risk of imminent harm to self and others due to psych conditions.

On 10/29/19 beginning at 3:13 PM, Assessor #3, who had a Master of Science in Counseling, performed a psychiatric IAD assessment addendum to determine if an emergency psychiatric condition existed and documented the patient reported she left inpatient treatment AMA around lunch today. The patient reported prior to coming back she used "1/10 of heroin IV [intravenous]...Denied use of any other substances and denied withdrawal symptoms...Denies SI [suicidal ideations] and HI [homicidal ideations]". The Assessor documented Patient #10 reported she has an appointment with an outpatient treatment center. Assessor notified patient that she will be provided with more outpatient referral sources. There was no documentation a LIP, physician or Psychiatrist performed an MSE to determine if an emergency medical condition (EMC) existed.

On 10/29/19 at 6:20 PM Patient #10 was discharged from Hospital #1 and referred to outpatient services.

Review of Hospital #1's daily census report revealed the hospital had beds available on this date to admit, stabilize and treat Patient #10.

14. Medical record review revealed Patient #11 was a 60 year old male with a history of hypertension and emphysema. The patient did not have insurance.

Review of Hospital #1's (an acute care/Psychiatric hospital) psychiatric IAD EMTALA log revealed Patient #11 presented via car on 10/30/19 at 11:30 AM with the chief complaint of "CD [chemical dependence]" and had an "Emergency Medical Psych Condition".

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 7 of 20 (Patients #1, 2, 7, 11, 12, 13, and 17) 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, "...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 provide immediate medical attention so that no deterioration of the condition is likely..."

2. Medical record review revealed Patient #1 was a 52 year old male with a history of suicidal ideations and hallucinations.

Review of Hospital #1's (an acute care/Psychiatric hospital) psychiatric IAD EMTALA log revealed Patient #1 presented via car to the psychiatric IAD on 10/31/19 at 4:20 PM with chief complaint of "psych" and had an "Emergency Medical Psych Condition."

Review of the Intake Assessment beginning at 8:20 PM revealed the patient was having suicidal ideations, feelings of sadness, depression, had a history of alcohol and drug use, and was experiencing auditory hallucinations. The patient was at low risk for suicide.

Review of the Crisis Assessment conducted from 9:46 PM through 10:40 PM revealed the patient presented to Hospital #1 on 10/31/19 because he was hearing voices, was off his meds for 2 weeks, and was having suicidal thoughts, was a danger to himself due to psychosis. Patient #1 was not able to remain at Hospital #1 (an acute care/Psychiatric hospital) due to patient having no Medicare days left. No one was able to contact for safety of patient. The plan was to transfer the patient to Hospital #3, a psychiatric hospital on an involuntary basis. Hospital #3 required the patient to be medically cleared prior to agreeing to accept him as a patient.

Review of the psychiatric IAD EMTALA log revealed Patient #1 was transferred from Hospital #1, which is an acute care/psychiatric hospital, to Hospital #2, which is an acute care/psychiatric hospital, on 11/1/19 at 9:10 AM for medical clearance. The patient's emergency room discharge diagnosis from Hospital #2 included Acute psychosis; medically cleared. Patient #1 was transported back to Hospital #1 at 1:27 PM via ambulance.

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.

Review of the psychiatric IAD EMTALA log revealed Patient #1 was transferred from Hospital #1, which is an acute care/psychiatric hospital to Hospital #3, which is a psychiatric hospital on 11/1/19 at 10:27 PM. The transfer of Patient #1 from Hospital #1 to Hospital #3 was not a transfer to a higher level of care. The patient's admitting diagnosis at Hospital #3 included, Schizoaffective Disorder, Bipolar Type.

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.

3. Medical record review revealed Patient #2 was a 64 year old male with a history of alcohol abuse. The patient had insurance.

Review of Hospital #1's (an acute care/Psychiatric hospital) psychiatric IAD EMTALA log revealed Patient #2 presented via car to the psychiatric IAD on 10/22/19 at 2:40 PM with chief complaint of "CD (chemical dependency)" and had an "Emergency Medical Psych Condition."

Review of the Intake Assessment beginning at 5:00 PM revealed the patient was severely depressed and was seeking treatment for alcohol abuse. The patient was at low risk for suicide. A note written on the EMTALA Medical Screening Exam (MSE) revealed the patient would require medical clearance prior to being admitted to the hospital.

Review of the IAD EMTALA log revealed Patient #2 was transferred from Hospital #1, which is an acute care/psychiatric hospital, to Hospital #2, which is an acute care/psychiatric hospital at 8:42 PM. The patient's emergency room discharge diagnosis from Hospital #2 included Alcohol abuse and was medically cleared.

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.

4. Medical record review revealed Patient #7 was a 44 year old male with a history of paranoid behavior, delusions, and hallucinations. The patient had no insurance.

Review of Hospital #1's (an acute care/Psychiatric hospital) psychiatric IAD EMTALA log revealed Patient #7 presented via car to the psychiatric IAD on 10/26/19 at 2:49 PM with chief complaint of "psych" and did not have an "Emergency Medical Psych Condition."

Review of the Intake Assessment beginning at 2:26 PM revealed the patient was delusional, paranoid, and experiencing auditory hallucinations. The patient was at low risk for suicide.

Review of the Crisis Assessment conducted from 4:00 PM through 5:18 PM revealed the patient presented to Hospital #1 on 10/26/19 because he was hearing voices and seeing people and experiencing paranoia and anxiety. The plan was to transfer the patient to Hospital #3, a psychiatric hospital on an involuntary basis.

Review of a Non-patient incident report dated 10/26/19 at 8:30 PM revealed, "...Patient psychotic. Attacked staff with fire extinguisher, spraying multiple employees in the face and damaging property. Police and Fire responded and patient taken by ambulance to hospital..."

Review of the IAD EMTALA log revealed Patient #7 was discharged from Hospital #1, which is an acute care/psychiatric hospital at 8:42 PM via ambulance. The disposition was documented as "referred." Ambulance records were obtained and revealed Patient #7 was found with hand cuffs on sitting in glass in the floor of the lobby of Hospital #1 with lacerations to his forearms, right knee and forehead. Police officers were also present. Patient #7 was transported to Hospital #4, which is an acute care hospital, and was diagnosed with Altered Mental Status and lacerations and abrasions. Patient #7 was transferred from Hospital #4 to Hospital #3 (a psychiatric hospital) by the police where he was admitted with diagnosis of Bipolar 1 Disorder and Stimulant Dependence.

The was no documentation of the incident or combative behaviors noted in Patient #7's IAD record. There was also no documentation that specified Patient #7 was taken to Hospital #4.

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.

5. Medical record review revealed Patient #11 was a 60 year old male with a history of hypertension and emphysema. The patient did not have insurance.

Review of Hospital #1's (an acute care/Psychiatric hospital) psychiatric IAD EMTALA log revealed Patient #11 presented via car on 10/30/19 at 11:30 AM with the chief complaint of "CD" and had an "Emergency Medical Psych Condition".

Review of the Intake Assessment beginning at 11:40 AM revealed the patient was seeking treatment for alcohol abuse. The patient reported he drank a fifth of vodka daily for the past 4 to 6 months. The patient denied suicidal or homicidal ideations, but was noted to be very anxious.

Review of the EMTALA Medical Screening Examination beginning at 12:40 PM, revealed the patient had an elevated blood pressure of 188/130 and was intoxicated with a breathalyzer (a test to determine the amount of alcohol in a person's breath) reading of 0.204 (0.08 is legal limit). Patient #11 was treated with Clonidine 0.1 mg by mouth at 1:10 PM for his blood pressure.

Review of the Crisis Assessment conducted from 8:00 PM through 8:25 PM revealed Patient #11 presented to Hospital #1 due to high anxiety, panic attacks, poor sleep, and alcohol abuse. The patient was not considered to be a danger to himself or others and was referred to the Crisis Stabilization Unit (CSU) at Hospital #3, which is a psychiatric hospital, on a voluntary basis.

Patient #11 received an additional dose of Clonidine 0.3 mg at 11:15 PM. His blood pressure was down to 102/75 by 12:25 AM on 10/31/19.

Review of the IAD EMTALA log revealed Patient #11 was transferred from Hospital #1, which is an acute care/psychiatric hospital at 1:01 AM via ambulance to the CSU at Hospital #3, which is a psychiatric hospital. The patient's admitting diagnosis at Hospital #3 was Alcohol Use Disorder, Severe.

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.

6. Medical record review revealed Patient #12 was a 57 year old male with history of alcohol abuse. The patient had insurance.

Review of Hospital #1's (an acute care/Psychiatric hospital) psychiatric IAD EMTALA log revealed Patient #12 presented via car to the psychiatric IAD on 10/30/19 with the chief complaint of "psych" and had an "Emergency Medical Condition".

Review of the EMTALA Medical Screening Examination conducted on 10/30/19 at 1:55 PM revealed the patient presented for alcohol detox. The Mental Health Tech reported the patient complained of dizziness after lunch and sat on the couch and went to sleep. Upon assessment, the patient's blood pressure was very low with a manual reading of 60/40. His blood pressure was then continually monitored with readings of 78/50, 72/49, and 69/50. The physician was called and an order was given to send the patient to Hospital #2 (an acute care/Psychiatric hospital). The Medical Response Team was also called and monitored the patient until the ambulance arrived. The Medical Response Team consisted of 2 Registered Nurses (RNs), the Chief Nursing Officer and the Assistant Chief Nursing Officer.

Under the assessment section titled Assessment Findings, RN #7 documented the patient met criteria for Emergency Medical Condition based on physical findings.

Review of the IAD EMTALA log revealed Patient #12 was transferred from Hospital #1, which is an acute care/psychiatric hospital at 2:15 PM via ambulance to Hospital #2, which is an acute care/psychiatric hospital. The patient was admitted to Hospital #2 with diagnoses which included Acute Hypoxic Respiratory Failure, Presumed Influenza, Acute Encephalopathy, Chronic Alcoholism, and Polysubstance Abuse.

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.

7. Medical record review revealed Patient #13 was a 62 year old male with a history of alcohol abuse. The patient had insurance.

Review of Hospital #1's (an acute care/Psychiatric hospital) psychiatric IAD EMTALA log revealed Patient #13 presented via car to the psychiatric IAD on 10/31/19 at 12:59 PM with chief complaint of "CD psych" and had an "Emergency Medical Psych Condition."

Review of the EMTALA Medical Screening Examination dated 10/31/19 at 2:28 PM revealed RN #5 performed the examination to determine if an emergency medical condition existed. RN #5 documented Patient #13 was "acutely intoxicated" with a breathalyzer reading of 0.108 (0.08 is legal limit) and had an elevated blood pressure of 161/90. The assessment section titled Assessment Findings on the MSE, RN #5 documented the patient met the criteria for Emergency Medical Condition based on physical finding and risk related to intoxication.

The Intake Assessment was not completed prior to Patient #13's departure from the hospital.

Review of the IAD EMTALA log revealed Patient #13 was transferred from Hospital #1, which is an acute care/psychiatric hospital at 2:55 PM to Hospital #2, which is an acute care/psychiatric hospital. The mode of departure was not documented. The patient was admitted to Hospital #2 with diagnoses that included a Left Pleural Effusion and Alcohol intoxication.

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.

8. Medical record review revealed Patient #17 was a 31 year old female with a history of suicidal ideations. The patient had insurance.

Review of Hospital #1's (an acute care/Psychiatric hospital) psychiatric IAD EMTALA log revealed Patient #17 presented via car to the psychiatric IAD on 11/4/19 at 9:15 AM with chief complaint of "psych" and had an "Emergency Medical Psych Condition."

Review of the Intake Assessment beginning at 9:35 AM revealed the patient complained of feeling severely depressed, sad, hopeless, with suicidal ideations and plan to take prescription medications. The patient was high risk for suicide.

Review of the EMTALA Medical Screening Examination at 11:00 AM revealed the patient met the criteria for an Emergency Medical Condition based on withdrawal from opiates and Xanax and had swelling in her throat, was having difficulty turning her head, and had an elevated temperature of 101.3 degrees. The disposition portion revealed, "Facilitate transfer to medical facility related to emergent medical/physical condition."

Review of the Intake Deflection form dated 11/4/19 revealed the reason for deflection was "Medically Complex/Services Not Available ..." RN #4 documented, patient was being deflected because of an elevated temperature, pain and swelling in her throat.

Review of the IAD EMTALA log revealed Patient #17 was transferred from Hospital #1, which is an acute care/psychiatric hospital at 2:55 PM to Hospital #2, which is an acute care/psychiatric hospital. The mode of departure was not documented. The patient was evaluated and treated for Exudative tonsillitis, prescribed antibiotics, and discharged in stable condition.

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

9. In an interview on 11/7/19 at 2:00 PM, in the conference room, Physician #2 was asked who determined if a patient met the criteria of an emergency medical or psychiatric condition. He stated, "Primarily the psychiatrists. We go by what we are told on the phone. We don't actually come in and see them..."

10. In an interview on 11/7/19 at 2:27 PM, in the conference room, RN #7 was asked to explain her role in the intake department. She reported she performed all of the physical assessments and pre-screenings to make sure the patients were medically cleared. If there was a concern such as an elevated blood pressure, she stated she would call the doctor. She was then asked if she assessed the patients to determine if they had a psychiatric emergency. She reported that she did at times, if there was no assessor available. She was then asked if the medical screening exam was okay, who notified the doctor. She reported "If there's not a medical emergency, there's no reason for me to call him." When asked who determined which patients were transferred out, she stated, "the doctor...the RN examines the patient and if they have a medical emergency, we call the doctor and they determine if we send them out." RN #7 continued and reported they completed the EMTALA forms, got vital signs, call the hospital, and send them out. She also reported they did not arrange for specific doctors, they would just send them to the emergency room.

Hospital #1 failed to ensure that Qualified Medical Personnel provided further evaluation and treatment as required to stabilize the medical conditions for patient #1, #2, #7, #11, #12, #13 and #17. Hospital #1 had the capabilities because the hospital was equipped with such staff, services and/or equipment necessary to stabilize patient #1, #2, #7, #11, #12, #13, and #17 prior to discharge or transfer.

Refer to 2406.

Based on policy review, medical record review, and interview the facility failed to provide a Physician Certification For Transfer for three (3) of 7 (Patient #7, #13 and #17) sampled patients transferred from Hospital #1's Intake Assessment Department.

The findings included:

1. Review of Hospital #1's "EMTALA (Emergency Treatment and Labor Act)" policy revealed, "...If [ Name of Hospital #1] is not able to provide the level of care the patient requires, it is the responsibility of the hospital and physician to...Provide medical care to stabilize the patient for transport so that...the individual's condition will not likely deteriorate materially as a result of the transfer...Contact a physician at the receiving health facility which has the appropriate capability of treatment and obtain acceptance of the transfer of the individual...Contact the receiving hospital to obtain acceptance...Arrange for transport of the individual by qualified personnel and equipment...Document on the patient's record...The need for transfer, risks, and benefits of transfer...Accepting physician and facility...Responsibility during transfer...Time of contact of the facility and physician...Name of accepting physician and vital signs at time of transfer...Report was given to accepting facility...Complete and sign the following forms, which become a permanent part of the medical record...a. Patient Transfer form b. Patient's Refusal of Transfer, Examination, and/or Treatment form..."

2. Medical record review revealed Patient #7 was a 44 year old male with a history of paranoid behavior, delusions, and hallucinations. The patient had no insurance.

Review of Hospital #1's (an acute care/Psychiatric hospital) psychiatric IAD EMTALA log revealed Patient #7 presented via car to the psychiatric IAD on 10/26/19 at 2:49 PM with chief complaint of "psych" and did not have an "Emergency Medical Psych Condition."

Review of the Intake Assessment beginning at 2:26 PM revealed the patient was delusional, paranoid, and experiencing auditory hallucinations. The patient was at low risk for suicide.

Review of the Crisis Assessment conducted from 4:00 PM through 5:18 PM revealed the patient presented to Hospital #1 on 10/26/19 because he was hearing voices and seeing people and experiencing paranoia and anxiety. The plan was to transfer the patient to Hospital #3, a psychiatric hospital on an involuntary basis.

There was no Memorandum of Transfer (EMTALA) form or Physician Certificate of Transfer form completed by Hospital #1.

In an interview on 11/7/19 at 4:00 PM, in the conference room, RN #4 reported Patient #7 was too aggressive to remain at the Hospital and no doctors would accept him for admission. He then reported the patient left the facility at 11:00 PM to go to Hospital #3.

Review of the IAD EMTALA log revealed Patient #7 was discharged from Hospital #1, which is an acute care/psychiatric hospital at 8:42 PM via ambulance.

3. Medical record review revealed Patient #13 was 62 year old male with a history of alcohol abuse. The patient had insurance.

Review of Hospital #1's (an acute care/Psychiatric hospital) psychiatric IAD EMTALA log revealed Patient #13 presented via car to the psychiatric IAD on 10/31/19 at 12:59 PM with chief complaint of "CD psych" and had an "Emergency Medical Psych Condition."

Review of the EMTALA Medical Screening Examination dated 10/31/19 at 2:28 PM revealed RN #5 performed the examination to determine if an emergency medical condition existed. RN #5 documented Patient #13 was "acutely intoxicated" with a breathalyzer reading of 0.108 (0.08 is legal limit) and had an elevated blood pressure of 161/90. The assessment section titled Assessment Findings on the MSE, RN #5 documented the patient met the criteria for Emergency Medical Condition based on physical finding and risk related to intoxication.

There was no Memorandum of Transfer (EMTALA) form or Physician Certificate of Transfer form completed by Hospital #1. There were no physician's orders for transfer noted.

Review of the IAD EMTALA log revealed Patient #13 was transferred from Hospital #1, which is an acute care/psychiatric hospital at 2:55 PM to Hospital #2, which is an acute care/psychiatric hospital.

4. Medical record review revealed Patient #17 was a 31 year old female with a history of suicidal ideations. The patient had insurance.

Review of Hospital #1's (an acute care/Psychiatric hospital) psychiatric IAD EMTALA log revealed Patient #17 presented via car to the psychiatric IAD on 11/4/19 at 9:15 AM with chief complaint of "psych" and had an "Emergency Medical Psych Condition."

Review of the Intake Assessment beginning at 9:35 AM revealed the patient complained of feeling severely depressed, sad, hopeless, with suicidal ideations and plan to take prescription medications. The patient was high risk for suicide.

Review of the EMTALA Medical Screening Examination dated at 11:00 AM revealed the patient met the criteria for an Emergency Medical Condition based on withdrawal from opiates and Xanax and had swelling in her throat, was having difficulty turning her head, and had an elevated temperature of 101.3 degrees. The disposition portion revealed, "Facilitate transfer to medical facility related to emergent medical/physical condition.

Review of the Intake Deflection form dated 11/4/19 revealed the reason for deflection was "Medically Complex/Services Not Available ..." RN #4 documented, patient was being deflected because of an elevated temperature, pain and swelling in her throat.

There was no Memorandum of Transfer (EMTALA) form or Physician Certificate of Transfer form completed by Hospital #1. There were no physician's orders for transfer noted.

Review of the IAD EMTALA log revealed Patient #17 was transferred from Hospital #1, which is an acute care/psychiatric hospital at 2:55 PM to Hospital #2, which is an acute care/psychiatric hospital.

In an interview on 11/17/19 at 4:03 PM, the Chief Sustainability Officer stated, "We don't have EMTALA forms on her ..."

Refer to 2406.