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Based on medical record review, interviews and policy review, the facility failed to ensure the medical screening examination was performed by the emergency room physician or attending physician (A2406) failed to provide stabilizing treatment (A2407) and failed to ensure appropriate transfer documentation (A2409). The cumulative effect of these systemic practices is a risk to all patients presenting to the emergency department.

Based on interview and observation, the facility failed to conspicuously place a sign specifying the rights of individuals under Emergency Medical Treatment and Active Labor Act.

Findings include:

On 03/04/13 at 3:04 P.M. a tour of the emergency department was conducted with the vice president of patient care services. Signage for patient rights under Emergency Medical Treatment and Active Labor Act was observed to be propped on the ground between a row of chairs and the wall. In an interview during the tour, the vice president couldn't explain what the sign was doing on the ground propped between a row of chairs and the wall rather than posted somewhere more conspicuous.

Based on clinical record review, policy review, review of the facility's bylaws and staff interview the facility failed to ensure the medical screening examination was performed by the emergency department physician or attending physician as required in the hospital's bylaws for four (Patient #9, #24, #25, and #27) of 27 clinical records reviewed.

Findings include:

The facility's bylaws were reviewed on 03/06/13. The facility's medical bylaws, last revised 10/29/12, stated, "all patients following triage, will undergo an appropriate medical screening exam and be offered stabilizing treatment either by the ED physician or an attending physician that is a qualified member of the medical staff. "

A review of the facility's Compliance with Emergency Medical Treatment and Active Labor Act policy (subject number E-11-4), effective 01/01, revised 06/09, revealed "the medical screening examination must be done by a physician ...".


1. The clinical record review for Patient #9 was completed on 03/06/13. The 21-year-old-patient was admitted to the emergency department on 11/01/12 with a chief complaint of suicidal ideation. A crisis assessment was completed by a licensed independent social worker on 11/01/12. The licensed independent social worker documented the patient had increased depression and the feeling of inability to control him/herself from self-harm. The patient had a plan to shoot and/or cut him/herself. A physician assistant (PA) assessed the patient and documented his/her findings on the Emergency Physician Record. The physician signed the Emergency Physician Record but did not mark he/she agreed with the assessment and care plan or confirm the diagnosis made by the PA. Although the record was signed by the emergency department (ED) physician and physician assistant, there was no way to determine what part of the medical screening exam was done by the physician. The patient was transferred to an inpatient mental health facility on 11/01/12.

2. The clinical record review for patient #24 was completed on 03/06/13. The 20-year-old patient was admitted to the emergency department with a chief complaint of back pain. A crisis assessment was completed by a licensed independent social worker. The licensed independent social worker documented the patient was depressed and had suicidal ideations. The patient was pink slipped and transferred to an inpatient mental health facility on 01/19/13. A physician assistant (PA) assessed the patient and documented his/her findings on the Emergency Physician Record . The physician signed the Emergency Physician Record but did not mark he/she agreed with the assessment and care plan or confirm the diagnosis made by the PA. Although the record was signed by the emergency department (ED) physician and physician assistant, there was no way to determine what part of the medical screening exam was done by the physician.

3. The clinical record review for Patient #25 was completed on 03/05/13, and revealed the 19- year-old patient presented to the emergency department on 01/08/13 at 1:23 A.M. An emergency physician record dated 01/08/13 at 1:30 A.M. that stated the patient's chief complaint was suicidal thoughts. A nursing note dated 01/08/13 at 2:36 P.M. revealed the patient stated he told his girlfriend he was going to take sleeping pills because he couldn't see her anymore. Further review of the clinical record revealed the emergency physician record was signed by a physician's assistant/nurse practitioner and the physician; however, there was no way to determine what part of the medical screening exam was done by the physician.

4. The clinical record review for Patient #27 was completed on 03/05/13. The clinical record review revealed the 21-year-old patient presented to the emergency department on 02/17/13 at 12:40 P.M. with a chief complaint of hearing voices after he/she had been baptized. An emergency physician record dated 02/17/13 at 12:50 P.M. stated that the patient denied being suicidal but was maybe going to hurt some children. A behavioral health assessment dated 02/17/13 at 12:57 P.M. stated after the patient got baptized he/she heard the devil tell him/her that he/she made the wrong decision.The record stated the patient's clinical impression was acute psychoses. Further review of the record revealed the emergency physician record was signed by a nurse practitioner and the physician, there was no way to determine what part of the medical screening exam was done by the physician.

On 03/04/13 at 4:05 P.M. in an interview, Physician D stated stated he could not demonstrate how one could tell from looking at the emergency physician record what part of the patient's exam was performed by him/her and what part was performed by the nurse practitioner.

On 03/06/13 at 9:00 A.M. in an interview with Director #1, Director #2, and Quality Manager #1 the facts were shared that for Patient #9, #24, #25, and #27 there was no way to determine what part of the medical screening exam was done by the physician.


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Based on clinical record review, policy review and staff interview, the facility failed to document evidence of the stabilization in the emergency department of five patients (Patient #1, #6, #7, #12 and #22) and failed to ensure recommended tests were completed prior to discharging one patient (Patient #6) of 27 clinical records reviewed.

Findings include:

1.The clinical record review for Patient #22 was completed on 03/05/13. The clinical record review revealed the 16-year-old patient presented to the emergency department on 02/25/13 at 12:46 P.M. The clinical record review revealed an emergency physician record that stated the patient had been discharged from a psychiatric facility 02/21/13 (four days prior), and currently had plans to kill him/herself including taking pills, ingesting bleach, hanging and cutting.

The clinical record review revealed a crisis assessment note dated 02/25/13 with a disposition note that stated the physician at the facility from which he/she was discharged on 02/21/13 stated he/she did feel that Patient #22 would benefit from another in-patient hospitalization. That said, the disposition note indicated placement for the patient was looked for elsewhere at two other major facilities in the area, stating,"currently no beds."

The crisis assessment note stated the emergency department physician was not in agreement with the social worker's recommendation to discharge the patient home with parents. The clinical record review revealed a crisis team documentation form dated 02/25/13 signed by the emergency department physician and social worker, but not the patient's emergency department nurse. The form stated the proposed disposition for the patient was to go home with father and mother. Handwritten onto the form was "Physician currently not in agreement with this proposal/disposition." The crisis assessment note stated the emergency department physician "allowed" family to sign out against medical advice.

The clinical record review revealed the emergency department physician signed the against medical advice form that stated, "Dad wants to take Patient #22 home and feels he/she is not unsafe going home" and that he/she would see his/her therapist the next day on 02/26/13 at 8:00 P.M. Other than that, the form did not indicate the reasons for leaving against medical advice. The form had lines to check for reasons to leave against medical advice which included not wanting further treatment, refusing admission, and wanting to be treated at another facility. None of these lines were checked.

On 02/26/13 at 9:29 P.M. (the next day) the patient presented again to the emergency department according to a clinical record review completed on 03/05/13. The clinical record review revealed a crisis assessment note dated 02/26/13 at 11:07 P.M. that stated the patient saw his/her therapist and was unable to contract for safety or utilize his/her coping skills. The note stated the patient had a suicide plan to either drink bleach, overdose, or hang him/herself and "Patient appears to have poor coping skills." The note also stated a bed was found at a local psychiatric unit, but that it was full at that time, but the patient could be transferred in the morning. The clinical record review revealed the patient did spend the night in the emergency department and was transferred to the psychiatric facility on 02/27/13 at 8:55 A.M.

On 03/06/13 Director #1 in an interview stated the facility has looked beyond the local area to find beds for patients and that the patient could have spent the night during his/her first visit to the emergency department on 02/25/13 had a bed been found further away. Director #1 stated if the emergency department physician felt the patient needed to stay, (as indicated by the crisis assessment and crisis team documentation form of 02/25/13) there were other avenues that could have been pursued rather than to "allow" the parent to sign the patient out against medical advice.



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2. The clinical record review for Patient #1 was completed on 03/06/13. The 15-year-old male was admitted to the emergency department on 02/17/13 with a diagnosis of suicide attempt. The police were called to the patient 's home by family due to the patient had threatened to kill him/herself with kitchen shears. The patient has a history of mood disorders and attention deficit disorder, has poor coping skills, difficulty getting along with his/her family and poor impulse control. The patient reported he/she becomes suicidal when upset. The patient reported to the licensed independent social worker he/she cannot keep him/herself safe at home. A physician examined the patient and did not document medical clearance, disposition or condition of the patient in the emergency physician record. A registered nurse documented the patient was transferred by ambulance on 02/18/13 at 2:50 PM.

3. The clinical record review for Patient #6 was completed on 03/06/13. The 36-year-old patient was admitted to the emergency department on 12/03/12 with a chief complaint of assault. The patient was examined by a physician and administered pain medications. The facility performed an x-ray of the right shoulder and a CT-scan of the head. The physician diagnosed the patient with a right eye contusion and right shoulder strain. The right shoulder x-ray final report was read at 4:24 PM on 12/03/12. The report stated suspect mildly impacted fracture of the humeral neck and that this can be further assessed with an unenhanced CT-scan through the shoulder. A CT-scan through the shoulder was never performed while the patient was in the emergency department. The patient was discharged home on 12/03/12. The clinical record review did not contain evidence the patient had been notified of the fracture prior to being discharged. On 12/11/12, the facility sent a letter to the patient instructing the patient to call regarding the results of tests. The mail was undeliverable due to an insufficient address.

4. The clinical record review for Patient #7 was completed on 03/06/13. The 49-year-old patient was admitted to the emergency department on 10/24/12 with a chief complaint of altered mental status. A crisis assessment was completed by the licensed independent social worker. The licensed independent social worker stated the patient was bipolar and had been off his/her prescribed medications. The patient had recently purchased a gun and a spent 9 mm shell was found in the patient's coat pocket. The licensed independent social worker reported the patient had a blunt presentation, angry, made no eye contact, and the patient's thought process was tangential. The patient has been decompensating for the past 10 days and family, co-workers and friends were concerned for the patient. The patient had an increase in lavish spending, social networking, relationship scams, had not been sleeping and had increased his/her alcohol consumption. The patient was transferred to an inpatient psychiatric facility on 10/24/12. The physician did not document the patient's condition prior to the transfer.

5. The clinical record review for Patient #12 was completed on 03/06/13. The 34-year-old patient was admitted to the emergency department with a chief complaint of suicidal ideation and possible drug ingestion. The patient was brought to the emergency department by emergency medical services and the police. The police completed an Application for Emergency Services stating the patient reported he/she wanted to kill him/herself and the patient was two months pregnant. Lab work was drawn on the patient and the results were positive for cocaine and alcohol.

A physician evaluated the patient and the physician's diagnostic impression was suicidal ideation, violent behavior, alcohol intoxication and cocaine abuse. The physician also documented the patient was belligerent, abusive toward staff and uncooperative. The patient was placed in four point restraints. The physician did not medicate the patient. The physician informed the patient the sheriff's department would be called to escort the patient out of the emergency department if the patient did not calm down. The patient continued to act inappropriately and the sheriff's department was called to the emergency department. The patient was taken in handcuffs from the emergency department to jail. The physician informed the patient to return to the emergency department for an evaluation once the patient calmed down. The physician did not document the patient was stable for transfer.

Based on clinical record review, interview and policy review, the facility failed to ensure The Certificate to Transfer Physician Assessment and Certification form was completed for nine (Patient #1, #3, #7, #9, #13, #14, #16, #23 and #24) of 27 clinical records reviewed.

Findings include:

1. The clinical record review for Patient #13 was completed on 03/05/13. The clinical record review revealed the 56-year-old patient presented to the emergency department on 12/13/12 with a chief complaint of being suicidal. A crisis assessment dated 12/13/12 at 10:06 A.M. stated the patient was very angry, hostile, and paranoid. The assessment stated the patient talked about laying on railroad tracks or cutting his/her throat. The patient also stated he/she wanted to stab people. The Certificate to Transfer Physician Assessment and Certification form for specialized care services was not signed by the physician and did not identify the mode of transport.

2. The clinical record review for Patient #14 was completed on 03/05/13. The clinical record review revealed the 28-year-old patient presented to the emergency department triage on 12/06/12 for a chief complaint of depression and not liking the place where he/she lived. The clinical record review revealed a crisis assessment dated 12/06/12 at 4:30 P.M. that stated the patient complained of being very tearful, not being able to control him/herself, fearful he/she would hurt his/her cat, and paranoid that drug dealers are going to hurt him/her. The Certificate to Transfer Physician Assessment and Certification form for specialized care services did not identify the receiving facility, the receiving physician nor was the time the receiving hospital was contacted or mode of transport.

3. The clinical record review for Patient #16 was completed on 03/05/13. The clinical record review revealed the 15-year-old patient presented to the emergency department triage with a chief complaint of suicide ideation and using a knife to threaten him/herself. The clinical record review revealed a crisis assessment dated 12/31/12 at 1:33 P.M. that stated the patient picked up a knife and threatened to kill him/herself. The note stated the patient presented with flat affect, depression, suicidal and very limited insight. The clinical record review revealed a Certificate to Transfer Physician Assessment and Certification form. The form did not provide a reason for the transfer, mode of transport, whether appropriate medical records were sent, and wasn't signed by a physician.

4. The clinical record review for Patient #1 was completed on 03/06/13. The 15-year-old male was admitted to the emergency department on 02/17/13 with a diagnosis of suicide attempt. The police were called to the patient 's home by family due to the patient had threatened to kill him/herself with kitchen shears. The patient has a history of mood disorders and attention deficit disorder, poor coping skills, difficulty getting along with his/her family and poor impulse control. The patient reported he/she becomes suicidal when upset and reported to the licensed independent social worker that he/she cannot keep him/herself safe at home.

A physician examined the patient and did not document medical clearance, disposition or condition of the patient in the emergency physician record. The Certificate to Transfer Physician Assessment and Certification form did not list the patient's condition on transfer, the mode of transportation and there was no evidence the appropriate clinical records were sent with the patient. A registered nurse documented the patient was transferred by ambulance on 02/18/13 at 2:50 PM.
The findings were shared with Staff E on 03/06/13 and confirmed.

5. The clinical record review for Patient #3 was completed on 03/06/13. The 25-year-old patient was admitted to the emergency department on 11/23/12 for a chief complaint of pregnancy test check. A pregnancy test was administered and the patient was discharged. The physician documented the patient's condition as improved and stable, but did not document the disposition.

Patient #3 was readmitted to the emergency department on 12/14/12 with a chief complaint of suicidal ideation. A crisis assessment was completed by a licensed independent social worker on 12/14/12. The licensed independent social worker documented the patient had increased depression and suicidal ideation with a plan to cut her wrists. The patient also reported relapsing on heroin. The patient was transferred to an inpatient mental health facility on 12/14/12. The Certificate to Transfer Physician Assessment and Certification form did not list the mode of transport nor did it contain the physician's signature.

6. The clinical record review for Patient #7 was completed on 03/06/13. The 49-year-old patient was admitted to the emergency department on 10/24/12 with a chief complaint of altered mental status. A crisis assessment was completed by the licensed independent social worker. The licensed independent social worker stated the patient was bipolar and had been off his/her prescribed medications. The patient had recently purchased a gun and a spent 9mm shell was found in the patient's coat pocket. The licensed independent social worker reported the patient had a blunt presentation, angry, made no eye contact, and the patient's thought process was tangential. The patient has been decompensating for the past 10 days and family, co-workers and friends were concerned for the patient. The patient had an increase in lavish spending, social networking, relationship scams, had not been sleeping and had increased his/her alcohol consumption.

The patient was transferred to an inpatient psychiatric facility on 10/24/12. The physician did not document the patient's condition or mode of transport on the Certifcate to Transfer Physician Assessment and Certification form. The physician did not indicate the patient's medical records were sent to the receiving facility on the form. The form did not contain the date and time of the physician's signature.

7. The clinical record review for Patient #9 was completed on 03/06/13. The 21-year-old patient was admitted to the emergency department on 11/01/12 with a chief complaint of suicidal ideation. A crisis assessment was completed by a licensed independent social worker on 11/01/12. The licensed independent social worker documented the patient had increased depression and the feeling of inability to control him/herself from self-harm. The patient had a plan to shoot or cut him/herself.

The patient was transferred to an inpatient mental health facility on 11/01/12. The Physician Assessment and Certification/certificate to transfer form did not list the patient's condition at discharge, did not list the mode of transport, did not signify the medical record was sent to the facility and the physician did not document the date and time he/she signed the form.

8. The clinical record review for Patient #23 was completed on 03/06/13. The 57-year-old patient was admitted to the emergency department on 09/26/12 with a diagnosis of schizoaffective disorder. A crisis assessment was completed by a licensed independent social worker. The licensed independent social worker documented the patient was pink slipped for attempting to walk into on-coming traffic. The patient had not been sleeping or eating. The patient was transferred to an inpatient mental health facility on 09/26/12. The physician did not document the patient was stable on the Certificate to Transfer Physician Assessment and Certification form or in the patient's emergency department record.

9. The clinical record review for patient #24 was completed on 03/06/13. The 20-year-old patient was admitted to the emergency department with a chief complaint of back pain. A crisis assessment was completed by a licensed independent social worker. The licensed independent social worker documented the patient was depressed and had suicidal ideations. The patient was pink slipped and transferred to an inpatient mental health facility on 01/19/13. The physician did not document the patient was stable on the Certificate to Transfer Physician Assessment and Certificationform and did not document the mode of transport or the date and time. The physician did not document a receiving physician on the Certificate to Transfer form.

A review of the facility's policy "Transfer Procedure", effective 02/2002, revised 09/07, revealed the "Physician must fill out Certificate to Transfer Form and complete form obtaining appropriate patient and physician signatures. " The facility's policy External Transfer Procedure was reviewed on 03/06/13. The policy stated a physician will contact a receiving physician to confirm acceptance of the patient being sent for test or procedure who will be discharged from the facility or transferred and to personally provide patient information prior to undertaking the transfer. A summary of the clinical status must be given to the receiving physician and verbal acceptance of the transfer must be given by the receiving physician. The physician must fill out the Certificate to Transfer form and complete the form obtaining appropriate patient and physician signatures.

On 03/06/13 at 9:00 A.M. in an interview with Director #1, Director #2, and Quality Manager #1, the incomplete transfer certificates for Patients #1, #3, #7, #9, #13, #14, #16, #23, and #24 were presented. Quality Manager #1 stated the medical record department might be looking at the transfer certificates, but was unable to provide a statistic on transfer certificate completeness.


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Based on clinical record review, policy review, review of the facility's bylaws and staff interview the facility failed to ensure the medical screening examination was performed by the emergency department physician or attending physician as required in the hospital's bylaws for four (Patient #9, #24, #25, and #27) of 27 clinical records reviewed.

Findings include:

The facility's bylaws were reviewed on 03/06/13. The facility's medical bylaws, last revised 10/29/12, stated, "all patients following triage, will undergo an appropriate medical screening exam and be offered stabilizing treatment either by the ED physician or an attending physician that is a qualified member of the medical staff. "

A review of the facility's Compliance with Emergency Medical Treatment and Active Labor Act policy (subject number E-11-4), effective 01/01, revised 06/09, revealed "the medical screening examination must be done by a physician ...".


1. The clinical record review for Patient #9 was completed on 03/06/13. The 21-year-old-patient was admitted to the emergency department on 11/01/12 with a chief complaint of suicidal ideation. A crisis assessment was completed by a licensed independent social worker on 11/01/12. The licensed independent social worker documented the patient had increased depression and the feeling of inability to control him/herself from self-harm. The patient had a plan to shoot and/or cut him/herself. A physician assistant (PA) assessed the patient and documented his/her findings on the Emergency Physician Record. The physician signed the Emergency Physician Record but did not mark he/she agreed with the assessment and care plan or confirm the diagnosis made by the PA. Although the record was signed by the emergency department (ED) physician and physician assistant, there was no way to determine what part of the medical screening exam was done by the physician. The patient was transferred to an inpatient mental health facility on 11/01/12.

2. The clinical record review for patient #24 was completed on 03/06/13. The 20-year-old patient was admitted to the emergency department with a chief complaint of back pain. A crisis assessment was completed by a licensed independent social worker. The licensed independent social worker documented the patient was depressed and had suicidal ideations. The patient was pink slipped and transferred to an inpatient mental health facility on 01/19/13. A physician assistant (PA) assessed the patient and documented his/her findings on the Emergency Physician Record . The physician signed the Emergency Physician Record but did not mark he/she agreed with the assessment and care plan or confirm the diagnosis made by the PA. Although the record was signed by the emergency department (ED) physician and physician assistant, there was no way to determine what part of the medical screening exam was done by the physician.

3. The clinical record review for Patient #25 was completed on 03/05/13, and revealed the 19- year-old patient presented to the emergency department on 01/08/13 at 1:23 A.M. An emergency physician record dated 01/08/13 at 1:30 A.M. that stated the patient's chief complaint was suicidal thoughts. A nursing note dated 01/08/13 at 2:36 P.M. revealed the patient stated he told his girlfriend he was going to take sleeping pills because he couldn't see her anymore. Further review of the clinical record revealed the emergency physician record was signed by a physician's assistant/nurse practitioner and the physician; however, there was no way to determine what part of the medical screening exam was done by the physician.

4. The clinical record review for Patient #27 was completed on 03/05/13. The clinical record review revealed the 21-year-old patient presented to the emergency department on 02/17/13 at 12:40 P.M. with a chief complaint of hearing voices after he/she had been baptized. An emergency physician record dated 02/17/13 at 12:50 P.M. stated that the patient denied being suicidal but was maybe going to hurt some children. A behavioral health assessment dated 02/17/13 at 12:57 P.M. stated after the patient got baptized he/she heard the devil tell him/her that he/she made the wrong decision.The record stated the patient's clinical impression was acute psychoses. Further review of the record revealed the emergency physician record was signed by a nurse practitioner and the physician, there was no way to determine what part of the medical screening exam was done by the physician.

On 03/04/13 at 4:05 P.M. in an interview, Physician D stated stated he could not demonstrate how one could tell from looking at the emergency physician record what part of the patient's exam was performed by him/her and what part was performed by the nurse practitioner.

On 03/06/13 at 9:00 A.M. in an interview with Director #1, Director #2, and Quality Manager #1 the facts were shared that for Patient #9, #24, #25, and #27 there was no way to determine what part of the medical screening exam was done by the physician.


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Based on clinical record review, policy review and staff interview, the facility failed to document evidence of the stabilization in the emergency department of five patients (Patient #1, #6, #7, #12 and #22) and failed to ensure recommended tests were completed prior to discharging one patient (Patient #6) of 27 clinical records reviewed.

Findings include:

1.The clinical record review for Patient #22 was completed on 03/05/13. The clinical record review revealed the 16-year-old patient presented to the emergency department on 02/25/13 at 12:46 P.M. The clinical record review revealed an emergency physician record that stated the patient had been discharged from a psychiatric facility 02/21/13 (four days prior), and currently had plans to kill him/herself including taking pills, ingesting bleach, hanging and cutting.

The clinical record review revealed a crisis assessment note dated 02/25/13 with a disposition note that stated the physician at the facility from which he/she was discharged on 02/21/13 stated he/she did feel that Patient #22 would benefit from another in-patient hospitalization. That said, the disposition note indicated placement for the patient was looked for elsewhere at two other major facilities in the area, stating,"currently no beds."

The crisis assessment note stated the emergency department physician was not in agreement with the social worker's recommendation to discharge the patient home with parents. The clinical record review revealed a crisis team documentation form dated 02/25/13 signed by the emergency department physician and social worker, but not the patient's emergency department nurse. The form stated the proposed disposition for the patient was to go home with father and mother. Handwritten onto the form was "Physician currently not in agreement with this proposal/disposition." The crisis assessment note stated the emergency department physician "allowed" family to sign out against medical advice.

The clinical record review revealed the emergency department physician signed the against medical advice form that stated, "Dad wants to take Patient #22 home and feels he/she is not unsafe going home" and that he/she would see his/her therapist the next day on 02/26/13 at 8:00 P.M. Other than that, the form did not indicate the reasons for leaving against medical advice. The form had lines to check for reasons to leave against medical advice which included not wanting further treatment, refusing admission, and wanting to be treated at another facility. None of these lines were checked.

On 02/26/13 at 9:29 P.M. (the next day) the patient presented again to the emergency department according to a clinical record review completed on 03/05/13. The clinical record review revealed a crisis assessment note dated 02/26/13 at 11:07 P.M. that stated the patient saw his/her therapist and was unable to contract for safety or utilize his/her coping skills. The note stated the patient had a suicide plan to either drink bleach, overdose, or hang him/herself and "Patient appears to have poor coping skills." The note also stated a bed was found at a local psychiatric unit, but that it was full at that time, but the patient could be transferred in the morning. The clinical record review revealed the patient did spend the night in the emergency department and was transferred to the psychiatric facility on 02/27/13 at 8:55 A.M.

On 03/06/13 Director #1 in an interview stated the facility has looked beyond the local area to find beds for patients and that the patient could have spent the night during his/her first visit to the emergency department on 02/25/13 had a bed been found further away. Director #1 stated if the emergency department physician felt the patient needed to stay, (as indicated by the crisis assessment and crisis team documentation form of 02/25/13) there were other avenues that could have been pursued rather than to "allow" the parent to sign the patient out against medical advice.



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2. The clinical record review for Patient #1 was completed on 03/06/13. The 15-year-old male was admitted to the emergency department on 02/17/13 with a diagnosis of suicide attempt. The police were called to the patient 's home by family due to the patient had threatened to kill him/herself with kitchen shears. The patient has a history of mood disorders and attention deficit disorder, has poor coping skills, difficulty getting along with his/her family and poor impulse control. The patient reported he/she becomes suicidal when upset. The patient reported to the licensed independent social worker he/she cannot keep him/herself safe at home. A physician examined the patient and did not document medical clearance, disposition or condition of the patient in the emergency physician record. A registered nurse documented the patient was transferred by ambulance on 02/18/13 at 2:50 PM.

3. The clinical record review for Patient #6 was completed on 03/06/13. The 36-year-old patient was admitted to the emergency department on 12/03/12 with a chief complaint of assault. The patient was examined by a physician and administered pain medications. The facility performed an x-ray of the right shoulder and a CT-scan of the head. The physician diagnosed the patient with a right eye contusion and right shoulder strain. The right shoulder x-ray final report was read at 4:24 PM on 12/03/12. The report stated suspect mildly impacted fracture of the humeral neck and that this can be further assessed with an unenhanced CT-scan through the shoulder. A CT-scan through the shoulder was never performed while the patient was in the emergency department. The patient was discharged home on 12/03/12. The clinical record review did not contain evidence the patient had been notified of the fracture prior to being discharged. On 12/11/12, the facility sent a letter to the patient instructing the patient to call regarding the results of tests. The mail was undeliverable due to an insufficient address.

4. The clinical record review for Patient #7 was completed on 03/06/13. The 49-year-old patient was admitted to the emergency department on 10/24/12 with a chief complaint of altered mental status. A crisis assessment was completed by the licensed independent social worker. The licensed independent social worker stated the patient was bipolar and had been off his/her prescribed medications. The patient had recently purchased a gun and a spent 9 mm shell was found in the patient's coat pocket. The licensed independent social worker reported the patient had a blunt presentation, angry, made no eye contact, and the patient's thought process was tangential. The patient has been decompensating for the past 10 days and family, co-workers and friends were concerned for the patient. The patient had an increase in lavish spending, social networking, relationship scams, had not been sleeping and had increased his/her alcohol consumption. The patient was transferred to an inpatient psychiatric facility on 10/24/12. The physician did not document the patient's condition prior to the transfer.

5. The clinical record review for Patient #12 was completed on 03/06/13. The 34-year-old patient was admitted to the emergency department with a chief complaint of suicidal ideation and possible drug ingestion. The patient was brought to the emergency department by emergency medical services and the police. The police completed an Application for Emergency Services stating the patient reported he/she wanted to kill him/herself and the patient was two months pregnant. Lab work was drawn on the patient and the results were positive for cocaine and alcohol.

A physician evaluated the patient and the physician's diagnostic impression was suicidal ideation, violent behavior, alcohol intoxication and cocaine abuse. The physician also documented the patient was belligerent, abusive toward staff and uncooperative. The patient was placed in four point restraints. The physician did not medicate the patient. The physician informed the patient the sheriff's department would be called to escort the patient out of the emergency department if the patient did not

Based on clinical record review, interview and policy review, the facility failed to ensure The Certificate to Transfer Physician Assessment and Certification form was completed for nine (Patient #1, #3, #7, #9, #13, #14, #16, #23 and #24) of 27 clinical records reviewed.

Findings include:

1. The clinical record review for Patient #13 was completed on 03/05/13. The clinical record review revealed the 56-year-old patient presented to the emergency department on 12/13/12 with a chief complaint of being suicidal. A crisis assessment dated 12/13/12 at 10:06 A.M. stated the patient was very angry, hostile, and paranoid. The assessment stated the patient talked about laying on railroad tracks or cutting his/her throat. The patient also stated he/she wanted to stab people. The Certificate to Transfer Physician Assessment and Certification form for specialized care services was not signed by the physician and did not identify the mode of transport.

2. The clinical record review for Patient #14 was completed on 03/05/13. The clinical record review revealed the 28-year-old patient presented to the emergency department triage on 12/06/12 for a chief complaint of depression and not liking the place where he/she lived. The clinical record review revealed a crisis assessment dated 12/06/12 at 4:30 P.M. that stated the patient complained of being very tearful, not being able to control him/herself, fearful he/she would hurt his/her cat, and paranoid that drug dealers are going to hurt him/her. The Certificate to Transfer Physician Assessment and Certification form for specialized care services did not identify the receiving facility, the receiving physician nor was the time the receiving hospital was contacted or mode of transport.

3. The clinical record review for Patient #16 was completed on 03/05/13. The clinical record review revealed the 15-year-old patient presented to the emergency department triage with a chief complaint of suicide ideation and using a knife to threaten him/herself. The clinical record review revealed a crisis assessment dated 12/31/12 at 1:33 P.M. that stated the patient picked up a knife and threatened to kill him/herself. The note stated the patient presented with flat affect, depression, suicidal and very limited insight. The clinical record review revealed a Certificate to Transfer Physician Assessment and Certification form. The form did not provide a reason for the transfer, mode of transport, whether appropriate medical records were sent, and wasn't signed by a physician.

4. The clinical record review for Patient #1 was completed on 03/06/13. The 15-year-old male was admitted to the emergency department on 02/17/13 with a diagnosis of suicide attempt. The police were called to the patient 's home by family due to the patient had threatened to kill him/herself with kitchen shears. The patient has a history of mood disorders and attention deficit disorder, poor coping skills, difficulty getting along with his/her family and poor impulse control. The patient reported he/she becomes suicidal when upset and reported to the licensed independent social worker that he/she cannot keep him/herself safe at home.

A physician examined the patient and did not document medical clearance, disposition or condition of the patient in the emergency physician record. The Certificate to Transfer Physician Assessment and Certification form did not list the patient's condition on transfer, the mode of transportation and there was no evidence the appropriate clinical records were sent with the patient. A registered nurse documented the patient was transferred by ambulance on 02/18/13 at 2:50 PM.
The findings were shared with Staff E on 03/06/13 and confirmed.

5. The clinical record review for Patient #3 was completed on 03/06/13. The 25-year-old patient was admitted to the emergency department on 11/23/12 for a chief complaint of pregnancy test check. A pregnancy test was administered and the patient was discharged. The physician documented the patient's condition as improved and stable, but did not document the disposition.

Patient #3 was readmitted to the emergency department on 12/14/12 with a chief complaint of suicidal ideation. A crisis assessment was completed by a licensed independent social worker on 12/14/12. The licensed independent social worker documented the patient had increased depression and suicidal ideation with a plan to cut her wrists. The patient also reported relapsing on heroin. The patient was transferred to an inpatient mental health facility on 12/14/12. The Certificate to Transfer Physician Assessment and Certification form did not list the mode of transport nor did it contain the physician's signature.

6. The clinical record review for Patient #7 was completed on 03/06/13. The 49-year-old patient was admitted to the emergency department on 10/24/12 with a chief complaint of altered mental status. A crisis assessment was completed by the licensed independent social worker. The licensed independent social worker stated the patient was bipolar and had been off his/her prescribed medications. The patient had recently purchased a gun and a spent 9mm shell was found in the patient's coat pocket. The licensed independent social worker reported the patient had a blunt presentation, angry, made no eye contact, and the patient's thought process was tangential. The patient has been decompensating for the past 10 days and family, co-workers and friends were concerned for the patient. The patient had an increase in lavish spending, social networking, relationship scams, had not been sleeping and had increased his/her alcohol consumption.

The patient was transferred to an inpatient psychiatric facility on 10/24/12. The physician did not document the patient's condition or mode of transport on the Certifcate to Transfer Physician Assessment and Certification form. The physician did not indicate the patient's medical records were sent to the receiving facility on the form. The form did not contain the date and time of the physician's signature.

7. The clinical record review for Patient #9 was completed on 03/06/13. The 21-year-old patient was admitted to the emergency department on 11/01/12 with a chief complaint of suicidal ideation. A crisis assessment was completed by a licensed independent social worker on 11/01/12. The licensed independent social worker documented the patient had increased depression and the feeling of inability to control him/herself from self-harm. The patient had a plan to shoot or cut him/herself.

The patient was transferred to an inpatient mental health facility on 11/01/12. The Physician Assessment and Certification/certificate to transfer form did not list the patient's condition at discharge, did not list the mode of transport, did not signify the medical record was sent to the facility and the physician did not document the date and time he/she signed the form.

8. The clinical record review for Patient #23 was completed on 03/06/13. The 57-year-old patient was admitted to the emergency department on 09/26/12 with a diagnosis of schizoaffective disorder. A crisis assessment was completed by a licensed independent social worker. The licensed independent social worker documented the patient was pink slipped for attempting to walk into on-coming traffic. The patient had not been sleeping or eating. The patient was transferred to an inpatient mental health facility on 09/26/12. The physician did not document the patient was stable on the Certificate to Transfer Physician Assessment and Certification form or in the patient's emergency department record.

9. The clinical record review for patient #24 was completed on 03/06/13. The 20-year-old patient was admitted to the emergency department with a chief complaint of back pain. A crisis assessment was completed by a licensed independent social worker. The licensed independent social worker documented the patient was depressed and had suicidal ideations. The patient was pink slipped and transferred to an inpatient mental health facility on 01/19/13. The physician did not document the patient was stable on the Certificate to Tran