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Based on review of documentation and staff interviews, the hospital's administrative staff failed to ensure the hospital staff followed the hospital's policies to provide stabilizing treatment within its capabilities and capacity, including care by the on-call physician for 6 patients. (#11, #32, #52,#53, #54 and #55).

Failure to provide stabilizing treatment with an emergency medical condition (EMC) may result in a delay in treatment or possibly death.

Findings included:

1. Review of the "Medical Staff Bylaws of Genesis Medical Center" adopted 12/5/13, revealed in part, "Responsibilities: As initial and ongoing conditions for appointment and reappointment to the Medical Staff and/or clinical privileges, each practitioner shall: ... comply with the Hospital's Emergency Department and Ambulatory Care call coverage policy(ies)...and consistent with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) and current Hospital policy. The obligation to comply with established call coverage policies applies regardless of assigned Medical Staff category."

The Medical Staff Bylaws defined Active Staff as follows: The Active Staff shall consist of those physicians, oral surgeons, and podiatrists performing more than twenty (20) patient contacts over a two (2) year period and assume all the functions and responsibilities of membership, including attendance of patients pursuant to the emergency patient call schedule approved by the Hospital."
The Medical Staff excluded rheumatologists, dermatologists, and allergists on Medical staff.

2. Review of the "Emergency Medical Treatment and Labor Act" (EMTALA) Policy effective 3/15/2010 and reviewed/revised 1/3/2017 revealed the hospital will provide an appropriate Medical Screening Examination (MSE) and stabilizing treatment within its capacity and capability to any individual presenting to the hospital and when a request for emergency care and treatment is made by the individual or on the individuals behalf. The hospital will follow this Policy at all times....

3. Review of the medical record revealed a 62 year old patient (# 11) presented to the Emergency Department (ED), on 12/21/16 at 8:42 PM. Upon arrival to the ED, the nurse documented patient's chief complaint was abdominal pain and vomiting.

ED Physician Notes, dated 12/22/16 at 10:08 PM reflected Patient #11 reported severe burning abdominal pain and vomiting. Final diagnosis included perforated gastric ulcer. On 12/22/16 at 12:53 AM, Staff F, ED physician consulted Staff G, on call general surgeon. Documentation reflected Staff G recommended transfer related to no intensive care unit (ICU) beds available.

Review of the Emergency Medical Condition Transfer Certification and Consent Form revealed Patient #11's condition as "unstable" prior to transfer.

During an interview on 3/16/17 at 9:30 AM, Staff F, ED physician, stated Patient #11 was unstable due to the patient's need for emergent surgery for a possible perforated gastric ulcer. The ED physician stated Patient #11 was high risk for sepsis with gastric contents leaking into the abdominal area. (Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death.)

Please refer to A2407 for additional information.

4. Review of Patient #32's medical record revealed Patient #32 presented to the hospital's ED on 1/20/17 at 4:47 PM per ambulance. Patient #32 reported adverse side effects related to medication that included increased anger, assault on staff and loss of appetite. According to Patient #32's nursing progress note dated 1/20/17 at 6:48 p.m. The patient refused to provide a urine sample and stated a preference to go to jail instead of back to the group home. Patient #32 stated a threat to cut their wrists once back at the group home.

Staff B, registered nurse (RN)/psychiatric screening associate (PSA), completed a psychosocial/Spiritual assessment on 1/20/17 at 6:02 PM. The psychosocial/spiritual assessment indicated Patient #32 had the following: suicidal ideas or preoccupation, past suicide attempts, impaired safety/judgment and below average mental status. Patient #32 wrote notes of suicide while at the RCF and refused medications.

Staff B's psychosocial/spiritual assessment identified a diagnosis of schizophrenia. Staff B's assessment reflected Patient #32 was manipulative and oppositional, with a history of oppositional behavior and with noncompliance with medications. The assessment reflected the nursing supervisor received notification regarding Patient #32's discharge. Staff B's documentation reflected the following, "Genesis is unable to admit adult patients due to alck [lack] of providers until 10:00 AM Sunday 1-22-17." The note reflected the RCF nursing supervisor expressed concern regarding the return of Patient #32 to the facility. Patient #32 received oral antipsychotic medications while in the ED. Patient #32 was discharged from the ED with RCF staff on 1/20/17 at 9:15 PM.

Review of Patient #32's ED record lacked evidence the on call psychiatrist was consulted regarding the patient's mental health. Failure in communication with the on call psychiatrist resulted in, Patient #32 did not receive an appropriate psychiatric mental health screening or stabilization treatment in the ED prior to discharge.

Please refer to A2407 for additional information.

5. Review of the medical record revealed Patient #52, a 27 year old, presented to the ED on 3/4/17 at 1:58 AM per ambulance. The patient's chief complaint was suicidal ideation which required psychiatric evaluation and admission.

The hospital behavioral health unit had beds available according to of review census information (maximum capacity of 27 adults), however due to the on call psychiatrist capped census of 20 patients, Patient #52 was transferred to another acute hospital for behavioral health. According to the on-call schedule, a psychiatrist was available.

The Emergency Medical Condition Transfer Certification and Consent Form, dated 3/4/17 at 12:10 PM, revealed Patient #52 transferred to another acute care hospital behavioral health unit. The form reflected the reason for transfer as "Services/Equipment Not Available at this Facility."

Review of Patient #52's ED record lacked evidence the on call psychiatrist was consulted regarding the patient's mental health. Failure in communication with the on call psychiatrist resulted in, Patient #52 did not receive an appropriate psychiatric mental health screening or stabilizing treatment in the ED prior to transfer to another acute care hospital for mental health services.

Please refer to A2407 for additional information.

6. Review of the medical record revealed Patient #53, a 16 year old, presented to the ED on 3/2/17 at 11:34 PM. The patient's chief complaint was suicidal ideation. The Nursing Progress Notes, dated 3/3/17 at 1:25 PM, revealed there are no beds available in the hospital's behavioral health unit. Review of the Pediatric behavioral health unit for 3/3/17 revealed a census of 5 and beds listed as available. (Maximum capacity of Pediatric unit was 7 patients)

Review of Patient #53's ED record lacked evidence the on call psychiatrist was consulted regarding the patient's mental health. Failure in communication with the on call psychiatrist resulted in, Patient #53 did not receive an appropriate psychiatric mental health screening or stabilizing treatment in the ED prior to discharge. The patient's transfer would have been unnecessary if the on-call psychiatrist had not limited the patient census on the behavioral health unit.

The Emergency Medical Condition Transfer Certification and Consent Form, dated 3/3/17 at 2:50 PM, revealed Patient #53 transferred to another acute care hospital behavioral health unit. The form reflected the reason for transfer as "Services/Equipment Not Available at this Facility."

The transfer caused a delay in the patient receiving psychiatric treatment and inpatient care.

Please refer to A 2407 for additional information.

7. Review of the medical record revealed Patient #54, a 44 year old, presented to the ED on 3/3/17 at 4:30 PM. The patient's chief complaint was suicidal ideation. While in the ED, Patient #54 reported thoughts of jumping off a bridge or hanging his/her self with cords in the examination room. The ED Notes, dated 3/3/17 at 7:02 PM, revealed there are no beds available in the hospital's behavioral health unit, and directed nursing staff call regional referral regarding placement in another acute care hospital's behavioral health unit. The behavioral health unit bed census for 3/3/17 indicated beds were available on behavioral health unit, (maximum capacity of 27 adults), however a capped census of 20 was directed by the on-call psychiatrist.

The Emergency Medical Condition Transfer Certification and Consent Form, dated 3/4/17 at 6:09 AM, revealed Patient #54 transferred to another acute care hospital behavioral health unit 356 miles away. The form reflected the reason for transfer as "Services/Equipment Not Available at this Facility."

Review of Patient #54's ED record lacked evidence the on call psychiatrist was consulted regarding the patient's mental health. Failure in communication with the on call psychiatrist resulted in, Patient #54 did not receive an appropriate psychiatric mental health screening or stabilizing treatment in the ED prior to transfer.

Please refer to A 2407 for additional information.

8. Review of the medical record revealed Patient #55, a 32 year old, presented to the ED by ambulance on 3/4/17 at 12:17 PM after a suicidal attempt by hanging. The ED Reexamination/Reevaluation dated 3/4/17 at 2:43 PM reflected the physician did not agree to discharge and initiated a 48 hour court ordered committal.

On 3/4/17 at 6:18 PM nursing staff notified regional referral regarding placement in another acute hospital's behavioral health unit and no beds or on-call services were available. The behavioral health unit bed census for 3/4/17 indicated beds were available (maximum capacity of 27 adults), on behavioral health unit, however the on-call physician directed a capped census of 20 for the behavioral health unit.

The Emergency Medical Condition Transfer Certification and Consent Form, dated 3/4/17 at 10:12 PM, revealed Patient #55 transferred to another acute care hospital behavioral health unit approximately 104 miles away even though beds were available. The form reflected the reason for transfer as "Services/Equipment Not Available at this Facility."

Review of Patient #55's ED record lacked evidence the on call psychiatrist was consulted regarding the patient's mental health. Failure in communication with the on call psychiatrist resulted in, Patient #55 did not receive an appropriate psychiatric mental health screening or stabilizing treatment in the ED prior to transfer.

Please refer to A 2407 for additional information.

Based on document review and staff interviews the hospital failed to ensure the on call surgeon and hospital adequately provided medical stabilizing treatment within their capability and capacity for one (1) of eighteen (18) sampled patients transferred to acute care hospitals from 12/21/16 - 3/5/17 (Patient #11). The staff identified an average of 83 patients transferred per month to another acute hospital.

Failure to provide on call services and medical stabilizing treatment within the hospital's capabilities for a patient with an emergency medical condition could potentially delay the appropriate treatment for the patient and result in further complications, including death.

Findings include:

Review of the medical record revealed a 62 year old patient (# 11) presented to the Emergency Department (ED) on 12/21/16 at 8:42 PM. Upon arrival to the ED, the nurse documented patient's chief complaint was abdominal pain and vomiting.

ED Physician Notes, dated 12/22/16 at 10:08 PM reflected Patient #11 reported severe burning abdominal pain and vomiting. Final diagnosis included perforated gastric ulcer. On 12/22/16 at 12:53 AM, Staff F, ED physician consulted Staff G, on call general surgeon. Documentation reflected Staff G recommended transfer related to no intensive care unit (ICU) beds available.

Review of the Emergency Medical Condition Transfer Certification and Consent Form revealed Patient #11's condition as "unstable" prior to transfer.

The clinical record indicated Patient #11 was transferred to another acute care facility on 12/22/16 at 1:41 AM for perforated gastric ulcer.

During an interview on 3/15/17 at 4:43 PM Staff I, Director of Nursing Operations (DNO), confirmed one patient was admitted to the East ICU on 12/21/16 between 8:00 PM and 9:00 PM. Staff I stated ICU Stabilize/Transfer process is related to staffing issues. The facility conducts meetings twice daily during the work week and once daily on weekends to project staffing needs throughout the hospital. With ICU, we count patients and acuity levels related to staff needed. Typically when more ICU patients require 1:1 or 2:1 staffing, the hospital begins ICU Stabilize/Transfer process. Staff I stated when ICU Stabilize/Transfer is in place, the hospital will still admit the hospital's current inpatients to ICU or a patient that is unsafe to transfer even if the patient is a higher level of care.
Patients that present to the hospital's ED will be transferred to other acute care hospitals for services.

During an interview on 3/15/17 at 3:51 PM, Staff H, registered nurse (RN) and nurse manager for the hospital East ED and Trauma, reviewed Patient #11's clinical record. Staff H stated typically the hospital was able to provide care for a perforated gastric ulcer, however there were no ICU beds available on 12/21/16.

During an interview on 3/16/17 at 9:23 AM, Staff I, Staff J, Manager of Nursing Regional Referral, and Staff K, RN and Nurse Manager of the hospital East ICU confirmed prior to Patient #11's transfer, the East ICU had two (2) patients admitted and one (1) patient discharged. The West ICU had one (1) patient admitted and one (1) patient discharged. Staff I stated if the hospital is on Stabilize/Transfer, patients are transferred regardless if a bed is available. She stated the policy does not include the budgeted hours. She added we may have beds available however the budgeted average daily census won't allow the bed to be filled.

During an interview on 3/16/17 at 8:00 AM Staff G, general surgeon, stated if Patient #11 was determined by the ED physician, based on ED care, and if stable was transferred. Patient #11 transferred due to ICU capability. Staff G stated in the past he had operated on a patient if the patient was not stable to transfer in order to stabilize the patient and then transfer the patient to another acute care hospital due to no ICU beds available.

During an interview on 3/16/17 at 9:30 AM, Staff F, ED physician, stated Patient #11 was unstable due to need for emergent surgery for a possible perforated gastric ulcer. The ED physician stated Patient #11 was high risk for sepsis with gastric contents leaking into the abdominal area. (Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death.)

I. Based on review of documentation and staff interviews, the hospital's Emergency Department (ED) staff failed to provide stabilizing treatment or appropriate disposition within the hospital's capability and capacity prior to discharging or transferring for 5 of 20 sampled patients with psychiatric emergencies related to the psychiatric physicians' imposed limit of outpatient admissions on the behavioral health unit (Patients #32, #52, #53, #54, and #55).

Failure to provide on call services and medical stabilizing treatment within the hospital's capabilities for a patient with an emergency medical condition could potentially delay the appropriate treatment for the patient and result in further complications, including death.

Findings include:

1. Review of the medical record revealed Patient #32, a 49 year old patient, presented to the ED by ambulance on 1/20/17 at 4:47 PM. The ED record reflected Patient #32 "attacked" staff members at the residential care facility (RCF) in which the patient resided. The patient reported increased aggression and decreased appetite as the result of a medication change. While in the ED Patient #32 refused to provide a urine specimen. Patient #32 stated he/she would rather go to jail than return to the RCF, and if returned to RCF would cut his/her wrists.

Staff B, registered nurse (RN)/psychiatric screening associate (PSA), completed a psychosocial/Spiritual assessment on 1/20/17 at 6:02 PM. The psychosocial/spiritual assessment indicated Patient #32 had the following: suicidal ideas or preoccupation, past suicide attempts, impaired safety/judgment and below average mental status. Patient #32 wrote notes of suicide while at the RCF and refused medications.

Staff B's psychosocial/spiritual assessment identified a diagnosis of schizophrenia. Staff B's assessment reflected Patient #32 was manipulative and oppositional, with a history of oppositional behavior and with noncompliance with medications. The assessment reflected the nursing supervisor received notification regarding Patient #32's discharge. Staff B's documentation reflected the following, "Genesis is unable to admit adult patients due to alck [lack] of providers until 10:00 AM Sunday 1-22-17." The note reflected the RCF nursing supervisor expressed concern regarding the return of Patient #32 to the facility. Patient #32 received oral antipsychotic medications while in the ED. Patient #32 was discharged from the ED with RCF staff on 1/20/17 at 9:15 PM.

Review of Patient #32's ED record lacked evidence the on call psychiatrist was consulted regarding the patient's mental health. Failure in communication with the on call psychiatrist resulted in, Patient #32 did not receive an appropriate psychiatric mental health screening or stabilization treatment in the ED prior to discharge.

On 1/23/17 at 2:54 PM Patient #32 was admitted to the hospital's Behavioral Health Unit under court order per RCF medical director recommendation for increased agitation.

During an interview on 3/14/17 at 4:37 PM, Staff B recalled on 1/20/17 Patient #32 arrived at the ED and was not admitted because the ED physician thought an adjustment of medications would stabilize the patient.

Staff B confirmed Patient #32's suicide risk, then stated the patient's mood changes related to a diagnosis of mild intellectual disability. Staff B stated the patient's impaired judgement was due to the intellectual disability and schizoaffective disorder.

Staff B confirmed her documentation reflected there was no provider available. She was aware the physician directed a "cap" of 20 patients in the hospital's 3 behavior units (2 adult units and 1 pediatric unit) when one psychiatrist was available. She stated patients admitted under court committal were accepted regardless of a "cap" on admissions.

During an interview on 3/15/17 at 10:01 AM Staff M, MD/Psychiatrist, stated he was on call the weekend of 1/20/17 - 1/23/17. Staff M stated the call psychiatrist is available to respond to Behavioral Health Unit emergencies as well as serve in a consulting role for Emergency Department (ED) physicians. The ED physician does not have admitting privileges to Behavioral Health Unit. Instead, the role of the ED physician is to provide medical stabilizing treatment for psychiatric patients that enter the ED.

Staff M was unsure why the Psychosocial/Spiritual Assessment included the notation: "Genesis is unable to admit adult patients due to alck [lack] of providers until 10 am on Sunday 1-22-17." The notation continued to reflect the RCF nursing supervisor was notified that no admissions could occur due to lack of providers.

Staff M stated if a patient presented to the ED with symptoms similar to those exhibited by Patient #32, and was unknown to psychiatric staff, that patient would probably be admitted.

Staff M stated there is no formal policy regarding the physician directed "cap" census of patients for the hospital's Behavioral Health Unit, instead each provider determines the number based on the provider ability.

During an interview on 3/14/17 at 5:10 PM Staff C, Nurse Manager of Behavioral Health Unit, stated there is no specific policy related to a "cap" on admissions to Behavioral Health Units, rather staff are notified per email. The email specifies the number of patients deemed appropriate and is completed on a week by week basis by the providers (psychiatrists).

Behavioral Health Unit census information provided identified the following:
a. On 1/20/17, one (1) adult patient was admitted and nine (9) patients discharged.
b. On 1/21/17, two (2) adult patients were admitted and one (1) discharged.
c. On 1/22/17, there were no admissions and two (2) discharged.
d. On 1/23/17, six (6) adult patients were admitted and no patients were discharged.

During an interview on 3/15/17 at 12:25 p.m. Staff C confirmed a patient was admitted to Behavioral Health Unit on 1/20/17 near the time Patient #32 was in ED. Staff C stated that patient (Patient #51) was inpatient on Neurology and required admission to the Behavioral Health Unit. Staff C provided a copy of an email dated 1/20/17 at 2:13 PM. The email indicated that due to limited provider coverage no adult patients would be accepted from 1/20/17 thru 1/22/127 at 8:00 AM. She stated Patient #51 was admitted to the hospital's behavioral health unit was planned prior to the email notification regarding the on call physician directed capped census.

On 3/15/17 the Director of Behavioral Health Unit provided an email, dated 3/3/17 at 11:59 AM, which directed the hospital's Behavioral Health Unit capped census of 20 patients over the weekend of 3/3/17 through 3/5/17 at 8:00 PM.

2. Review of the medical record revealed Patient #52, a 27 year old, presented to the ED on 3/4/17 at 1:58 AM per ambulance. The patient's chief complaint was suicidal ideation.

The hospital behavioral health unit had beds available, however due to the on call psychiatrist capped census of 20 patients, Patient #52 was transferred to another acute hospital for behavioral health. According to the on-call schedule, a psychiatrist was available.

Review of Patient #52's ED record lacked evidence the on call psychiatrist was consulted regarding the patient's mental health. Failure in communication with the on call psychiatrist resulted in, Patient #52 did not receive an appropriate psychiatric mental health screening or stabilizing treatment in the ED prior to transfer to another acute care hospital for mental health services.

The Emergency Medical Condition Transfer Certification and Consent Form, dated 3/4/17 at 12:10 PM, revealed Patient #52 transferred to another acute care hospital behavioral health unit. The form reflected the reason for transfer as "Services/Equipment Not Available at this Facility."

3. Review of the medical record revealed Patient #53, a 16 year old, presented to the ED on 3/2/17 at 11:34 PM. The patient's chief complaint was suicidal ideation. The Nursing Progress Notes, dated 3/3/17 at 1:25 PM, revealed there are no beds available in the hospital's behavioral health unit. Review of behavioral health unit census information revealed beds listed as available.

Review of Patient #53's ED record lacked evidence the on call psychiatrist was consulted regarding the patient's mental health. Failure in communication with the on call psychiatrist resulted in, Patient #53 did not receive an appropriate psychiatric mental health screening or stabilizing treatment in the ED prior to discharge. The patient's transfer would have been unnecessary if the on-call psychiatrist had not limited the patient census on the behavioral health unit.

The Emergency Medical Condition Transfer Certification and Consent Form, dated 3/3/17 at 2:50 PM, revealed Patient #53 transferred to another acute care hospital behavioral health unit. The form reflected the reason for transfer as "Services/Equipment Not Available at this Facility."

The transfer caused a delay in the patient receiving psychiatric treatment and inpatient care.

4. Review of the medical record revealed Patient #54, a 44 year old, presented to the ED on 3/3/17 at 4:30 PM. The patient's chief complaint was suicidal ideation. While in the ED, Patient #54 reported thoughts of jumping off a bridge or hanging his/her self with cords in the examination room. The ED Notes, dated 3/3/17 at 7:02 PM, revealed there are no beds available in the hospital's behavioral health unit, and directed nursing staff call regional referral regarding placement in another acute care hospital's behavioral health unit. The behavioral health unit bed census for 3/3/17 indicated beds were available on behavioral health unit, however a capped census was directed by the on-call psychiatrist.

The Emergency Medical Condition Transfer Certification and Consent Form, dated 3/4/17 at 6:09 AM, revealed Patient #54 transferred to another acute care hospital behavioral health unit 356 miles away. The form reflected the reason for transfer as "Services/Equipment Not Available at this Facility."

Review of Patient #54's ED record lacked evidence the on call psychiatrist was consulted regarding the patient's mental health. Failure in communication with the on call psychiatrist resulted in, Patient #54 did not receive an appropriate psychiatric mental health screening or stabilizing treatment in the ED prior to transfer.

5. Review of the medical record revealed Patient #55, a 32 year old, presented to the ED by ambulance on 3/4/17 at 12:17 PM after a suicidal attempt by hanging. The ED Reexamination/Reevaluation dated 3/4/17 at 2:43 PM reflected the physician did not agree to discharge and initiated a 48 hour court ordered committal.

On 3/4/17 at 6:18 PM nursing staff notified regional referral regarding placement in another acute hospital's behavioral health unit and no beds or on-call services were available. The behavioral health unit bed census for 3/4/17 indicated beds were available on behavioral health unit, however the on-call physician directed a capped census for the behavioral health unit.

The Emergency Medical Condition Transfer Certification and Consent Form, dated 3/4/17 at 10:12 PM, revealed Patient #55 transferred to another acute care hospital behavioral health unit approximately 104 miles away even though beds were available. The form reflected the reason for transfer as "Services/Equipment Not Available at this Facility."

Review of Patient #55's ED record lacked evidence the on call psychiatrist was consulted regarding the patient's mental health. Failure in communication with the on call psychiatrist resulted in, Patient #55 did not receive an appropriate psychiatric mental health screening or stabilizing treatment in the ED prior to transfer.

Review of the hospital's Behavioral Health Unit census revealed the following: (Maximum capacity of 27 adults and 7 pediatric patients).

a. On 3/3/17 Behavioral Health Census revealed 17 adult patients and 5 pediatric patients (total 22 patients).

b. On 3/4/17 Behavioral Health Census revealed 18 adult patients and 5 pediatric patients (total 23 patients).

c. On 3/5/17 Behavioral Health Census revealed 20 adult patients and 4 pediatric patients (total 24 patients).

The hospital policy titled Admission Criteria (Adult Psychiatric), revision date 8/16, directed, "Patients will be admitted to the Behavioral Health Program due to the presence of a serious treatable mental impairment as defined below...." Criteria identified included the following, "Failure of outpatient psychiatric treatment so that the individual requires 24-hour professional observation and care. Reasons for the failure of outpatient treatment could include: increasing severity of psychiatric symptoms, noncompliance with medication regimen due to the severity of psychiatric symptoms, inadequate clinical response to psychotropic medications and due to the severity of psychiatric symptoms, the patient is unable to participate in an outpatient psychiatric treatment program."

II. Based on review of documentation and staff interviews, the hospital failed to ensure medical stabilizing treatment within their capability and capacity was provided for one (1) of eighteen (18) sampled patients transferred to acute care hospitals from 12/21/16 - 3/5/17 (Patient #11). The staff identified an average of 83 patients transferred per month to another acute hospital.

Failure to provide medical stabilizing treatment within the hospital's capabilities for a patient with an emergency medical condition could potentially delay the appropriate treatment for the patient and result in further complications, including death.

Findings include:

Review of the medical record revealed a 62 year old patient (# 11) presented to the ED on 12/21/16 at 8:42 PM. Upon arrival to the ED, the nurse documented patient's chief complaint was abdominal pain and vomiting.

ED Physician Notes, dated 12/22/16 at 10:08 PM reflected Patient #11 reported severe burning abdominal pain and vomiting. Final diagnosis included perforated gastric ulcer. On 12/22/16 at 12:53 AM, Staff F, ED physician consulted Staff G, on call general surgeon. Documentation reflected Staff G recommended transfer related to no intensive care unit (ICU) beds available.

Review of the Emergency Medical Condition Transfer Certification and Consent Form revealed Patient #11's condition as "unstable" prior to transfer.

The clinical record indicated Patient #11 was transferred to another acute care facility on 12/22/16 at 1:41 AM for perforated gastric ulcer.

During an interview on 3/15/17 at 4:43 PM Staff I, Director of Nursing Operations (DNO), confirmed one patient was admitted to the East ICU on 12/21/16 between 8:00 PM and 9:00 PM. Staff I stated ICU Stabilize/Transfer process is related to staffing issues. The facility conducts meetings twice daily during the work week and once daily on weekends to project staffing needs throughout the hospital. With ICU, we count patients and acuity levels related to staff needed. Typically when more ICU patients require 1:1 or 2:1 staffing, the hospital begins ICU Stabilize/Transfer process. Staff I stated when ICU Stabilize/Transfer is in place, the hospital will still admit the hospital's current inpatients to ICU or a patient that is unsafe to transfer even if the patient is a higher level of care.
Patients that present to the hospital's ED will be transferred to other acute care hospitals for services.

During interview on 3/15/17 at 3:51 PM, Staff H, registered nurse (RN) and nurse manager for the hospital East ED and Trauma, reviewed Patient #11's clinical record. Staff H stated typically the hospital was able to provide care for a perforated gastric ulcer, however there were no ICU beds available on 12/21/16.

During an interview on 3/16/17 at 9:23 AM, Staff I, Staff J, Manager of Nursing Regional Referral, and Staff K, RN and Nurse Manager of the hospital East ICU confirmed prior to Patient #11's transfer, the East ICU had two (2) patients admitted and one (1) patient discharged. The West ICU had one (1) patient admitted and one (1) patient discharged. Staff I stated if the hospital is on Stabilize/Transfer, patients are transferred regardless if a bed is available. She stated the policy does not include the budgeted hours. She added we may have beds available however the budgeted average daily census won't allow the bed to be filled.

During an interview on 3/16/17 at 8:00 AM Staff G, general surgeon, stated if Patient #11 was determined by the ED physician, based on ED care, and if stable was transferred. Patient #11 transferred due to ICU capability. Staff G stated in the past he had operated on a patient if the patient was not stable to transfer in order to stabilize the patient and then transfer the patient to another acute care hospital due to no ICU beds available.

During an interview on 3/16/17 at 9:30 AM, Staff F, ED physician, stated Patient #11 was unstable due to need for emergent surgery for a possible perforated gastric ulcer. The ED physician stated Patient #11 was high risk for sepsis with gastric contents leaking into the abdominal area. (Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death.)