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Based on review of documents and interview, it was determined the Hospital failed to ensure compliance with 42 CFR 489.20 and 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure on-call physicians was available in the Hospital's Emergency Department (ED) to proved required psychological examinations and evaluation for patients who present with emergency psychological problems. (Refer to tag A 2404)

2. The Hospital failed to ensure patients who arrive in the ED with emergency psychological conditions are evaluated for the need of stabilizing treatment prior to discharge (Refer to tag 2407)

Based on document review, and interview it was determined for 2 of 20 (Pt. # 2 and Pt. #3) emergency department patient records reviewed. the Hospital failed to ensure the on-call psychiatrist was available in the hospital to proved required psychological examinations of patients in the emergency department.

Findings include:

1. On 10/20/14 the Hospital's Medical Staff rules and regulations (amended 12/12) were reviewed and required, " ...a staff physician on-call to the emergency room in the area of his or her expertise shall be considered to be available at the hospital...members of the medical staff on call to the emergency department shall be obligated to respond to a call for consultation within a reasonable time period, but no more that one to two hours from the time of consultation or sooner as may be determined by the attending emergency department physician and the responding on call physician..." .

2. On 10/22/14 the clinical record of Pt. #2 was reviewed. Pt. #2 was a 55 year old patient admitted to the ED on 10/14/14 at 11:25 pm with a diagnosis of hallucinations, requiring a psychological evaluation. The clinical record lacked documentation Pt. #2 received a face to face evaluation by the hospital's on call ED psychiatrist (MD #3). MD #3 gave telephone orders to discharge Pt. #2 home on 10/15/14 at 2:45am.

3. On 10/22/14 the clinical record of Pt. #3 was reviewed. Pt. #3 was a 23 year old patient admitted to the ED on 10/14/14 at 9:20 am with a diagnosis of paranoid behavior requiring a psychological evaluation. Pt. #3 arrived with an involuntary admission form dated 10/14/14 at 9:31 pm that was initiated by the group home where Pt. #3 resided. The clinical record lacked documentation of a face to face evaluation by the ED on call psychiatrist. Pt. #3 was discharged by telephone order by the ED on call psychiatrist at 1:40am.

4. On 10/22/14 at approximately 3:30pm during an interview, the VP of Safety and Compliance confirmed that Pt. #2 and #3 did not have a face to face evaluation by the on call psychiatrist. The VP stated the Hospital was trying to improve compliance with On Call Physicians coming to the ED to examine patients.