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Based on observations, record reviews, interviews, review of the hospital's emergency department's Emergency Medical Treatment And Labor Act (EMTALA) policies and procedures, review of the hospital's Rules and Regulations, and the hospital's Telepsychiatry Contract, the hospital failed to place EMTALA signage in the ED (Emergency department) waiting room and treatment areas, failed to consult with the hospital's 24/7 telepsychiatry program for an evaluation and psychiatric medical screening examination, and failed to document any stabilizing psychiatric or medical treatment prior to the patient's transfer, and failed to initiate the patient's transfer to a hospital with the capability and capacity to treat the patient for 1 of 20 medical records reviewed (Patient #8). This had the potential to affect all patients that present to the ED.

The findings are:


Cross Reference to A 2406: Hospital A failed to ensure that an appropriate psychiatric medical screening examination was provided within the capability of the hospital's Emergency Department(ED), including ancillary services(telepsychiatry) routinely available to the emergency department on a seven day/twenty four hour basis for consultation to determine whether or not an emergency psychiatric condition existed for 1 of 20 sampled emergency department patients. (Patient #8)

Cross Reference to A 2407: Hospital A (transferring hospital)failed to ensure that stabilizing psychiatric treatment was provided within the capability of the hospital's Emergency Department (ED), including ancillary services (telepsychiatry) routinely available to the emergency department for consultation on a seven (7) day / twenty four (24) hours basis for 1 of 20 sampled emergency department patients (Patient #8).

Cross Reference to A 2409: The hospital failed to ensure that patients presenting to the hospital's Emergency Department (ED) received a medical screening examination and stabilizing treatment to determine if the patient had an Psychiatric Emergency Medical Condition that required a higher level of care, and failed to ensure the transfer was appropriate in that the receiving hospital did not have the capability to provide the higher level of care (psychiatric services), and failed to ensure the patient was accepted for transfer by a physician at the receiving hospital (Hospital B) for 1 of 20 sampled emergency department patient records reviewed (Patient #8).

Based on observations, review of the hospital's policy related to Emergency Medical Treatment and Labor Act (EMTALA) and interview, Hospital A failed to provide signage specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and failed to post conspicuously information indicating whether or not the hospital participates in the Medicaid program throughout the hospital's Emergency Department (ED).

The finding include:

On 08/08/2019 at 09:00 AM, observations in Hospital A's Emergency Department(ED) revealed there was an EMTALA sign in the ED located at the entrance to the waiting area and an EMTALA sign located in the ED at the entrance to the ambulance bay. There was no signage regarding EMTALA observed in the ED waiting room or in any of the ED's treatment areas. During an interview on 08/08/2019 at 09:00 AM, the findings were verified by RN 9 (Chief Quality Officer) during the tour.

Hospital policy, titled, "EMTALA Signage Policy", reads, "Each Hospital with a Dedicated Emergency Department must post one or more signs in a place or places to be noticed by all individuals entering the Dedicated Emergency Department, as well as those individuals waiting for examination and treatment in areas other than traditional Dedicated Emergency Departments for example, entrance, admitting area, waiting room, treatment area, Obstetrics Department and ambulance bay."

Based on medical record reviews, review of the hospital's Emergency Medical Treatment And Labor ACT (EMTALA) policies and procedure, review of the hospital's Telepsychiatry contract, and review of the hospital's Rules and Regulations, and interviews, it was determined Hospital A failed to ensure that an appropriate psychiatric medical screening examination was provided within the capability of the hospital's Emergency Department (ED), including ancillary services(telepsychiatry) routinely available to the emergency department on a seven day/twenty four hour basis for consultation to determine whether or not an emergency psychiatric condition existed for 1 of 20 sampled emergency department patients. (Patient #8)

The findings are:

Patient #8
On 08/07/2019 at 1:00 PM, review of Patient #8's ED chart revealed the patient presented to the Hospital A's ED on 7/22/2019 at 3:29 PM with a chief complaint of a "psychiatric problem". The patient arrived with Law Enforcement (LE) with "pick up papers that stated the patient had not been taking his/her medication and is verbally aggressive with mother." Documentation by Triage Registered Nurse #10 at 3:29 PM showed the patient's blood pressure as 136/84, pulse as 77, respirations as 18, temperature as 98.0 Fahrenheit (F), and Oxygen saturation level as 100 %(percent) room air. The Triage Nurse documented the presenting complaint as "Law enforcement states: Brought in by LE (Law Enforcement) on pick up papers stating patient has not been taking her medication and is verbally aggressive with mother. Stating family members are afraid of what she may do. Not sleeping and up all night." Patient #8's Emergency Severity Index triage level was 2 (patients requiring more detailed observation or intervention). Emergency Department (ED) Physician #1 examined the patient at 3:33 PM and performed a medical screening examination. Patient #8's differential diagnosis was documented as "acute psychotic break, acute anxiety disorder." Emergency Department (ED) course notes revealed "patient was seen and examined ED today with a chief complaint of need psychiatric evaluation. He/She does have a previous history of bipolar disease. He/She has normal stable vitals overall well appearing and will be transferred at this time for further evaluation. He/she will be going to ED Physician #2 (Hospital B). At this time, unfortunately, we cannot have another psychiatric hold since we are over a threshold. We have called their ED, and they do have availability for at least one psychiatric patient evaluation. He/she will be sent over at this time by Sheriff's department. Additional history and physical: the patient is 34-year-old. Review of Systems (ROS) unable to obtain ROS due to patient being uncooperative."

Physical Examination Documented by ED Physician #1 (Hospital #A- transferring hospital):
Constitutional: "This is a well-developed, well-nourished patient who is awake, alert, and in no acute distress.
Psychiatric: "Behavior /mood is pleasant, uncooperative, affect is calm. Judgement/insight is impaired. Delusions/hallucinations are present and described as appears the patient is having some delusions but is unclear what they may be.
Unable to obtain exam due to patient being uncooperative. No medications were administered.
Outcome: 3:41 PM "ED care complete, transfer ordered by .....Physician #1" .
Disposition: Physician #1 at 3:42 PM Transfer ordered to Other Acute Care Facility. Diagnosis is encounter for general psychiatric examination, requested by authority.
Reason for transfer: Other. Accepting physician is ED Physician #2. Condition is stable for transfer. Problem is chronic. Symptoms are unchanged."

Review of the Physician Certification form for the patient's transfer completed by the ED Licensed Practical Nurse #1 (LPN #1) and signed by ED Physician #1 (Hospital A) at 3:47 PM. Nurse Notes at 3:52 p.m. by Registered Nurse (RN) #7, reads, "Report called to Charge Nurse at receiving acute care Hospital ED (Hospital B ). Patient on pick up orders with LE present. LE transport patient to ED lobby per instructions given by nurse."

There was no documentation in Patient 8's chart or the physician progress notes that showed ED Physician #1(transferring hospital) consulted a psychiatrist via Hospital A's(transferring hospital) telepsychiatry program for an evaluation of the patient to determine if a psychiatric emergency condition existed or to determine a psychiatric treatment plan for stabilization of Patient #8 prior to the patient's transfer to Hospital B's Emergency Department (receiving hospital).

Interviews
ED Physician #1 ( Hospital A)
A telephone interview with the ED Physician (#1) from Hospital A on 8/7/2019 at 5:30 PM revealed, "I have worked in this ED for one month. I just finished residency 07/01/2019. After 9-10 days of orientation days, I was on my own. I did get a lot training on EMTALA in orientation, and in all my days as an ED doctor, I have never not called a physician. I messed up, and LE took the patient based on our conversations at the bedside before I had a chance to talk to Physician #2 (Hospital B). We did speak while the patient was in route with the sheriff and when he(ED Physician #2) refused the patient because they don't have psychiatric inpatient services either. We offered to take the patient back despite our diversion status, but they said they couldn't send them back. When ED Physician #2(Hospital B) said they couldn't accept pt(patient) even though they had an open bed because they don't have psychiatry either. It was a miscommunication. I was able to give report. That day we were on diversion from early that morning, and Patient #8 was our tenth psychiatric patient, and the hospital was full."

ED Physician #2 (Hospital B)
A telephone interview with the ED Physician #2 at Hospital B on 8/6/2019 at 4:15 PM revealed, "The Charge Nurse got a telephone call asking if (Hospital B) was on diversion. Hadn't gotten a call from (ED Physician #1 (Hospital A). Nurse was on phone. Then, I got on the phone and spoke with ED Physician #1(Hospital A). Concerned, I informed (ED Physician #1) we couldn't accept the pt(patient), we don't have inpt (inpatient) psych either. I didn't know about the diversion. First time I heard about it was when (ED Physician #1) was asking. He/She offered to take the patient back, but I told him it would be an EMTALA for us if we didn't treat pt(patient). ED Physician #2 (Hospital B) and ED Physician #1(Hospital A) did talk on the phone when our charge nurse called them back to tell them that we were declining to take the patient out of concerns of EMTALA violation. They agreed to take the patient back to their ED when they arrived, explaining a miscommunication, but when the patient arrived shortly after, we treated the patient once they were at our facility."

Hospital A's Telepsychiatry Contract
Review of the Emergency Department's contracts revealed Hospital A has a contract for Telepsychiatry Services via the South Carolina Department of Mental Health(SCDMH) authenticated by Hospital A's Chief Executive Officer on 08/10/2018. Under the section, labeled Definitions, reads, "Evaluation and Associated Recommendation - any Hospital telemedicine contact with SCDMH for telemedicine psychiatric evaluation and associated recommendation to Hospital in Hospital evaluating and/or providing treatment or care to a person in the Hospital ED, regardless of the psychiatric recommendation of Hospital disposition." Review of the document, titled, "SCDMH Telepsychiatry Consultation Program Contract", reads, "1.0 Responsibilities: SCDMH.....
1.2 Provide licensed psychiatrists to provide behavioral health consultation services.
1.5 Provide Program psychiatrist duty schedules available for Program consultation up to a twenty - four (24) hour a day, seven (7) days a week access by Hospital. .....".

Policies and Procedures
Hospital policy and procedure, titled, "EMTALA Medical Screening / Stabilization Policy", revision date 8/3/2015 and reviewed date 11/27/2018, reads,
" I. Overview:
All individuals presenting on Hospital property requesting medical services, individuals presenting to a Dedicated Emergency Department requesting medical services, and patients arriving/presenting via ambulance requesting medical services shall receive an appropriate Medical Screening Examination and Stabilization services as required by the Emergency Medical Treatment and Active Labor Act ("EMTALA"), 42 U.S.C. Section 1395 and all Federal regulations and interpretive guidelines promulgated thereunder.

II. Policy:
Each Hospital must have written guidelines outlining the requirements for appropriate medical screening and stabilization procedures which comply with applicable federal and state law.

III. Procedure:
Definitions:
Medical Screening/Stabilization
General Requirements
In general, when an individual comes, by himself or herself, with another person, or by EMS (Emergency Medical System) to the Dedicated Emergency Department of the Hospital and a request is made on the individual's behalf for a medical examination or treatment, the Hospital must provide an appropriate Medical Screening Examination within the capability of the Hospital (including ancillary services routinely available in the Dedicated Emergency department and emergency services offered at other outpatient departments or facilities) to determine whether an Emergency Medical Condition exists, or with respect to a pregnant woman having contractions, whether the woman is in active labor, and if necessary, the Hospital must execute an Appropriate Transfer according to the guidelines of EMTALA and these policies. These same requirements apply if a prudent layperson would believe the individual is in need of an emergency examination or treatment.

The Location in Which the Medical Screening Examination Should Be Performed:

The Medical Screening Examination and other emergency services need not be provided in a location specialty identified as an emergency room or Dedicated Emergency Department. If an individual arrives at a facility and is not technically in the Dedicated Emergency Department but is in the premises of the Hospital and requests emergency care, he or she is entitled to a Medical Screening Examination: For example, all pregnant women may be directed to the labor and delivery area of the Hospital, if the Hospital has adopted and approved such a policy. The Hospital may use areas to deliver emergency services which are also used for other inpatient or outpatient services. Medical Screening Examinations or Stabilization may require ancillary services available only in areas or facilities outside of the Dedicated Emergency Department.
Medical Screening Examination Requirements
1. Hospitals are obligated to perform the Medical Screening Examination to determine if an Emergency Medical Condition exists.
4. The Medical Screening Examination includes both a generalized assessment and a focused assessment based in the patient's chief complaint, with the intent to determine the presence or absence of an Emergency Medical Condition.
5. A Hospital, regardless of size or patient mix, must provide screening and stabilizing treatment within the scope of its capabilities, as needed, to the individuals who come to the Hospital for examination and treatment.
6. The Medical Screening Examination must be the same Medical Screening Examination that the hospital would perform on any individual coming to the Hospital's Dedicated Emergency Department with those signs and symptoms, regardless of the individual's ability to pay for medical care. If the Medical Screening Examination is appropriate, and does not reveal an Emergency Medical Condition, the Hospital has no further obligations under EMTALA or this policy.
7. Medical Screening Examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or an Appropriate Transfer occurs. There should be evidence of this evaluation prior to discharge or Transfer.
10. A Hospital that is not in diversionary status may not refuse or fail to accept a telephone or radio request for Transfer or admission. Such failure or refusal cold represent a violation of the Hospital's obligation under EMTALA. Even when on diversionary status, if a patient arrives on campus, Hospital must provide a Medical Screening Examination within its Capacity and Capability, as well as Stabilizing Treatment.

Hospital Rules and Regulations
1.4 Suicidal Patients
"For the protection of patients, the medical and nursing staff , and the hospital, the care of the potentially suicidal patient shall be as follows:
1.4(a) A patient suspected to be suicidal in intent shall be placed in a room consistent with the patient's medical needs. If these accommodations are not available, the patient shall be transferred, if possible, to another institution where suitable facilities are available. Appropriate restraints may be used as permitted by these Rules & (and) Regulations or hospital policy. The patient will be afforded psychiatric consultation.

1.4(b) The hospital social worker should be consulted for assistance; and

1.4 (c) If the patient presents to the emergency room, the steps set forth in Section 1.4(a) shall be followed, except that the patient shall not be transferred absent an appropriate medical screening examination, any necessary stabilizing treatment, and a certification, pursuant to the hospital's EMTALA policy, that the benefits of transfer outweigh the risks."

"Article VI, Emergency Medical Screening, Treatment, Transfer & ON-Call Roster Policy
6.1 Screening, Treatment, & Transfer
6.1(a) Screening
(1) Any individual who presents to the Emergency department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition. generally, an "emergency medical condition" is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual or unborn child.
(4) Services available to Emergency Department patients shall include all ancillary services routinely available to the Emergency Department, even if not directly located in the department."

6.1(b) Stabilization
(1) Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge, excepting conditions set forth below.
(3) A patient is Stable for Transfer if the treating physician has determined, within reasonable clinical confidence, that the patient is expected to leave the Hospital and be received at a second facility, with no material deterioration in his/her medical condition; and the treating physician reasonably believes the receiving facility has the capability to manage the patient's medical condition and any reasonably foreseeable complication of that condition. The patient is considered to be Stable for Transfer when he/she is protected and prevented from injuring himself/herself or others.

Based on medical record reviews, review of the hospital's Emergency Medical Treatment and Labor Act (EMTALA) policies and procedures, review of Hospital A's Telepsychiatry Contract, review of the Rules and Regulations, and interviews, it was determined that Hospital A (transferring hospital) failed to ensure that an appropriate psychiatric medical screening examination and stabilizing treatment was provided within the capability of the hospital's Emergency Department (ED), including ancillary services (telepsychiatry) routinely available to the emergency department for consultation on a seven (7) day / twenty four (24) hours basis for 1 of 20 sampled emergency department patients (Patient #8).

The findings are:

Hospital A's Telepsychiatry Contract
Review of the Emergency Department's contracts revealed Hospital A has a contract for Telepsychiatry Services via the South Carolina Department of Mental Health(SCDMH) authenticated by Hospital A's Chief Executive Officer on 08/10/2018. Under the section, labeled Definitions, reads, "Evaluation and Associated Recommendation - any Hospital telemedicine contact with SCDMH for telemedicine psychiatric evaluation and associated recommendation to Hospital in Hospital evaluating and/or providing treatment or care to a person in the Hospital ED, regardless of the psychiatric recommendation of Hospital disposition." Review of the document, titled, "SCDMH Telepsychiatry Consultation Program Contract", reads, "1.0 Responsibilities: SCDMH.....
1.2 Provide licensed psychiatrists to provide behavioral health consultation services.
1.5 Provide Program psychiatrist duty schedules available for Program consultation up to a twenty - four (24) hour a day, seven (7) days a week access by Hospital. .....".

Patient #8
On 08/07/2019 at 1:00 PM, review of Patient #8's ED chart revealed the patient presented to the hospital's ED on 7/22/2019 at 3:29 PM with a chief complaint of a "psychiatric problem". The patient arrived with Law Enforcement (LE) with "pick up papers that stated the patient had not been taking his/her medication and is verbally aggressive with mother." The Triage Nurse documented the presenting complaint as "Law enforcement states: Brought in by LE (Law Enforcement) on pick up papers stating patient has not been taking her medication and is verbally aggressive with mother. Stating family members are afraid of what she may do. Not sleeping and up all night." Patient #8's Emergency Severity Index triage level was 2( patients requiring more detailed observation or intervention). Emergency Department(ED) Physician #1 examined the patient at 3:33 PM and performed a medical screening examination. Patient #8's differential diagnosis was documented as "acute psychotic break, acute anxiety disorder." Emergency Department (ED) course notes revealed "patient was seen and examined ED today with a chief complaint of need psychiatric evaluation. He/She does have a previous history of bipolar disease. He/She has normal stable vitals overall well appearing and will be transferred at this time for further evaluation. He/she will be going to ED Physician #2(Hospital B). At this time, unfortunately, we cannot have another psychiatric hold since we are over a threshold. We have called their ED, and they do have availability for at least one psychiatric patient evaluation. He/she will be sent over at this time by Sheriff's department. Additional history and physical: the patient is 34-year-old. Review of Systems (ROS) unable to obtain ROS due to patient being uncooperative."

Outcome: 3:41 PM "ED care complete, transfer ordered by .....Physician #1" .
Disposition: Physician #1 at 3:42 PM Transfer ordered to Other Acute Care Facility. Diagnosis is encounter for general psychiatric examination, requested by authority.

Reason for transfer: Other. Accepting physician is ED Physician #2. Condition is stable for transfer. Problem is chronic. Symptoms are unchanged." Review of the Physician Certification form for the patient's transfer completed by the ED Licensed Practical Nurse #1(LPN #1) and signed by ED Physician #1(Hospital A) at 3:47 PM. Nurse Notes at 3:52 PM by Registered Nurse (RN) #7, reads, "Report called to Charge Nurse at receiving acute care Hospital ED (Hospital B ). Patient on pick up orders with LE present. LE transport patient to ED lobby per instructions given by nurse."

There was no documentation in Patient 8's chart or the physician progress notes that showed ED Physician #1(Hospital A) consulted a psychiatrist via Hospital A's telepsychiatry program for an evaluation of the patient to determine if a psychiatric emergency condition existed or to determine a psychiatric treatment plan for stabilization of Patient #8 prior to the patient's transfer to Hospital B's Emergency Department (receiving hospital).

Interviews
ED Physician #1 (Transferring Hospital)
A telephone interview with the ED Physician #1 from Hospital A on 8/7/2019 at 5:30 PM revealed, "I have worked in this ED for one month. I just finished residency 07/01/2019. After 9-10 days of orientation days, I was on my own. I did get a lot training on EMTALA in orientation, and in all my days as an ED doctor, I have never not called a physician. I messed up, and LE took the patient based on our conversations at the bedside before I had a chance to talk to Physician #2 (receiving hospital). We did speak while the patient was in route with the sheriff and when he(ED Physician #2) refused the patient because they don't have psychiatric inpatient services either. We offered to take the patient back despite our diversion status, but they said they couldn't send them back. When ED Physician #2(Hospital B) said they couldn't accept pt(patient) even though they had an open bed because they don't have psychiatry either. It was a miscommunication. I was able to give report. That day we were on diversion from early that morning, and Patient #8 was our tenth psychiatric patient, and the hospital was full."

Policies and Procedures
Hospital policy and procedure, titled, "EMTALA Medical Screening / Stabilization Policy", revision date 8/3/2015 and reviewed date 11/27/2018, reads,
" I. Overview:
All individuals presenting on Hospital property requesting medical services, individuals presenting to a Dedicated Emergency Department requesting medical services, and patients arriving/presenting via ambulance requesting medical services shall receive an appropriate Medical Screening Examination and Stabilization services as required by the Emergency Medical Treatment and Active Labor Act ("EMTALA"), 42 U.S.C. Section 1395 and all Federal regulations and interpretive guidelines promulgated thereunder.

II. Policy:
Each Hospital must have written guidelines outlining the requirements for appropriate medical screening and stabilization procedures which comply with applicable federal and state law.

III. Procedure:
Definitions:
Medical Screening/Stabilization

5. A Hospital, regardless of size or patient mix, must provide screening and stabilizing treatment within the scope of its capabilities, as needed, to the individuals who come to the Hospital for examination and treatment.

7. Medical Screening Examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or an Appropriate Transfer occurs. There should be evidence of this evaluation prior to discharge or Transfer.

10. A Hospital that is not in diversionary status may not refuse or fail to accept a telephone or radio request for Transfer or admission. Such failure or refusal cold represent a violation of the Hospital's obligation under EMTALA. Even when on diversionary status, if a patient arrives on campus, Hospital must provide a Medical Screening Examination within its Capacity and Capability, as well as Stabilizing Treatment.

Hospital Rules and Regulations
1.4 Suicidal Patients
"For the protection of patients, the medical and nursing staff , and the hospital, the care of the potentially suicidal patient shall be as follows:
1.4(a) A patient suspected to be suicidal in intent shall be placed in a room consistent with the patient's medical needs. If these accommodations are not available, the patient shall be transferred, if possible, to another institution where suitable facilities are available. Appropriate restraints may be used as permitted by these Rules & (and) Regulations or hospital policy. The patient will be afforded psychiatric consultation.

1.4(b) The hospital social worker should be consulted for assistance; and

1.4 (c) If the patient presents to the emergency room, the steps set forth in Section 1.4(a) shall be followed, except that the patient shall not be transferred absent an appropriate medical screening examination, any necessary stabilizing treatment, and a certification, pursuant to the hospital's EMTALA policy, that the benefits of transfer outweigh the risks."

"Article VI, Emergency Medical Screening, Treatment, Transfer & ON-Call Roster Policy
6.1 Screening, Treatment, & Transfer
6.1(a) Screening

(4) Services available to Emergency Department patients shall include all ancillary services routinely available to the Emergency Department, even if not directly located in the department.

6.1(b) Stabilization
(1) Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge, excepting conditions set forth below.

(3) A patient is Stable for Transfer if the treating physician has determined, within reasonable clinical confidence, that the patient is expected to leave the Hospital and be received at a second facility, with no material deterioration in his/her medical condition; and the treating physician reasonably believes the receiving facility has the capability to manage the patient's medical condition and any reasonably foreseeable complication of that condition. The patient is considered to be Stable for Transfer when he/she is protected and prevented from injuring himself/herself or others.

Based on record reviews, interviews, review of Hospital A's policy, titled, "EMTALA (Emergency Medical Treatment And Labor Act) Emergency Transfers Policy", review of the Rules and Regulations, and review of Hospital A's Telepsychiatry Contract, the hospital failed to ensure that patients presenting to the hospital's Emergency Department (ED) received a psychiatric medical screening examination and stabilizing treatment to determine if the patient had a psychiatric emergency medical condition that required a higher level of care, and failed to ensure the transfer was appropriate in that the receiving hospital did not have the capability to provide the higher level of care (psychiatric services), and failed to ensure the patient was accepted for transfer by a physician at the receiving hospital (Hospital B) for 1 of 20 sampled emergency department patient records reviewed (Patient #8).

The findings are:

Hospital policy, titled, "EMTALA(Emergency Medical Treatment And Labor Act) Emergency Transfers Policy, reads, "The Hospital, through its designated personnel and/or emergency department physicians, must obtain the consent of the receiving or recipient Hospital before the Transfer of the patient and must make the appropriate arrangements for the patient Transfer with an authorized representative of the receiving Hospital."

Hospital A's Telepsychiatry Contract
Review of the Emergency Department's contracts revealed Hospital A has a contract for Telepsychiatry Services via the South Carolina Department of Mental Health(SCDMH) authenticated by Hospital A's Chief Executive Officer on 08/10/2018. Under the section, labeled Definitions, reads, "Evaluation and Associated Recommendation - any Hospital telemedicine contact with SCDMH for telemedicine psychiatric evaluation and associated recommendation to Hospital in Hospital evaluating and/or providing treatment or care to a person in the Hospital ED, regardless of the psychiatric recommendation of Hospital disposition." Review of the document, titled, "SCDMH Telepsychiatry Consultation Program Contract", reads, "1.0 Responsibilities: SCDMH.....
1.2 Provide licensed psychiatrists to provide behavioral health consultation services.
1.5 Provide Program psychiatrist duty schedules available for Program consultation up to a twenty - four (24) hour a day, seven (7) days a week access by Hospital. .....".

Patient #8
On 08/07/2019 at 1:00 PM, review of Patient #8's ED chart revealed the patient presented to the hospital's ED on 7/22/2019 at 3:29 PM with a chief complaint of a "psychiatric problem". The patient arrived with Law Enforcement (LE) with "pick up papers that stated the patient had not been taking his/her medication and is verbally aggressive with mother." The Triage Nurse documented the presenting complaint as "Law enforcement states: Brought in by LE (Law Enforcement) on pick up papers stating patient has not been taking her medication and is verbally aggressive with mother. Stating family members are afraid of what she may do. Not sleeping and up all night." Patient #8's Emergency Severity Index triage level was 2 (patients requiring more detailed observation or intervention). Emergency Department (ED) Physician #1 examined the patient at 3:33 PM and performed a medical screening examination. Patient #8's differential diagnosis was documented as "acute psychotic break, acute anxiety disorder." Emergency Department (ED) course notes revealed "patient was seen and examined ED today with a chief complaint of need psychiatric evaluation. He/She does have a previous history of bipolar disease. He/She has normal stable vitals overall well appearing and will be transferred at this time for further evaluation. He/she will be going to ED Physician #2 (Receiving Hospital #B). At this time, unfortunately, we cannot have another psychiatric hold since we are over a threshold. We have called their ED, and they do have availability for at least one psychiatric patient evaluation. He/she will be sent over at this time by Sheriff's department. Additional history and physical: the patient is 34-year-old. Review of Systems (ROS) unable to obtain ROS due to patient being uncooperative."

Physical Examination Documented by ED Physician #1:
Constitutional: "This is a well-developed, well-nourished patient who is awake, alert, and in no acute distress.
Psychiatric: "Behavior /mood is pleasant, uncooperative, affect is calm. Judgement/insight is impaired. Delusions/hallucinations are present and described as appears the patient is having some delusions but is unclear what they may be.
Unable to obtain exam due to patient being uncooperative. No medications were administered.
Outcome: 3:41 PM "ED care complete, transfer ordered by Physician #1(transferring hospital)" .
Disposition: Physician #1 at 3:42 PM Transfer ordered to Other Acute Care Facility. Diagnosis is encounter for general psychiatric examination, requested by authority.
Reason for transfer: Other. Accepting physician is ED Physician #2. Condition is stable for transfer. Problem is chronic. Symptoms are unchanged." Review of the Physician Certification form for the patient's transfer completed by the ED Licensed Practical Nurse #1 (LPN #1) and signed by ED Physician #1 (Transferring hospital) at 3:47 PM. Nurse Notes at 3:52 p.m. by Registered Nurse (RN) #7, reads, "Report called to Charge Nurse at receiving acute care Hospital ED (Hospital #2). Patient on pick up orders with LE present. LE transport patient to ED lobby per instructions given by nurse."

Interviews
ED Physician #1 (Hospital A)
A telephone interview with the ED Physician #1 from Hospital A on 8/7/2019 at 5:30 PM revealed, "I have worked in this ED for one month, I just finished residency 07/01/2019. After 9-10 days of orientation days, I was on my own. I did get a lot training on EMTALA in orientation, and in all my days as an ED doctor .I have never not called a physician. I messed up, and LE took the patient based on our conversations at the bedside before I had a chance to talk to ED Physician #2 (Hospital B). We did speak while the patient was in route with the sheriff and when he (ED Physician #2) refused the patient because they don't have psychiatric inpatient services either. We offered to take the patient back despite our diversion status, but they said they couldn't send them back. When ED Physician #2 (Hospital B) said they couldn't accept pt (patient) even though they had an open bed because they don't have psychiatry either. It was a miscommunication. I was able to give report. That day, we were on diversion from early that morning, and Patient #8 was our tenth psychiatric patient, and the hospital was full."

ED Physician #2 (Receiving Hospital)
A telephone interview with the ED Physician #2 at Hospital B on 8/6/2019 at 4:15 PM revealed, "The Charge Nurse got a telephone call asking if .....(Hospital B) on diversion. Hadn't gotten a call from ....(ED Physician #1 - Hospital A). Nurse was on phone. Then, I got on the phone and spoke with ED Physician #1 (Hospital A). Concerned, I informed (ED Physician #1( Hospital A) we couldn't accept the pt(patient), we don't have inpt (inpatient) psych either. I didn't know about the diversion. First time I heard about it was when ED Physician #1 (Hospital A) was asking. He/She offered to take the patient back, but I told him it would be an EMTALA for us if we didn't treat pt. We (ED Physician #2 (Hospital B) and ED Physician #1 (Hospital A) did talk on the phone when our charge nurse called them back to tell them that we were declining to take the patient out of concerns of EMTALA violation. They agreed to take the patient back to their ED when they arrived, explaining a miscommunication, but when the patient arrived shortly after, we treated the patient once they were at our facility."

ED Registered Nurse #1(Transferring Hospital)
A face to face interview conducted with ED Registered Nurse #1 on 8/7/2019 at 9:00 AM revealed ED RN #1 verbalized understanding of EMTALA. RN #1 stated "Yes, we have on-line training, talk about it at skills fairs, and at staff meetings. We talk about it (EMTALA) all the time. We have policy and procedures on EMTALA, and there is always someone I can call if I have a concern . Administration is very responsive." Regarding psychiatric patients, RN #1 stated, "It is very difficult to find psychiatric placement for our patients. There just are not enough psychiatric beds in our state. We use to have case managers who would find placement for the psychiatric patients, but the hospital cut them. The ED nurses are now responsible to transfer the patients."

ED Charge Nurse - RN #4 (Receiving Hospital #B)
A telephone interview was conducted with the ED Charge Nurse (ED RN #4) at Hospital B on 8/7/2019 at 12:30 PM. ED RN #4 revealed "I do remember the patient. I was the charge nurse (Hospital B) that day, and I spoke to ED RN #10 (Hospital A ) who informed me that their ED and two other area hospital EDs were on diversion. At that time, ED RN #10 asked me if we had any psych hold beds in our ED because there was a patient in their ED that they wanted to transfer. We did have one available psych bed, but I asked her (ED RN #10) if she meant to call the other acute care hospital since we only have telemetry psychiatric services in our ED same as theirs. I was not aware of patients being transferred to our hospital(Hospital B) in such a manner. I explained to her (ED RN #10) that I would have to notify my ED Physician and Nursing Supervisor about the issue. I called back and notified ED RN #10 that both the ED Physician and the Nursing Supervisor stated patient couldn't be transferred to our hospital's ED. RN #4 (Hospital B) stated patient was accepted by ED Physician #2 (Hospital B) from ED Physician #1(Hospital A). While she (ED RN #10) told me about the patient, I informed her (ED RN #10) that ED Physician #2 (Hospital B) stated he did not speak with anyone about the patient's transfer. ED RN #10 (Hospital A) stated that he/she would call back to have ED Physician #1 (Hospital A) speak with ED Physician #2 (Hospital B). At 4:20 PM, I (ED RN #4) called back to Hospital A and reiterated that their ED doc (doctor) didn't speak with ED Physician #2 (Hospital B). ED RN #10 stated there was a miscommunication, but ED Physician #1 (Hospital A) was available to speak with ED Physician #2 (Hospital B)about the patient. The two doctors did speak, and the transfer was declined by ED Physician #2 (Hospital B). At 4:48 PM, the patient arrived at our ED (Hospital B). At 4:50 PM,. Hospital A was called back. I spoke with the Chief of Nursing (CNO). The CNO explained it was a miscommunication on the behalf of her staff, and the patient was transferred prior to them knowing the patient wasn't officially accepted by our doctor. The CNO stated to send the patient back. I transferred the call to ED Physician #2 (Hospital B)."

ED Medical Director(Hospital #A - Transferring Hospital)
On 8/07/2019 at 2:00 p.m., ED Medical Director (MD) #3 at Hospital A was interviewed about the facility's EMTALA policies and procedures. ED Medical Director(MD #3 - Hospital A) stated, "ED physician requests transfer of the patient. We also complete Physician Certification which states the reason for the transfer, and the benefits and risks. There are two forms we fill out, and the nurse, MD, and patient sign documenting the patient is stable for transfer." ED MD #3 stated, "We don't have psychiatric limits. No, we don't put limits because where will the patients go? We do try to get them to the safe appropriate places for treatment as soon as possible. Often we call local hospitals to assist when we are stretching our resources. It is not unusual to ask for help from each other, and we reciprocate."

ED RN #7 (Transferring Hospital #A)
A telephone interview with the ED RN #7 who verified that he/she provided care for the patient on 8/7/2019 at 5:00 PM revealed he/she has worked in the ED on and off for 3 years, and verified that he/she has a good understanding of EMTALA policies and procedures. ED RN #7 stated, "We get yearly training on EMTALA." ED RN #7 verified he/she remembered caring for the patient on 7/22/2019, and stated, "Yes, I remember, we were on diversion when the patient came in, but LE brought the patient anyway. Due to EMTALA, we did a Medical Screening Exam (MSE), and determined the patient was stable. I called report and spoke to the accepting nurse who earlier had said they weren't on diversion and had an open psychiatric bed in their ED. As far as I knew, yes, the ED Physician called (Hospital B), and they had talked to each other."

Policies and Procedures

Hospital policy, titled, EMTALA Emergency Transfers Policy, Revision Date: 8/3/2015 and Review Date: 11/27/2018
I." Overview: Hospitals that participate in the Medicare program must comply with the heightened documentation, staffing, and equipment requirements imposed by EMTALA when they initiate an Appropriate Transfer. ......."

II. Policy:
Each hospital must have written guidelines outlining the requirements for an Appropriate Transfer to another Hospital in accordance with federal and state laws. Any Transfer of an individual with an Emergency Medical Condition must be initiated either by the written request from the patient or the legally responsible person acting on the patient's behalf for such Transfer, or by a physician's order with the appropriate Physician certification. .....".

III. Procedure:
1. The Hospital must develop written guidelines for transferring a patient with an Emergency Medical Condition to another Hospital in accordance with federal and state laws.

3. The Hospital shall take reasonable steps to initiate an Appropriate Transfer when (a) the patient requests a transfer; or (b) the physician determines that the hospital has exhausted its Capabilities, and the benefits of an Appropriate Transfer outweigh the risks.

4. Patients must also be Stable for Transfer as defined in EMTALA when the Appropriate Transfer is initiated. Stable for Transfer is different than Stable for Discharge,and each Term is defined in Emergency Medical Treatment and Patient Transfer Policy.

6. Emergency Transfer
An emergency Appropriate Transfer to another Hospital will be appropriate only in those cases in which:
· The patient has an Emergency Medical Condition and has not been Stabilized for Discharge
· The patient is stable for Transfer as defined by EMTALA. A patient is Stable for Transfer if the treating physician has determined, within reasonable clinical confidence, that the patient is expected to leave the Hospital and be received at a second facility, with no material deterioration in his/her medical condition; and the treating physician believes the receiving facility has the capability to manage the patient's medical condition and any reasonably foreseeable complication of that condition. For psychiatric conditions, the patient is considered Stable for Transfer when he/she is protected and prevented from injuring himself/herself or others.
· The transferring Hospital provided medical treatment within it Capabilities that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the woman and the unborn child.
· The receiving Hospital has available space and Qualified Medical Personnel for the treatment of the individual and has agreed to accept Transfer of the individual and to provide appropriate treatment.
· The Transfer is affected through Qualified Medical Personnel and appropriate transportation and equipment..... Personal vehicles are not considered "appropriate transportation" because they do not include equipment or life support measures, they are not driven or staffed by trained emergency professionals, and the physician cannot ensure the vehicle reaches the receiving hospital.
· The Hospital, through its designated personnel and/or emergency department physician, must obtain the consent of the receiving or recipient Hospital before the Transfer of the patient and must make the appropriate arrangements for the patient Transfer with an authorized representative of the receiving Hospital.
· The physician at the transferring Hospital has the responsibility to ensure the Appropriate Transfer meets the heightened standards under EMTALA. ....."


Hospital Rules and Regulations
1.4 Suicidal Patients
"For the protection of patients, the medical and nursing staff , and the hospital, the care of the potentially suicidal patient shall be as follows:
1.4(a) A patient suspected to be suicidal in intent shall be placed in a room consistent with the patient's medical needs. If these accommodations are not available, the patient shall be transferred, if possible, to another institution where suitable facilities are available. Appropriate restraints may be used as permitted by these Rules & (and) Regulations or hospital policy. The patient will be afforded psychiatric consultation.

1.4(b) The hospital social worker should be consulted for assistance; and

1.4 (c) If the patient presents to the emergency room, the steps set forth in Section 1.4(a) shall be followed, except that the patient shall not be transferred absent an appropriate medical screening examination, any necessary stabilizing treatment, and a certification, pursuant to the hospital's EMTALA policy, that the benefits of transfer outweigh the risks."

"Article VI, Emergency Medical Screening, Treatment, Transfer & ON-Call Roster Policy

6.1(b) Stabilization
(1) Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge, excepting conditions set forth below.
(3) A patient is Stable for Transfer if the treating physician has determined, within reasonable clinical confidence, that the patient is expected to leave the Hospital and be received at a second facility, with no material deterioration in his/her medical condition; and the treating physician reasonably believes the receiving facility has the capability to manage the patient's medical condition and any reasonably foreseeable complication of that condition. The patient is considered to be Stable for Transfer when he/she is protected and prevented from injuring himself/herself or others.

6.1(c) Transfers
(1) The Emergency Department Physician shall obtain the consent of the receiving hospital facility before the transfer of an individual. Said person shall also make arrangements for the patient transfer with the receiving hospital. "