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Based on interview and record review, the facility failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) as evidenced by:

1. The facility failed to ensure two of 21 sampled patients (Patients 1 and 2) had physician transfer certifications completed that included a summary of the specific risks or benefits of transfer. There were no accepting physicians at the receiving hospitals, appropriate transportation was not arranged for Patient 1, and a copy of the patients' records were not sent with them. (Refer to C2409)

Based on interview and record review, Hospital A failed to ensure an appropriate transfer for two of 21 sampled patients (Patients 1 and 2).

1. Patient 1, who had presented with suicidal ideations at Hospital A's Emergency Department (ED), was sent to Hospital B in a taxi. There was no signed physician certification that addressed the risks and benefits of transfer, there was no accepting physician at the receiving hospital (Hospital B), appropriate transportation was not arranged, and a copy of Patient 1's records was not sent with him.

2. Patient 2, who presented with delusions (a belief or impression that is firmly maintained despite being contradicted by what is generally accepted by reality) and erratic behavior (not appropriate to the circumstances) at Hospital A's ED was sent to Hospital C. There was no signed physician certification that addressed the risks and benefits of transfer, there was no accepting physician at the receiving hospital (Hospital C), and a copy of Patient 2's records was not sent with her.

These failures had the potential to result in harm and a decline in both patients' condition, especially during transport for Patient 1.

Findings:

1. A review of Patient 1's record indicated he presented by ambulance to Hospital A's ED on 12/29/18 at 5:10 pm, with suicidal thoughts and depression. Patient 1 had not attempted suicide, but stated he would try to shoot himself or cut his throat if his depression worsened.

A document titled,"ED Note" dated 12/30/18 written by The ED physician was reviewed and indicated that Patient 1 was medically cleared for psychiatric referral on 12/30/18 at 11:15 am. He further noted Patient 1, "will be transferred to Hospital B for further mental health evaluation. This was the patient's request. He had requested to be transferred to Hospital B when he had called 911, he did not want to come to this facility because he knew there was no psychiatric services here. He still is contemplating harming himself and he did lock up his guns but stated he would cut his wrists if he had the opportunity. He agrees that he would not do anything on the transportation to Hospital B and that he just wanted to be re-evaluated at that facility and possibly admitted." The last note which referenced suicidal ideations was under a section titled "clinical impression." Under this section ED physician (MD A) wrote, on 12/30/18 at 11:15 am: "major depression, suicide ideation." On 12/20/18 at 11:10 am, MD A documented the following under a section titled "disposition": "transfer, patient was discharged from the emergency room and given transportation to Hospital B. Per the instructions County Mental Health department, they preferred to evaluate him at Hospital B."

The last note in the ED nursing notes, written by Registered Nurse (RN) B regarding suicide, was charted on 12/20/18 at 5:20 am, when Patient 1 was asked if he was still having suicidal thoughts. Patient 1 stated, yes. When questioned on his plan, Patient 1 stated, "Cut my wrists, I guess." At 12:09 pm RN B charted Patient 1 was given discharge instructions and a taxi was there to transport Patient 1 to Hospital B. Patient 1 was given discharge instructions that included "Depression Management for Older Adults" and told to follow up with the County Mental Health worker at Hospital B.

Records from Hospital B were reviewed and indicated Patient 1 presented at the ED on 12/30/18 at 1:23 pm. The RN triage note, dated 12/20/18, indicated Patient 1 reported having suicidal thoughts of either cutting his wrists or shooting himself. The ED MD noted in his initial assessment notes on 12/30/18, Patient 1 was seen in the ED at Hospital A and sent to this facility in a taxi for possible admission to the psychiatric unit. He noted Patient 1 was having thoughts of using a knife or gun to harm himself. Patient 1 was placed on an involuntary hold (patient is a danger to himself or others) on 12/30/18 at 6:26 pm, following a mental health evaluation . On 12/31/18 at 6:10 am, in a subsequent follow up note, the ED MD noted Patient 1 was medically cleared. On 12/31/18 at 12:51 pm, Patient 1 was discharged from the ED and admitted to the mental health unit. He was discharged from the inpatient mental health unit on 1/8/19.

During interviews on 2/11/19 at 11:35 am and 1:45 pm, RN B at Hospital A stated she worked day shift on 12/30/18. Patient 1 was in their ED and she asked him about suicidal thoughts and a plan. She reported Patient 1 said he would cut his wrists. She confirmed she charted this at 5:20 am. She said she contacted County Mental Health who asked that Patient 1 be sent to Hospital B but did not specify the method of transportation. RN B said she asked Patient 1 to agree not to hurt himself on the trip to Hospital B and he agreed. She said she assumed this was a discharge and not a transfer so no transfer paperwork was completed and copies of medical records were not sent with Patient 1. Before Patient 1 left the ED, RN B said she spoke to a female staff at Hospital B, who she thought was an ED technician.

During an interview on 2/11/19 at 12 pm, MD A said Patient 1 had been in the ED overnight. When he saw Patient 1 he did not think he was suicidal. He confirmed he did not speak to anyone at County Mental Health but assumed the ED RN did so. He said he thought this was a discharge not a transfer so he did not complete the transfer paperwork or arrange for an ambulance to take him to Hospital B. MD A said he thought Patient 1 was going to the mental health unit and not the ED at Hospital B.

During an interview on 2/11/19 at 2 pm, the Chief Nursing Officer (CNO) confirmed this was a transfer and not a discharge. She said there was no assessment in the record that showed a lack of suicidal ideation prior to transfer. She confirmed the transfer paperwork had not been completed.

During an interview on 2/7/19 at 1:55 pm, RN C (charge nurse in the ED at Hospital B) said Patient 1 came to their ED after being dropped off in their parking lot by a taxi, after being seen in the ED at Hospital A. She said there was no accepting physician at Hospital B and no physician to physician report. She had not received report and did not know Patient 1 was coming to their ED. She said their ED has an overflow unit for mental health patients but they need an accepting physician. She confirmed no copies of medical records accompanied Patient 1.

During an interview on 2/22/19 at 2:15 pm, County Mental Health Director (CMHD) said her staff had asked Hospital A to send Patient 1 to Hospital B, on 12/30/18, in an ambulance so he could be evaluated by County Mental Health. CMHD said her staff had spoken to a nurse at the overflow unit at Hospital B.

On 2/11/19 at 12:30 pm, a copy of Hospital A's transfer forms were provided by the CNO. These forms included a patient transfer acknowledgment form; a physician certification form that included the patient's condition, reason for transfer, hospital acceptance, risks during transfer, benefits of transfer, and medical necessity for ambulance; and a transfer communication check list form that included the name of destination hospital and physician receiving the patient, RN to RN report, means of transportation, and listed parts of the medical record that staff were to indicate had been copied and sent with the patient upon transfer. None of these forms had been completed for Patient 1.

On 2/11/19 at 12:30 pm, the CNO provided EMTALA policies for physician coverage and policies for transfer of trauma patients and transfer of patients via air ambulance. The facility had no other EMTALA policies available.

2. A review of Patient 2's record indicated she presented to the ED on 10/27/18 at 2:17 am. The ED MD's assessment note dated 10/27/18 at 2:45 am, indicated the patient was delusional. Patient 2 had been dropped off in the ED parking lot and was wet from being in a creek. She said people were trying to kill her. A drug screen tested positive for methamphetamines (a synthetic drug used illegally as a stimulant) and THC (a compound that is the main active ingredient in marijuana). The physician's follow up progress note at 3:25 am indicated, "Patient is cooperating and laying on the gurney. We called the Sheriff's office and I spoke with a Sergeant (name) about the case and that the patient is a danger to herself. His plan is to have a deputy come pick up the patient and transport her to Hospital C." At 3:40 am, it was noted the Deputy was present and transporting Patient 2. No transfer forms or documentation regarding physician to physician contact between the Hospital A and C were found in the record.

During a telephone interview on 4/2/19 at 4 pm, the Regulatory Compliance Officer at Hospital C stated Patient 2 arrived at their ED, on 10/27/18 at 4:57 am, from Hospital A, via law enforcement on a 5150 involuntary hold (patient is a danger to himself or others).

During a concurrent interview and record review on 4/4/19 at 11:30 am, the ED Director (EDD) at Hospital C confirmed Patient 2 was on a 5150 hold written by law enforcement on 10/27/18 at 5:08 am. She said the ED record from Hospital A had been faxed to them on 10/27/18 at 5:19 am. EDD confirmed there were no transfer forms from Hospital A. The ED physician documented his impression as: "acute danger to self, acute hallucinations," on 10/27/18 at 7:59 am. A follow up note from another ED physician was documented on 10/17/18 at 2:57 pm and indicated the plan of care was, "continue plan as per tele-psychiatry, patient awaiting final evaluation and disposition by County mental health.

On 4/2/19, a copy of Hospital A's transfer forms were provided by the CNO. These forms included a patient transfer acknowledgment form; a physician certification form that included the patient's condition, reason for transfer, hospital acceptance, risks during transfer, benefits of transfer, and medical necessity for ambulance; and a transfer communication check list form that included the name of destination hospital and physician receiving the patient, RN to RN report, means of transportation, and listed parts of the medical record that staff were to indicate had been copied and sent with the patient upon transfer.

During an interview on 4/2/19 at 5:25 pm, the CNO confirmed none of these forms were included in Patient 2's record.

During a telephone interview on 4/2/19 at 4:15 pm, RN E confirmed she cared for Patient 2 in the ED at Hospital A. (This interview was done from the nurse's memory of this patient and she did not have the record to refresh her memory). RN E recalled Patient 2 being dropped off in the ED soaking wet and she complained of being freezing. She said Patient 2 did not say she wanted to hurt herself but said the cops were chasing her, so RN E said they called the police who reported they were not chasing Patient 2. RN E remembered MD F called the Sheriff and when Patient 2 left the ED, in the presence of the Sheriff, she thought Patient 2 was being given a ride home by the Sheriff. She said she thought the Sheriff knew Patient 2 and was giving her a ride home. RN E said she did not know Patient 2 was going to be taken to Hospital C.

During an interview on 4/3/19 at 10:30 am, MD F confirmed he recalled Patient 2. (This interview was done from the physician's memory of this patient and he did not have the record to refresh his memory). He was the ED physician on duty at Hospital A. He said he called the Sheriff regarding Patient 2. He said, "we were trying to figure out what to do and the Sheriff said he would take her to Hospital C." MD F confirmed Patient 2 was medically stable and said Patient 2 needed a higher level of care for mental health purposes not physical purposes. He confirmed he was aware transfer paperwork was needed for all patients transferred to another hospital and additional paperwork for patients who were a danger to themselves and placed on a 5150 hold. MD explained these forms were done routinely but was not able to explain why the transfer forms were not completed in this case and confirmed there should have been a call to get an accepting ED physician at Hospital C.