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Based on observation and interview, the hospital failed ensure the signage of the EMTALA rights with respect to the examination and treatment for emergency medical conditions and women in labor was posted conspicuously in the treatment areas where the signage would likely be noticed by individuals visiting the ED. This failure could result in individuals to not be aware of their rights to the examination and treatment in the event of an emergency medical condition.

Findings:

On 4/2/19 at 0900 hours, during the initial tour of the ED with the Director of ED, two posted EMTALA signs showing the patients' rights with EMC were observed on the wall of the waiting area by the admission area and along the hallway where people walked by in front of the ED nurse station. However, there was no EMTALA signage in the treatment areas of the ED where the patients, family members, and visitors could sit, read, and understand what those signages really meant.

On 4/2/19 at 1030 hours, during an interview, the above observation was acknowledged by the Director of ED.

Based on interview and record review, the hospital failed to ensure the ED physicians adhered to the hospital's P&P on obtaining on-call psychiatric consultation to provide further mental health evaluation and/or treatment necessary for Patient 3, who was a minor, to determine whether the mental health crisis continued to exist and provide any treatment necessary to stabilize the EMC while being involuntarily detained for a 72-hour hold due to the danger of harming self. When the psychiatric hold had expired, Patient 3 was released to the mother (legal guardian) after three days in the ED without a psychiatric re-evaluation and possible treatment and was instructed to go to Hospital B for a psychiatric evaluation. The failure could result in the delay in the stabilizing treatment to Patient 3 and result in substandard healthcare outcomes.

Findings:

On 4/3/19 at 1000 hours, review of the hospital's P&P titled Screening, Stabilization, and Transfer of Individuals with Emergency Medical Conditions revised 6/18 showed in part:

1. Emergency Medical Condition (EMC) means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
a. Placing the health of the individual (or the health of a pregnant woman or her unborn child) in serious jeopardy.
b. Serious impairment to bodily functions.
c. Serious dysfunction of any bodily organ.

2. Medical Screening Examination (MSE) is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists or a woman is in labor.

3. On-Call List refers to the list the hospital is required to maintain that defines those physicians who are on the hospital's medical staff who are available to provide treatment necessary after the initial examination to stabilize individuals with EMCs. The purpose of the on-call list is to ensure the dedicated ED is aware of which physicians, including specialists and sub-specialists, are able to provide treatment necessary to stabilize individuals with EMCs.

Review of the hospital's General Rules and Regulations under the section for Admission of Suicidal Patients showed:

a. The admitting practitioner shall be held responsible for giving such information as may be necessary to help ensure the protection of the patient from self harm and ensure the protection of others whenever the patient be a source of danger.

c. Any patient known or suspected to be suicidal, in intent, and is refusing treatment, shall be admitted or transferred to the appropriate Behavioral Health Unit. If there are no accommodations available in the area, the patient shall be referred to another institution where suitable facilities are available; the patient will be placed on Suicide Precautions and monitored every 15 minutes around the clock. There will be circumstances when this monitoring is not enough to ensure safety and the patient will be placed on 1:1 nursing per hospital policy.

d. Any person admitted to the hospital due to serious chemical overdose or a suicide attempt, and is refusing treatment, upon finding a probable cause by a staff member in accordance with the Lanterman-Petris-Short Act (LPS), shall be detained under section 5150 of the Welfare and Institutions Code to strive to ensure that they receive the benefit of a psychiatric consultation prior to leaving the hospital.

Review of Patient 3's medical record was initiated on 4/3/19. The patient was brought to the ED by EMS on four point restraint on 1/25/19, due to suicidal ideation and danger to self as reported by the mother to the local PD.

Review of the EMS report dated 1/25/19 at 1246 hours, showed Patient 3 was extremely combative and continuously fighting off the applied restraints. The county CYBH agency provided the initial psychiatric evaluation placing Patient 3 on a 72-hour hold (5585 for minor equivalent to 5150 for adults).

Review of the ED physician's (MD 4) history and physical examination on 1/25/19, showed Patient 3 was medically clear for psychiatric management. However, there were no other progress notes in the medical record, i.e. assessment or plan of care or treatment, from other medical staff provider from 1/25 to 1/28/19, except for the initial laboratory and urine tests.

Review of the nursing assessment failed to show documented evidence Patient 3 was assessed, at least on a daily basis from 1/26 to 1/28/19.

Further medical record review showed Patient 3's discharge instructions were handed to the mother with the instructions in a non-English language to go to Hospital B to get a psychiatric evaluation.

On 4/3/19 at 1000 hours, an interview with MD 5 (acting Medical Director of the ED) was conducted. MD 5 acknowledged the hospital lacked the process of using their on-call psychiatrists for possible stabilization of EMCs, especially concerning adolescents, and to meet the community needs since the hospital was an LPS facility, and should not rely on the county agency to provide psychiatric re-evaluation and clearance.

In an interview on 4/3/19 at 1305 hours, MD 4 stated the ED physicians usually did not document their daily progress notes unless something unusual occurred on the patient. He stated the ED physicians provided the medical screening clearance but were "hands off" on psychiatric evaluation/clearance, especially on a minor patient. When asked about the on-call pediatric psychiatric consult to re-evaluate Patient 3 and verify any possible stabilizing treatment, the ED physician stated it had been their practice to not call the on-call psychiatrists to evaluate the patients who were minor. MD 4 stated the usual process as he could recall for the last nine years was to rely on the county CYBH agency to provide the psychiatric evaluation and locate the appropriate placement specific for the adolescent patients. Unfortunately, for Patient 3's case, none of the staff from the county agency was available until the psychiatric hold had expired. MD 4 further stated when Patient 3's psychiatric hold had expired, the hospital ED would be violating patient rights if they continued to hold the patient against his will, "though we know he was a danger to himself." MD 4 stated he documented the "mother's decision to leave the hospital before a psychiatric evaluation."

On 4/4/19 at 1105 hours, a telephone interview was conducted with RN 3. When asked regarding Patient 3's stay in the ED, RN 3 stated he made sure Patient 3 was kept safe the whole time the patient was on the legal hold.

Based on interview and record review, the hospital failed to ensure an accurate central log was maintained and included the disposition for five of 29 sampled patients (Patients 3, 7, 9, 12, and 20). This failure had the potential to result in the hospital not being able to accurately track the care provided to the individuals who presented to the ED for treatment for an emergency medical condition.

Findings:

On 4/3/19, review of the hospital's ED central log for the period from October 2018 to April 2019 showed the patients' dispositions were not accurate as follows:

1. Review of Patient 19's medical record showed the patient was seen in the ED on 9/22/18, for the chief complaint of chest pain. The MSE was done at 1325 hours, and the patient was stable to discharge home later. However, the ED central log showed the patient was "LWBS."

2. Review of Patient 20's medical record showed the patient was seen in the ED on 9/29/18 at 1514 hours, for a right hand pain. The MSE was done at 1325 hours, and the patient was discharged home later. However, the ED central log showed the patient "eloped."


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3. On 4/4/19, medical record review showed Patient 2 was seen in the ED on 6/16/18, due to skin rashes. Patient 2 was on two prescribed antibiotics. The MSE was done 35 minutes after the triage. Review of the ED central log showed Patient 2 left without being seen (LWBS); however, review of the medical record showed Patient 2 was discharged home.

4. On 4/4/19, medical record review showed Patient 3 was brought in by the ambulance on 1/25/19, for depression and suicidal ideation. The MSE was done 20 minutes after the triage. Review of the ED central log showed the patient eloped; however, medical record review showed RN 4 gave the mother of Patient 3 the discharge instructions to go to another hospital.

Further review of the medical record showed MD 4 documented the following: "Mother's decision to leave the hospital before psychiatric evaluation." However, no AMA form was signed.

5. On 4/4/19, medical record review showed Patient 7 was seen in the ED on 4/9/18, due to depression and suicidal ideation. The MSE was done 19 minutes after the triage. Review of the ED central log showed Patient 7 was discharged home. However, medical record review showed the patient was transferred to a youth facility on 4/10/18.

On 4/4/19 at 1130 hours, the Director of ED acknowledged the above findings.

Based on interview and record review, the hospital failed to ensure the necessary stabilizing treatment was provided within its licensed capability to treat the emergency medical condition of a psychiatric disturbance for one of 29 sampled patients (Patient 3). Patient 3 was brought to the ED on 1/25/19, for depression, suicidal ideation, and was on 5585 hold for danger to self. During the patient's three day stay in the ED, the hospital failed to provide the necessary treatments or services to address the patient's psychiatric disturbance that had brought the patient to the ED.

Findings:

Review of the hospital's P&P titled Screening, Stabilizations, and Transfer of Individuals with Emergency Medical Conditions revised 6/18 showed if the MSE demonstrate that the person has an EMC, the hospital will provide stabilizing treatment within its capabilities to resolve the person's EMC, unless the person refuses the stabilizing treatment at the hospital, then the individual will be transferred in accordance with Section 6 of this policy. The hospital capabilities include ancillary services available at the hospital, including physicians on call to the ED.

Review of the hospital's General Rules and Regulations revised 11/18 showed for admission of suicidal patients, the admitting practitioner shall be responsible for giving such information as may be necessary to help ensure the protection of the patient from self-harm and to strive to ensure the protection of others whenever his/her patients might be a source of danger from any cause whatsoever; any patient known or suspected to be suicidal, in intent, and is refusing treatment, the patient will be placed on Suicide Precautions, and monitored every 15 minutes, around the clock; there will be circumstances when this monitoring is not enough to ensure safety and the patient will be placed on 1:1 nursing staffing per the hospital's policy; and any person admitted to the hospital due to serious chemical overdose or suicide attempt, and is refusing treatment upon finding the probable cause by a staff member in accordance with Lanterman-Petris-Short-Act (LPS), shall be detained under the section 5150 of the Welfare and Institution Code (5585 for a minor) to strive to ensure that they receive the benefit of psychiatric consultation prior to leaving the hospital.

Review of the hospital's P&P titled Triage reviewed 9/16 showed the triage will be involving a rapid and directed patient assessment which provides an assignment of an acuity level for each patient presenting to the emergency department, using the ESI, a five-level ED triage algorithm that provides clinically relevant classification of patients into five groups from 1 (most urgent) to 5 (least urgent).

ESI Level 2 was described as an emergent acuity if the patient presents with a high-risk condition posing a potential threat to life, limb, or function and requires rapid medial intervention. The following will be done for a patient triaged as ESI Level 2:
- The patient will be placed in the first available appropriate treatment area.
- The triage nurse will notify the Charge Nurse of this patient as soon as possible.
- Vital signs will be taken at a minimum of every 30 minutes until in a treatment area and condition is stabilized.

Medical record review showed Patient 3 was brought to the hospital's ED on 1/25/19, due to suicidal ideation and danger to self. Prior to Patient 3 being brought to the hospital ED, Patient 3's mother called the local PD when the patient ran away from home and stated he would kill himself if he could not go back to his country. The county CYBH agency provided the initial psychiatric evaluation placing Patient 3 on a 72-hour hold (5585 for minor equivalent to 5150 for adults) on 1/25/19 at 1318 hours.

Review of the EMS Report dated 1/25/19 at 1246 hours, showed Patient 3 was restrained with handcuffs by the PD because he was extremely combative and consistently trying to get out of his restraint. The EMS placed Patient 3 on a four point restraints on the way to the hospital; however, Patient 3 became combative and consistently tried to get out of his restraints. Upon arrival to the hospital, Patient 3 was taken to the ED and immediately began fighting against the restraints, causing the top sit belt to break, and the hospital security and receiving staff were brought in to help restrain Patient 3.

Review of the CPOE dated 1/25/19, showed the laboratory tests including a urine test were ordered; however, there were no physician's orders for any stabilizing treatment to address Patient 3's psychiatric disturbance.

Review of the ED physician's (MD 4) history and physical examination on 1/25/19, showed Patient 3 was medically cleared for psychiatric management. Under the section for Disposition, the following was documented:
- For "Condition," the word "Stable" was selected.
- For "Discharge," the word "Transfer" was selected.
- For "Transfer to," MD 4 documented "Pediatric Psychiatric facility.:
- For "Accepted by Dr.," MD 4 documented "Psychiatrist."

Patient 3's condition was stable, and to to "Transfer" the patient to a "Pediatric Psychiatric facility" and accepted by "Psychiatrist." However, there were no other progress notes in the medical record, i.e. assessment or plan of care or treatment, from other medical staff provider from 1/25 to 1/28/19, except for the initial laboratory and urine tests.

Further medical record review showed Patient 3's discharge instructions were handed to the mother with the instructions in a non-English language to go to Hospital B to get a psychiatric evaluation.

In an interview on 4/3/19 at 1305 hours, MD 4 stated the ED physicians usually did not document their daily progress notes unless something unusual occurred on the patient. He stated the ED physicians provided the medical screening clearance but were "hands off" on psychiatric evaluation/clearance especially on a minor patient. When asked about the on-call pediatric psychiatric consult to re-evaluate Patient 3 and verify any possible stabilizing treatment, the ED physician stated it had been their practice to not call the on-call psychiatrists to evaluate the patients who were minors. MD 4 stated the usual process as he could recall for the last nine years was to rely on the county CYBH agency to provide a psychiatric evaluation and locate appropriate placement specific for the adolescent patients. Unfortunately, for Patient 3's case, none of the staff from the county agency was available until the psychiatric hold had expired. MD 4 further stated when Patient 3's psychiatric hold had expired, the hospital ED would be violating patient rights if they continued to hold the patient against his will, "though we know he was a danger to himself." MD 4 stated he documented the "mother's decision to leave the hospital before a psychiatric evaluation." When asked about the treatment he provided for a psychiatric minor patient on a 5585 hold for 72 hours, MD 4 stated, "I'm hands off." MD 4 stated he performed the medical screening only. When asked to explain "Patient has been stable," on his discharged notes dated 1/28/19 at 1354 hours and entered at 1447 hours, MD 4 stated Patient 3 was medically stable.

On 4/4/19 at 0915 hours, an interview was conducted with RN 4. When asked about Patient 3's triage level (ESI level 2), RN 4 stated when the patient was triaged as an ESI level 2, and the assessment should be performed until the patient was medically cleared and at least for two hours. When asked what should be assessed for a patient with a psychiatric condition who came to the ED with an ESI level 2, RN 4 stated if the patient came in for DTS she made sure the patient was safe and would have a sitter.

On 4/4/19 at 1054 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was the ED Charge Nurse on 1/25, 1/26, and 1/27/19. When asked if the ED physician could prescribe the treatments for minors with psychiatric conditions in the ED, RN 2 stated he had not seen the ED physicians prescribe medications for minors. When asked what treatment was provided to Patient 3 during his stay in the ED from 1/25 to 1/28/19, RN 2 stated there was no treatment provided to Patient 3; they basically baby sat and fed Patient 3 and there was no medication given.

On 4/4/19 at 1105 hours, a telephone interview was conducted with RN 3. When asked what treatment was provided to address Patient 3's psychiatric disturbance during the 72 hour 5585 hold in the ED from 1/25 to 1/28/29, RN 3 stated he made sure Patient 3 was safe and fed the entire time he was in the ED. RN 3 stated the psychiatric consult should be completed before the 72 hour hold expired. When asked about the discharge instructions, RN 3 stated Patient 3's mother did not want the patient to be in this hospital in the first place but wanted the patient to go to Hospital B. RN 3 stated he gave Patient 3's mother the address of Hospital B, which he documented on the discharge instructions and had the patient sign the discharge instructions. However, there was no documented evidence to show RN 3 had assessed Patient 3 for safety during his shifts on 1/26, 1/27, and 1/28/19. In addition, there was no documentation in the medical record to show a psychiatric consult was provided prior to the expiration of the psychiatric hold.

Based on interview and record review, the hospital failed to ensure the ED physician documented and certified the determination of the transfer to not create a medical hazard to the patient and sent all medical records related to the emergency condition the individual had presented to be available at the time of the transfer to the receiving hospital for one of 29 sampled patients (Patient 18). This had the potential for the patient to not receive the appropriate care from the receiving hospital.

Findings:

Review of the hospital's P&P titled Transferring Patients, Emergency Service And Care Of reviewed 9/16 showed in part:

V. Procedure-Initiating and Arranging Patient Transfer: The physician responsible for the individual must make the determination that the transfer would not create a medical hazard to the patient and must document same in the patient's medical record.

VII. Transfer of Patient with Unstable Medical Condition: If a patient at an emergency medical condition (which has not been stabilized), the hospital may not transfer the patient unless there is a transfer document. Risks and benefits must be documented by the transferring physician with the date, time, and signature justifying the appropriateness of the transfer.
B. Physician Certification of Medical Benefits (No Emergency Condition Exists) A physician has signed a certification that based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of emergency medical treatment at another facility outweigh the increased risks to the child, from effecting the transfer. When a transfer is made, the form Interhospital Patient Transfer/Acknowledgment should be completed and signed by the physician. (If the physician is not physically present at the time and the individual is transferred, a Registered Nurse shall sign the certification after a physician, in consultation with the registered nurse, has made the determination described and subsequently countersigns the certification).

VII. Transfer of Patient Records:
A. All relevant medical information will accompany the patient including, but not limited to the following: Copies of the individual medical records related to the emergency condition for which the individual presented and which are available at the time of transfer. Includes: records related to the individual's emergency medical condition, observations of signs and symptoms, preliminary diagnosis, treatment provided and results of any tests.

On 4/3/19 at 1005 hours, Patient 18's medical record was reviewed with the Clinical Support Specialist. The patient arrived to the ED on 9/22/18 at 1211 hours, with a chief complaint of fall from a second story window.

Patient 18 was seen by MD 4 on 9/22/18 at 1212 hours. The physical examination showed the patient was awake, alert, responsive, and crying on examination. A contusion (bruise) was assessed on the left side of the patient's head and around the left eye. The patient was assessed as having a pain of 10/10 using a face picture rating scale from zero to 10 (0 represent no pain and 10 represents the worst pain). Vital signs were taken at 1229 hours. MD 4 documented the patient was stable, and unable to obtain CT of the head/c-spine because the patient was crying and moving. MD 4 documented the case was discussed with a physician at Hospital C and the patient was accepted for the transfer. The diagnosis was documented as head injury due to a fall from the second story. The patient was assessed as "stable" to transfer to Hospital C's ED. The MD signed the ED notes at 1254 hours on 9/22/18.

On 9/22/18 at 1310 hours, the ED nurse documented a report was given to the paramedics upon arrival to transfer the patient to Hospital C, and Patient 18's parents were at the bedside to assist as needed. The ED nurse documented at 1312 hours a report was given to an RN at Hospital C's ED that the RN was unable to obtain the intravenous access, radiology was unable to perform the CT, and the ED physician was aware. The ED nurse documented on 9/22/18 at 1312 hours, Patient 18 was discharged from the hospital's ED by ambulance to Hospital C's ED.

However, further review of the medical record showed no documented evidence a physician's certification was completed indicating the medical benefits outweighed the risks of the transfer. In addition, there was no documented evidence to show the medical records related to the emergency condition was sent with Patient 18 at the time of the transfer.

On 4/3/19 at 1025 hours, MD 5 was interviewed. When asked what documents should be sent to the receiving hospital with the patient, MD 5 stated all the available ED physician and nurse's notes.

On 4/4/19 at 0826 hours, an interview and concurrent medical record review was conducted with the Clinical Support Specialist. The Clinical Support Specialist confirmed the only document sent with Patient 18 was the local county's EMS Interfacility Transfer Report and there was no Interhospital Patient Transfer/Acknowledgment form.

On 4/4/19 at 1540 hours, the findings were shared with the hospital administrative staff. The ED Director stated she would review the hospital record and update the surveyor if there were more documents sent to Hospital C with Patient 18 on 9/22/18. However, as of exit date of 4/4/19, the ED Director had not provided the surveyor with any updates.