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Based on documentation and interviews, the hospital failed to ensure compliance with requirements of 42 CFR 489.24, when the hospital failed to provide an appropriate transfer for a patient who presented to the ED resulting in deficient practice cited at 42 CFR 489.24 (a) A2409.

Based on observations during a tour of the emergency department (ED) on August 6, 2012, and interviews, the hospital failed to post conspicuously in the ED or in a place likely to be noticed by individuals waiting for examination and treatment in the ED signs specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment in the emergency room. In addition, the facility failed to post conspicuously in the ED signs indicating whether or not the hospital participates in the Medicaid program under the state plan approved under Title XIX. Findings include:

A tour of the ED was conducted at 10:10 a.m. on August 6, 2012, with employee (A)/director of nursing. The ED had a dedicated entrance with a waiting room. There were six ED bays, three that were used consistently and three that were utilized for overflow ED patients. No signs were posted informing individuals of their EMTALA rights in the ED waiting room and the three overflow bays. In addition, there were no signs informing patients whether the hospital participated in the Medicaid program in the waiting room, entrance to the ED or the six bays.

Interview with employee (A) during the ED tour confirmed the required signs for EMTALA rights and signs whether the hospital participated in the Medicaid program were not posted as required..

Based on documentation review and interviews, the hospital failed to ensure the receiving hospital agreed to accept a transfer and had available space and had personnel available for 1 of 20 (#1) patient ED records reviewed that required a transfer for a higher level of care. Findings include:

Review of Patient #1's ED record indicated the patient presented to the ED at 4:30 p.m. on 7/20/2012, escorted by the police for suicidal ideation and a drug overdose. Patient #1 reported to the ED staff she had attempted suicide by taking Valium (anti-anxiety medication) 90 of her 5 milligram (mg) tablets and an unspecified amount of Remeron (anti-depressant medication). Patient #1 told the ED staff she had the right to kill herself. Patient #1 ' s ED admission vital signs were a pulse of 127, respirations of 24, oxygen saturation of 93% on room air. Patient #1 refused to have a blood pressure taken and was non-compliant with medical testing in the ED. According to Patient #1 ' s ED record, at 11:00 p.m. the patient became extremely disruptive, throwing medical supplies off of shelves in the ED bay and yelling at staff. With the physician present, Patient #1 was placed in physical restraints. Thorazine (anti-psychotic medication) 100 mg intra-muscular (IM) was administered at 11:15 p.m. and Ativan (anti-anxiety medication) 2 mg IM was administered at 11:45 p.m. which had minimal effect of Patient #1's behavior. Patient #1 left the transferring hospital ' s ED at 12:40 a.m. by ambulance in restraints to be admitted for psychiatric care at the receiving hospital.

Review of the ambulance record for Patient #1 on 7/21/2012, established the ambulance left the transferring hospital with the patient at 12:38 a.m. and arrived at the receiving hospital at 2:05 a.m. Patient #1 was irritable during the transport refusing vital signs be taken. Patient #1 continued to require physical restraints for combative behavior during the transport.

Review of the transferring hospital's Transfer Assessment and Certification Hospital to Hospital consent form dated 7/20/12 (actual date 7/21/2012), at 12:30 a.m. documented under the benefit section was a symbol that appeared to look like a four. There was no documented risk analysis completed by the physician. In addition, there was no evidence of physician to physician contact or nurse to nurse contact to the receiving hospital. The transferring hospital did not ensure the receiving hospital had the capacity to provide the treatment necessary for Patient #1, available space and personnel to care for the patient or that the receiving hospital had accepted the transfer of the patient.

Review of the receiving hospital's ED record for Patient #1 established the ambulance staff en route to the receiving hospital called the hospital to inform the staff that the patient was to be a direct admission to the psychiatric unit. There was no psychiatric bed available at the receiving hospital for Patient #1 nor had the transferring hospital made contact or arrangements for the patient to be admitted. The ambulance was directed to the ED of the receiving hospital where Patient #1 received a medical screening examination and lab. Patient #1 was admitted to the Intensive Care Unit (ICU) with diagnoses that included suicide attempt and depression.

Employee (B)/physician was interviewed at 9:47 a.m. on 8/10/2012, and revealed he did not contact the receiving hospital prior to Patient #1 leaving for the receiving hospital. Employee (B) stated the symbol that looked like the number 4 under the benefit section of Patient #1's consent form was the Greek symbol for psychiatry.


Interview with employee (A)/director of nursing at 8:49 a.m. on 8/6/2012, confirmed the transferring hospital physician and nurse did not contact the receiving hospital prior to sending Patient #1 to the receiving hospital by ambulance.

Review of the hospital's EMTALA policy with an effective date of 8/23/2004, stated the physician would make the patient transfer arrangements with the selected receiving physician and facility. The nurse would contact the receiving facility and provide a nurse to nurse report. The policy indicated the nurse would obtain the patient's signature on the transfer consent form. The policy further stated the physician would discuss with the patient and/or family and document the benefits and potential risks of a transfer to a receiving facility and probable risks of not being transferred. The policy indicated all of the above information was to be documented on the hospital's Transfer Assessment and Certification form.