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Based on observation, interview, and record review, the hospital failed to comply with 489.24 when:

1. The facility failed to meet the regulatory obligations to maintain an accurate Emergency Department (ED) Log for 10 of 33 sampled patients when: a. one sampled patient (Patient 33) presented to the ED seeking medical evaluation but was not entered into the ED log and
b. the final dispositions for nine sampled patients (Patients 1, 5, 6, 8, 10, 12, 16, 24 and 27) were either not recorded in the log, or were inaccurate. (A 2405)

2. The facility failed to meet the regulatory obligations to provide a medical screening examination for 1 of 33 sampled patients (Patient 33) who presented to the emergency room. (A 2406)

3. The facility failed to meet the regulatory obligations to ensure that 2 of 33 sampled patients (Patients 9 and 25)were stabilized prior to their discharge home, when there was no documentation the 5150 psychiatric hold for danger to self/danger to others that had been imposed on them was lifted by qualified staff prior to their discharge home. (A 2407)

4. The facility failed to meet the regulatory obligations to obtain written and informed refusal of examination or treatment for 2 of 33 sampled patients (Patients 2 and 21). (A 2407)

5. The facility did not meet the regulatory obligations regarding the transfer of patients to other acute hospitals for when:

a. five of the 33 sampled patients were transferred to other acute care facilities without documented evidence that the risks and benefits of the transfer had been explained to the patient and the patient had consented to the transfer (Patients 3,13, 14, 28, and 29);

b. two of the 33 sampled patients were transferred to other acute care facilities without a signed physician certification explaining the risks and benefits of such a transfer (Patients 4 and 29); and,

c. the dictated information regarding the medical screening examination and the stabilizing treatment provided were not sent with the patient to the receiving hospital for one of the 33 sampled patients (Patient 17). (A2409)

Based on record review and interview, the facility failed to maintain an accurate Emergency Department (ED) Log for 10 of 33 sampled patients (Patients 33, 1, 5, 6, 8, 10, 12, 16, 24, and 27) when:

1. One sampled patient (Patient 33) presented to the ED seeking medical evaluation but was not entered into the ED log;

2. The final dispositions for nine sampled patients (Patients 1, 2, 5, 6, 8, 10, 12, 16, 24 and 27) were either not recorded in the log, or were inaccurate.

Findings:

1. Patient 33
A complaint was placed with the Department that Patient 33 presented for an emergency medical evaluation on 7/22/11 and was turned away.

Record review on 8/8/11 of the ED Log for 7/22/11 found it did not indicate Patient 33 presented for medical evaluation.

During interview with the Senior Director of Cardiovascular Services and Critical Care (SDCSCC) on 8/9/11 at 9 AM, he said that a facility security officer had reported a 7/22/11 incident that happened on the night shift. The SDCSCC said the security officer reported he had been watching the security monitors and saw a person in handcuffs being placed in a police car outside the ED entrance. The security officer reported he went to the ED and spoke to the Charge Nurse, who said he told the police the facility could not provide adult psychiatric services. The SDCSCC said the security officer's report quoted the Charge Nurse as saying, "This was a 5150 that was trying to be admitted and I told them this was not an adult psych (psychiatric) facility and they left."

The SDCSCC said he set up an interview and met with the Charge Nurse on 7/26/11. The SDCSCC said the Charge Nurse's initial story was that on 7/22/11, he was working triage with another patient when a police officer with Patient 33 knocked at the triage window. The Charge Nurse told the SDCSCC he asked the police officer who sent him there and said the facility did not have adult psych and would just transfer the patient out. The Charge Nurse told the SDCSCC he referred the police officer to other psych facilities.

The SDCSCC said he conducted a follow-up investigation of the 7/22/11 incident with interviews of two other nurses on duty at the time and staffing records. His investigation found that the ED had enough staff on duty at the time of the incident, and indicated the Charge Nurse was not in triage with another patient when Patient 33 was brought to the triage window by the police officer.

2.The final dispositions for the following nine sampled patients (Patients 1, 2, 5, 6, 8, 10, 12, 16, 24 and 27) were either not recorded in the log, or were inaccurate:

a.. Patient 1
Record review of the ED log on 8/8/11 indicated Patient 1 presented to the ED on 4/15/11 at 1:01 AM, with a complaint of, "suicidal." The ED Log indicated on 4/14/11 at 2:53 AM, Patient 1's final disposition was LWBS.

Review of Patient 1's ED triage record dated 4/15/11 at 1:55 AM indicated Patient 1 stated he was suicidal, wanted to cut his wrists and drank half a gallon of alcohol that night.

Review of the Registered Nurse (RN)'s notes dated 4/15/11 at 2:52 AM, indicated Patient 1's discharge disposition was LWBS.

Review of the ED physician's report dictated 4/15/11 at 3:42 AM, indicated that the physician confronted Patient 1 with his multiple visits to the ED, his multiple referrals to outpatient treatment clinics, and that he had been given prescriptions for medications. The ED report indicated Patient 1 accused the physician of lying and let out a loud amount of flatulence, after which the physician "...stepped out briefly." The ED report indicated Patient 1 threw down the chair he was sitting in and stormed out of the ED. The physician wrote Patient 1 had made suicidal threats in the past, but had made no specific attempts other than superficial, and the physician did not feel Patient 1 posed a significant threat to himself. Under, Diagnoses 3., the physician indicated Patient 1, "Left AWOL."

During interview with the SDCSCC on 8/9/11 at 4 PM, he said the Medical Director of ED Physicians said the term "AWOL" meant a patient left after the work-up was initiated, but before follow-up was completed; and said the term "LWBS" meant the patient left before being seen in triage or by the physician for the medical screening exam. The SDCSCC said the facility had no policy or procedure for completion of the ED log.

b. Patient 2
Record review on 8/9/11 of Patient 2's ED triage note dated 3/9/11 at 6:34 PM indicated he had been discharged earlier that day from an inpatient admission for chest pain and was found upstairs in the facility by security complaining of inability to walk due to pain.

Review of the ED physician's handwritten RD report indicated Patient 2 had a physicial examination at 8 PM but was signed by the physician on 3/13/11 at 6:39AM. Under disposition on the handwritten ED report, the physician circled AWOL.

Review of the physician's orders dated 3/13/11 indicated at 8:23 PM, the physician ordered blood tests, an electrocardiogram (tracing of the heart's electrical activity), and a chest x-ra. Review of the nurses notes dated 3/9/11 indicated that at 9:09 PM, Patient 2 was taken to x-ray by gurney. At 10:38 PM, the RN documented that Patient 2 was, "...completely dressed and leaving the premises," refused to allow the intravenous access to be discontinued and "stormed out of premises." The RN noted security was at site, the patient was informed the police department would be notified, and the primary nurse was notified.

Review of the RN's ED discharge note dated 3/9/11 at 11:05 PM indicated that, Patient 2 was discharged AMA (against medical advice). Review of the physician's ED report dictated on 3/13/11 at 6:41 AM indicated the physician doubted acute coronary syndrome.
The physician's ED report indicated Patient 2 "...ambulated from emergency department without being discharged."

There was no indication in the nurses notes that the physician was notified or that an attempt was made to inform the patient of risks associated with his leaving before the physician discharged him. There was no signed AMA form found in the record.

c. Patient 5
Record review of the ED Log on 8/8/11 indicated Patient 5 presented to the ED on 3/18/11 at 2:06 PM with the complaint of "psych." The ED log indicated Patient 5 was discharged on 3/18/11 at 6:38 PM but had no final disposition indicated.

Record review view of Patient 5's ED record indicated she was seen in triage on 3/18/11 at 2:42 PM for complaint of having thoughts of hurting herself. At 6:04 PM on 3/18/11, the RN noted Patient was to be admitted. Review of the physician's dictated ED report dated 3/18/11 at 6:19 PM, indicated Patient 5 was accepted for admission to the facility's pediatric psychiatric ward.

During interview with Clinical Informatics Nurse 1 (CIN 1) on 8/9/11 at 10:50 AM, she said no ED discharge form was completed to indicate Patient 5 was admitted. This was why the ED log showed a blank disposition. The CIN 1 said based on the date and time, the computer showed that when Patient 5 was admitted, a new account was opened instead of "rolling over" Patient 5's ED account to inpatient status.

d. Patient 6
Record review of the ED Log on 8/8/11 indicated Patient 6 presented to the ED on 4/13/11 at 9:48 AM with a complaint of epistaxis (bleeding from the nose). The ED log indicated Patient 6 was discharged at 2:48 PM on 4/13/11, but had no final disposition.

Review of Patient 6's ED record indicated he was seen in triage on 4/13/11 at 9:56 AM for complaint of epistaxis left nostril for two days with dizziness. The RN noted at 2:46 PM on 4/13/11 that Patient 6 was, "transferred to 8 E via gurney ..."

Review of Patient 6's ED physician's report dictated 4/13/11 at 2:50 PM indicated Patient 6 would be admitted to the facility.

During interview with CIN 1 on 8/9/11 at 11 AM, she said there was no ED discharge form completed to indicate Patient 6's account should have been rolled over to admit status. CIN 1 said she would expect to see the disposition "med-surg" (medical-surgical) on the ED log.

e. Patient 8:
Record review of the ED Log on 8/8/11, indicated Patient 8 presented to the ED on
4/20/11 at 7:52 PM with a complaint of alcohol withdrawal. The ED log indicated Patient 8 was "MAP transferred" on 4/20/11 at 11:56 PM.

Review of Patient 8's ED record on 8/9/11 indicated the RN noted on 4/20/11 at 11:55 that Patient 8 was transferred to a discharge location of MAP with aftercare instructions.

Review of the ED physician's report dictated 4/21/11 at 4:07 AM, indicated Patient 8 was diagnosed with alcoholism, "...cannot rule out early withdrawal." The physician indicated Patient 8 was willing to go to a particular facility and was sent there by van.

During interview with the SDCSCC on 8/9/11 at 10:15 AM, he verified that the disposition "transfer" indicated transferred to a higher level of acute care. He said the disposition "mental health facility" indicated an outpatient discharge referral. He said MAP was a transportation van service used by the facility, not a location.


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i. Patient 24:
Patient 24 was brought in by ambulance to the emergency department for evaluation on 02/06/11 for alcohol intoxication. The patient was discharged home. The ED Log did not have any disposition stated.

During a document review and interview on 8/08/11 at 2:58 PM, CIN 2 stated the information for the ED Log disposition is done by the nurse in the computer system. CIN 2 confirmed that the nurse did not enter the disposition for Patient 24 in the electronic charting .

j. Patient 27:
Patient 27 was brought in by ambulance to the emergency department for evaluation on 5/25/11 for right side numbness and diarrhea. The physician's dictated report done on 5/25/11 stated the following: "The patient does not appear to need acute hospitalization. (The patient's primary hospital) will arrange for an ambulance transfer back home".

The patient eventually was transported to her primary hospital via ambulance due the patient's home being fumigated and there was no one to take care of her. The ED Log disposition stated "transfer" when in fact it was a discharge since the treating physician evaluated the patient to be stable and to be sent home.

On an interview on 8/10/11 at 1:50 PM, the case was discussed with the SDCSCC and agreed it should have been logged as a "discharge".























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f. Patient 10
Patient 10 was a 97 year old admitted to the ED on 6/11/11 with the chief complaint of "fall". Review of the ED Log on 8/8/11 indicated this patient was admitted to pediatrics.

In an interview on 8/10/11 at 10:30 AM, the Director of Quality stated it was obvious that the ED Log Final Disposition of "Pediatrics" was inaccurate since the facility did not have an inpatient pediatric unit and Patient 10 was 97 years old. The Director reviewed Patient 10's ED record and stated Patient 10 was admitted from the ED to an Observation Unit on 8 West in the facility. The Director added Patient 10 was eventually admitted to the Telemetry Unit. During this record review, the Director looked at the computer selection screen and stated pediatrics was in the next column after med/surg and she felt the inaccurate log entry was due to a selection mistake by the nurse.

g. Patient 12
Patient 12 was admitted to the ED on 6/7/11 with a chief complaint of "Suicidal Ideation." Patient 12 was placed on a 5150 involuntary detention by the ED physician because she was a danger to herself. Patient 12 was a minor (16 year old) who was accompanied to the ED by her mother.

Record review of the ED Log indicated Patient 12 was transferred to a "Mental Health Facility."

In an interview on 8/9/11 at 2:30 PM, the Senior Director supervising the ED stated that patients who were sent to a Mental Health Facility should have the designation of "Transferred" as the final disposition in the ED Log.

After record review on 8/10/11 at 9:20 AM, this Senior Director noted that Patient 12 had actually been admitted to the Adolescent Psychiatric Unit located at the facility. The Senior Director stated the facility needed to clarify this in the ED Log and he speculated the best selection was probably "Admitted to Behavioral Health" which was more accurate than Mental Health Facility.

h. Patient 16
Patient 16 was admitted to the ED on 7/22/11 after police placed Patient 16 on a 5150 involuntary detention for threatening harm to others.

Record review on 8/9/11 indicated Patient 16 had a Medical Screening Examination and stabilizing treatment prior to his transfer by ambulance to an acute psychiatric hospital on 7/23/11. The ED Log indicated Patient 16 went to a "Mental Health Facility."

In an interview on 8/9/11 at 2:30 PM, the Senior Director supervising the ED stated the ED Log was incorrect and Patient 16's final disposition in the Log should have been "Transferred." This Senior Director stated the ED staff needed retraining on the computer selections for final disposition because the many different staff interpretations were causing inaccurate final disposition entries in the ED Log.

Based on record review and interview, the facility failed to provide a medical screening examination for 1 of 33 sampled patients (Patient 33) who presented to the emergency department seeking an emergency medical evaluation.

After the facility refused to see Patient 33, he was taken to another facility (Facility A) ED, where he received a medical screening examination, was observed overnight in the ED, and cleared for discharge the next day after evaluation by a psychiatrist.

Findings:

The Department received a complaint that Patient 33, who was under a 5150 involuntary hold for psychiatric evaluation presented at the facility ED on 7/22/11, and was refused a medical screening examination. The complaint indicated Patient 33 was referred to the emergency room at another facility (Facility A). The complaint indicated a different patient (Patient 16) who was also under a 5150 had been brought to the facility's ED about twenty minutes earlier and had received a medical screening examination.

Record review on 8/8/11 of the facility's ED log for 7/22/11 found it did not indicate Patient 33 presented for medical evaluation. The ED log for 7/22/11 indicated Patient 16 presented at the facility on 7/22/11 under a 5150 hold at 8:38 PM and was transferred to a mental health facility at 6 AM on 7/23/11.

Review of Patient 16's dictated physician's ED report dictated 7/22/11 at 9:44 PM, indicated, "...We are currently in the process of trying to find a psychiatric accepting facility for this patient..." Review of the physician's addendum note dictated at 7/23/11 at 5:49 AM, indicated, "...Multiple centers ... were contacted ...who also refused to take the patient. Finally, ...accepted the patient in transfer for a higher level of care..."

During interview with the Senior Director of Cardiovascular Services and Critical Care (SDCSCC) with the Chief Nursing Officer present, on 8/9/11 at 9 AM, he said a facility security officer had reported a 7/22/11 incident that happened on the night shift. The SDCSCC said the security officer reported he had been watching the security monitors and saw a person in handcuffs being placed in a police car outside the ED entrance. The security officer reported he went to the ED and spoke to the Charge Nurse. The Charge Nurse told the security officer he told the police the facility could not provide adult psychiatric services. The SDCSCC said the security officer's report quoted the Charge Nurse as saying, "This was a 5150 that was trying to be admitted and I told them this was not an adult psych (psychiatric) facility and they left."

The SDCSCC said he set up an interview and met with the Charge Nurse on 7/26/11. The SDCSCC said the Charge Nurse's initial story was that on 7/22/11, he was working triage with another patient when a police officer with Patient 33 knocked at the triage window. The Charge Nurse told the SDCSCC he asked the police officer who sent him there and said the facility did not have adult psych and would just transfer the patient out. The Charge Nurse told the SDCSCC he referred the police officer to other psych facilities. The Charge Nurse told the SDCSCC he saw the patient was not needing help right away.

The SDCSCC said he conducted a follow-up investigation of the 7/22/11 incident with interviews of two other nurses on duty at the time of the incident, and reviewed staffing records. His investigation found that the ED had enough staff on duty at the time of the incident, and indicated the Charge Nurse was not in triage with another patient when Patient 33 was brought to the triage window by the police officer. The facility ' s investigation found that at the time the Charge Nurse refused Patient 33, another patient who presented under a 5150 hold was being evaluated in the ED.

Review of the facility's policy and procedure (P&P), EMTALA: Medical Screening Examination (MSE), revised 3/11, indicated under Policy: "...An MSE must be performed on all patients who present to the dedicated emergency department (DED) and request or are in need of examination or treatment for a medical condition. Qualified Medical personnel (QMP) shall be responsible for conducting the MSE of presenting patients... QMP are licensed independent physicians and appropriate allied health professionals approved by the Medical Staff and the Community Board to practice in this capacity..." Under Procedure, the P&P read: "1. The medical screening exam (examination) will be conducted on all patients presenting to the DED to determine the presence or absence of an emergency medical condition. 2. The triage assessment, conducted by the registered nurse, will not be done in lieu of the MSE..."

Record review on 8/15/11 of Patient 33's Facility A ED record, indicated he arrived at Facility A's ED on 7/22/11 at 9:25 PM with complaint of a psychiatric problem. Patient 33's Facility A triage record indicated he was brought to the ED by police who had placed him under a 5150 involuntary hold for danger to others.

Review of Facility A's ED physician notes dated 7/22/11 at 11:13 PM indicated Patient 33 had abnormal judgement. The physician noted he suspected Patient 33 had some degree of paranoia and poor decision making. The Facility A ED physician notes indicated Patient 33 was medically cleared though basic laboratory testing and serial examinations for disposition by psychiatry.

Review of the psychiatrist's consult note dated 7/23/11 at 8:39 AM, indicated Patient 33 had impaired ability to make good judgement decisions and was likely experiencing an adjustment reaction to acute and recent stressors. The psychiatrist wrote Patient 33 had no acute psychiatric concerns based on "...observed behavior for many hours in the ED..." A physician's order to discontinue the 5150 hold was written on 7/23/11 at 5:15 PM, and Patient 33 was discharged from Facility A.

Based on record review and interview, the facility failed to ensure that:
A. Two of 33 sampled patients (Patients 9 and 25)were stabilized prior to their discharge home, when there was no documentation the 5150 psychiatric hold for danger to self/danger to others that had been imposed on them was lifted by qualified staff prior to their discharge home.

B. One of 33 sampled patients (Patients 21)had documentation of the specific treatment proposed and the risks of refusing the treatment when the pt. left the hospital against medical advice.

Findings:

A . Patient 9
Patient 9 was admitted to the Emergency Department (ED) on 7/12/11 at 1:10 PM after she was brought to the ED by a policeman after she assaulted/was assaulted by family members. On 7/12/11 the police had placed Patient 9 on a 5150 involuntary hold. The patient's psychiatric condition as a danger to others was the basis of her emergency medical condition.

Record review of Patient 9's ED record indicated a Mobile Crisis Team LCSW (Licensed Clinical Social Worker) had met with Patient 9 on 7/12/11, not timed, and recommended the 5150 hold be released.

The Physician Assistant's "Emergency Reports" dictated 7/13/11 at 3:17 PM indicated the Mobile Crisis Team released the 5150 hold prior to escorting Patient 9 home on 7/12/11.

Record review of the clinincal records on 8/10/11 at 1:30 PM indicated there was no examination by a psychiatrist or a psychologist prior to Patient 9's discharge and there was no physician order to discontinue the 5150 hold.

In an interview on 8/10/11 at 1:30 PM, the Director of Case Management confirmed that there was no psychiatric evaluation of Patient 9 by a psychiatrist or psychologist prior to Patient 9's discharge home and there was no physician order releasing the 5150 involuntary detention requirements. The Director stated it was facility practice to allow the informal release of the 5150 legal hold by a member of the Mobile Crisis Team. The Director stated this member was usually an LCSW.

Patient 9 was not properly released from her 5150 involuntary detention and, therefore, the emergency medical condition, potential for harm to others, had not been formally stabilized.

A. Patient 25
Patient 25 was a minor who was brought to the hospital's emergency department on 02/07/11 at 1:07 AM by police on a 5150 involuntary hold after he cut his left wrist with scissors when he had an altercation with his father.

A social worker from the Child Crisis Center evaluated the patient on 02/07/11 (no time documented)and recommended the 5150 be released.

Review of the facility policy and procedure, "Patients Receiving Psychiatric Evaluation", dated 3/08, indicated that for the 5150 hold patients ("involuntary detention of individuals for psychiatric evaluation") "Only a psychiatrist or a psychologist in consultation with the psychiatrist can remove an involuntary hold prior to the 72 hours."

On the dictated report dated 02/07/11 at 4:59 AM, the emergency room physician documented, "The patient was evaluated by the Child Crisis who did also speak with the patient's mother. It was determined at this time the patient was not a danger to himself or anyone else. The mother was comfortable taking the patient home. Child Crisis did break the 5150, and the patient was discharged home in the care of his mother.





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B. Patient 21:
Record review indicated Patient 21 was brought to the hospital's emergency department on 02/12/11 at 11:45 AM via ambulance for head laceration from an assault. The emergency department physician's assistant documented doing the medical screening exam at 13:00.

The emergency department nurse electronically documented on 02/12/11 at 12:46 PM the following: "Pt. (patient)cleared himself from a c collar (cervical collar), requesting to leave to smoke. Pt. agrees to have head ct (computerized tomography- a radiological procedure) scan done". The nurse further documented at 13:30: "Pt. unable to sit still for ct scanner, pt. abusive to ct tech (technician)... PA (physician's assistant)... called to bs (bedside), pt a/o (alert/oriented)x4, and agrees to sign AMA form. Steady gait on ambulation to exit".

The dictated progress note done by the physician's assistant and co-signed by the physician was dated 02/12/11 at 3:58 PM documented the following: "I offered the patient a head CT, but he declined. He did initially agree to a head CT, and then while at CT scan became verbally hostile towards the CT tech. He returned to the emergency department stating he would like to go. He was ambulatory, with stable gait, alert and oriented x4. Although appears intoxicated, does appear capable of making his own decisions. He then left the emergency department against medical advice".

The medical screening exam form was dated and signed by the physician on 02/12/11 at 3:55 PM.

The form, "Leaving Hospital Against Medical Advice" was signed and dated by the patient on 02/12/11 at 1305 with one witness. The form's section titled in bold print, "The Following Section Must Be Completed By The Physician", was not signed, dated, or timed. The physician would be signing to the following declaration on this form: "I declare that I have personally explained to the patient the risks and consequences involved in leaving the hospital at this time, the benefits of continued treatment and hospitalization, and the alternatives, if any to continued treatment and hospitalization".






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Based on interview and record review, the facility did not meet the regulatory obligations regarding the transfer of patients to other acute hospitals when:
A. five of the 33 sampled patients were transferred to other acute care facilities without documented evidence that the risks and benefits of the proposed transfer had been explained to the patient and the patient had consented to the transfer (Patients 3,13, 14, 28, and 29);
B. two of the 33 sampled patients were transferred to other acute care facilities without a signed physician certification explaining the risks and benefits of such a transfer (Patients 4 and 29); and,
C. the dictated information regarding the medical screening examination and the stabilizing treatment provided were not sent with the patient to the receiving hospital for one of the 33 sampled patients (Patient 17).

Findings:

A. Review of the hospital's policy titled, EMTALA: Transfer/Discharge of Emergency Patients, number PC-120, Revision Date 3-11, page 3 of 6, b, "Patient Request", documented the following: "An individual with an emergency medical condition that is not stabilized may be transferred if the individual (or legally responsible person acting on the individual's behalf)makes a written request to be transferred after being informed of the Hospital's responsibility to provide stabilizing treatment to the individual and the risks and benefits of transfer. 1)The request for transfer must be in writing and signed by the patient (or legally responsible person acting on the individual's behalf). 2)Before signing the request, the transferring physician will explain to the individual (or his/her representative)(i)the obligation of (the hospital)to provide further examination and stabilizing treatment; (ii)the risks associated with the proposed transfer; and (iii)the benefits of continuing treatment at (the hospital) and any alternatives to the transfer. 3)The written consent must be signed after the individual (or his/her representative)has been provided the information listed above, and decides that, despite the information, he/she requests the transfer to another facility. The individual (or his/her representative)will be given the opportunity to ask questions before signing the request for the transfer. 4)The request must be filed in the patient's medical record, and copy sent to the receiving facility when the individual is transferred.

A. Patient 3
Record Review on 8/9/11 of Patient 3's triage record dated 4/22/11, indicated she was brought in to the ED by family for nose bleed and vomiting blood at 6:30 AM. Patient 3 was alert and oriented.

Review of the ED physician's notes dated 4/22/11 at 6:35 AM indicated diagnoses including hemoptysis (coughing or spitting of blood from any part of the respiratory tract) versus hematemesis (vomiting blood), dyspnea (difficulty breathing), pneumonia, and hypoxia (low oxygen saturation in the blood). The ED physician indicated Patient 3 was in serious condition and was to be transferred to another acute care facility where she had been accepted by a physician.

During interview on 8/9/11 at approximately 3:55 PM, the CIN 1 looked through Patient 3's record and was unable to find a Patient Transfer Acknowledgement Form signed by Patient 3 that risks and benefits of the transfer had been explained to her and that she agreed to the transfer.

A. Patient 13
Patient 13, a 15 year old, was brought to the ED by his father on 6/3/11 at 11:27 AM with a chief complaint of sore throat. The ED physician indicated Patient 13 had critical upper airway stenosis (narrowing) with stridor (high pitched breathing noises), massive palantine (upper mouth) and cervical (neck) adenopathy (disease with swelling of the adenoid glands in the upper airway) secondary to acute infectious mononucleosis. The ED physician's "Emergency Reports" summary, dictated 6/3/11 at 3:37 PM, indicated he discussed the case with two physicians at another acute facility and the decision was made to transfer Patient 13 to another acute facility for pediatric intensive care. The "Emergency Reports" did not indicate any discussion with Patient 13's father regarding the need for the transfer and the risks and benefits of the transfer. The ED record did not contain the facility's Transfer Acknowledgement form or any document in which Patient 13's father acknowledged he understood the risks and benefits of the proposed transfer and that he agreed to have his son transferred to another acute facility for pediatric intensive care observation and treatment.

Patient 13 was transferred by ambulance on 6/3/11 at 4:31 PM accompanied by family.

On 8/9/11 at 11:35 AM, the Director of Quality reviewed Patient 13's computerized ED record and stated there was no documentation that the ED physician had discussed the risks and benefits of transfer with Patient 13's father, and there was no documentation Patient 13's father had consented to the transfer to another acute facility.

On 8/9/11 at 2:15 PM, the Senior Director supervising the ED reviewed Patient 13's non-computerized ED record and stated the Transfer Acknowledgement form had not been completed and there was no written documentation that Patient 13's father understood the risks and benefits of the proposed transfer of his son, nor was there written documentation that Patient 13's father agreed to the transfer.

A. Patient 14
Patient 14 was admitted to the ED on 7/21/11 with a chief complaint of hip pain. The Medical Screening Examination determined Patient 14 had a right hip fracture.

Record review of the ED physician's "Emergency Reports" summary, dictated 7/21/11 at 10:18 PM indicated Patient 14 requested a transfer to another acute hospital where she wanted to have the orthopedic surgery performed, and the other hospital accepted the transfer. The Nursing Neurological Assessment performed 7/21/11 at 5:00 PM indicated Patient 14 was alert and oriented to person, place, and time. Nursing documentation indicated Patient 14 was transferred by ambulance, in stable condition, on 7/21/11 at 9:42 PM.

On 8/9/11 at 2:15 PM, the Senior Director supervising the ED reviewed Patient 14's ED record and stated there was no written request for transfer, signed by Patient 14, in her record, and there was no documentation the risks and benefits of the proposed transfer had been explained to Patient 14 by the ED physician.

A. Patient 28
Patient 28 ambulated on her own to the hospital's emergency department after taking public transportation on 02/27/11 at "15:27" with acute second degree facial and hand burns (partial thickness burns affecting both the outer and underlying layer of skin that can present with reddened patches, blisters, and pain) that affected 10% of her body surface. The patient was at home and had kerosene on the stove and the kerosene caught on fire. The patient had shortness of breath and stated she had inhaled some smoke. The patient was alert and oriented and had a past medical history of bipolar affective disease (a psychiatric diagnosis defined by the presence of one or more episodes of abnormally elevated energy levels, cognition or mood with or without one or more depressive episodes) and diabetes mellitus (a metabolic disease in which a person has high blood sugar). The medical screening exam was performed at "15:30".

On 02/27/11, the physician's dictated report done at 5:07 PM stated, " The patient presented with acute facial burns, is at risk for pulmonary edema, ARDS (Acute Respiratory Distress Syndrome), and airway swelling, she was thus intubated..." Intubation is defined as a tube inserted through the mouth or nose and into a patient's lungs to help them breath. Usually followed by mechanical ventilation which is the use of a machine to breath for the patient. The patient was intubated at "15:45".

The results of a 1 view chest x-ray taken on 02/27/22 at 4:53 PM read by the emergency department physician showed, "... bilateral interstitial infiltrates, consistent with pulmonary edema." Pulmonary edema is fluid accumulation in the lungs which leads to impaired gas exchange and may cause respiratory failure.

Subsequently, the emergency room physician documented oh the dictated report on 02/27/11 at 5:07 PM, "The patient will require a burn center admission for burn care of hand burns as well as for possible airway burn management..." Since the hospital did not have an acute burn center, the emergency room physician spoke with the receiving physician at another facility which had a burn center. The documentation showed the following: "I spoke with (the receiving physician), who accepted the patient for a higher level of care".

The "Patient Transfer" form signed by the emergency room physician documented the following for reason for transfer: "Burn center, risk of crash", and was dated 02/27/11 at "17:00". The patient was transferred via ambulance at "18:00". The physician did not specifically indicate whether the patient was stable or unstable for transfer. The dictated note by the physician dated 02/27/11 stated under "Disposition": "Transferred for a higher level of care" and under "Condition": "Guarded". Additionally, the second page of this form titled, "Patient Transfer Acknowledgement" was not done. This form would indicate the patient's acknowledgement of receiving medical screening, examination, and evaluation and was informed of the reasons for transfer.

During an interview on 8/11/11 at 10:55 AM, the Senior Director of Cardiovascular Services and Critical Care (SDCSCC)agreed the "Patient Transfer Acknowledgement" form was not done and that if the patient could not sign because of physical or mental incapacity, the hospital should have documented so on the form.

A. Patient 29
Patient 29 was admitted to the ED on 6/22/11 at 1:23 PM with a chief complaint of neck pain. The Medical Screening Examination indicated Patient 29 had an emergency medical condition of subarachnoid hemorrhage (bleeding under the covering of the brain). The ED physician's "Emergency Reports" summary dictated 6/22/11 at 7:19 PM indicated the ED physician spoke with a neurosurgeon at another acute care facility who agreed to accept Patient 29 as a transfer. This note did not outline any discussion with Patient 29 regarding the risks and benefits of the proposed transfer nor did it contain any indication that Patient 29 accepted the transfer. The nursing documentation indicated Patient 29 was transferred by critical care ambulance on 6/22/11 at 5:28 PM.

On 8/10/11 at 2:40 PM, the Senior Director supervising the ED reviewed Patient 29's ED record and stated the facility's Transfer Acknowledgement form had not been completed nor was there any signed documentation that the risks and benefits of the transfer had been explained to Patient 29 by the ED physician, nor was there any signed documentation that Patient 29 consented to the transfer.

B. Review of the facility policy and procedure, EMTALA: Transfer/Discharge of Emergency Patients, revised 13-11, indicated, "...B. Patient Transfer- Emergency Medical Condition Unstabilized...a. Physician Certification 1) An individual with an emergency medical condition that is not stabilized may be transferred if the transferring physician, based on information available at the time of transfer, signs a certification that the medical benefits reasonably expected from the provision of medical treatment at another facility outweigh the increased risks to the individual ...from the transfer. 2) The certification must be in writting and contain the reason(s) for the transfer and a summary of the risks and benefits upon which it is made..."

B. Patient 4
Record review of Patient 4's ED record dated 3/11/11, indicated he presented to the ED by ambulance at 11:44 PM under a 5150 hold for psychiatric evaluation that was placed by paramedics.

Review of the 3/11/11 physician's handwritten notes indicated Patient 4 was examined at 00:10 AM and was diagnosed with suicide ideation and pneumonia. The notes indicated the pneumonia was treated with antibiotics and that Patient 4 was medically stable for psychiatric admission. Under disposition, the physician indicated transfer to an acute psychiatric unit under the care of a specific physician. The space designated for date and time the physician accepted Patient 4 was left blank.

Review of the RN notes dated 3/12/11 indicated Patient 4 was accepted for PES (Psychiatric Emergency Services) at 5:11 AM, and that Patient 4 was informed he would be transferred there at 5:30 AM. At 7:06 AM, the RN noted that the ambulance was there to collect the patient and that the patient was ready to go.

Review of the physician's ED report dictated 3/11/11 at 7:26 AM indicated that Patient 4 was accepted at a hospital under the care of a specific doctor for impatient psychiatric care.

There was no physician's certification containing a summary of the risks and benefits of Patient 4's transfer to another acute facility for psychiatric evaluation and treatment in the record.

During interview with CIN 2 on 8/10/11 at 8:40 AM, she reviewed Patient 4's record and acknowledged the physician did not document the time Patient 4 was accepted by the physician at the receiving facility. She was unable to locate a physician's certification indicating the risks and benefits of the patient's transfer in the record.

C. Patient 17
Patient 17 was admitted to the ED on 7/15/11 at 8:35 PM with a chief complaint of overdose on Seroquel (an antipsychotic prescription medication). Record review indicated Patient 17 was placed on a 5150 involuntary detention by the ED physician because Patient 17 was a danger to himself.

Record review indicated Patient 17 had a Medical Screening Examination and treatment, and was transferred by ambulance in serious but stable condition to an acute psychiatric facility on 7/16/11 at 12:05 AM.

During record review on 8/9/11 at 11:50 AM, the Director of Quality noted that Patient 17's Medical Screening Examination and the ED Course and Medical Decision Making components of Patient 17's ED record were dictated on 7/15/11 at 11:42 PM but this dictation was not transcribed until 7/16/11 at 3:05 AM, three hours after Patient 17 had been transferred to another facility. The Director of Quality acknowledged this important clinical information was not sent with Patient 17 at the time of his transfer. This Director also acknowledged there was no documentation in the ED record to indicate this clinical information had been faxed to the receiving hospital after transcription was completed.