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Based on findings documented in data tags 2406, 2407 and 2409, the hospital failed to comply with requirements of 42 CFR 489.24.

Based on record review and interview, the hospital emergency department (ED) failed to provide an appropriate medical screening examination (MSE) for one of 35 patients (Patient 4) to determine whether an emergency medical condition existed when the physician failed to review laboratory test results before Patient 4 was transferred to another hospital. The hospital failed to ensure the computer system used by the ED staff included results of pending laboratory test results to ensure a complete MSE. Findings:

1. Patient 4's record was reviewed on 2/3/10. Patient 4 was treated in the emergency department (ER) four times from 1/5/10 to 1/10/10. He was hospitalized on 1/6/10 and discharged home on 1/7/10 with diagnosis of altered mental status secondary to a concussion.

On 1/10/10, the patient was seen in the ER and transferred to a psychiatric unit at another hospital.

Patient 4 arrived by ambulance on 1/10/10 at 12:25 p.m. because of altered mental status and loss of consciousness. Patient 4 was triaged by a nurse at 12:25 p.m. The physician (A) examined the patient, ordered a CT scan and several laboratory tests, including a CPK (creatinine phosphokinase). CPK is an enzyme found mainly in the heart, brain and skeletal muscle. The record review indicated the results of the CPK test were available at 4:26 p.m. and were abnormal at 23,349 U/L (units per liter). The normal range is 35-232 U/L.

Physician A's notes indicated there was no treatable medical condition identified. The physician ordered a 72 hour psychiatric hold (California Welfare and Institutions Code, Section 5150) because Patient 4 had been agitated, confused for the past one to two days, was gravely disabled, and his family refused to take him home.

According to the California Welfare and Institutions Code, Section 5150, "When any person, as a result of mental disorder, is a danger to others, or to himself or herself, or gravely disabled, a peace officer, member of the attending staff, as defined by regulation, of an evaluation facility designated by the county, designated members of a mobile crisis team provided by Section 5651.7, or other professional person designated by the county may, upon probable cause, take, or cause to be taken, the person into custody and place him or her in a facility designated by the county and approved by the State Department of Mental Health as a facility for 72-hour treatment and evaluation."

Physician A advised Patient 4 of the order for 72-hour hold at 3:40 p.m. and arranged for his transfer to a psychiatric unit at another hospital for a mental evaluation. Patient 4 arrived at the receiving hospital on 1/10/10 at 5:30 p.m.

Physician A was interviewed on 2/3/10 at 1:30 p.m. He stated he did not review all the laboratory tests he had ordered before the patient was discharged to another hospital on 1/10/10. The test results he did review indicated the patient required no further medical treatment. Physician A stated he would have admitted the patient to the hospital if he had seen the CPK test results.

Patient 4's condition deteriorated when he arrived at the psychiatric unit and he was sent to the emergency department for an examination. He was admitted to the coronary care unit for further treatment. The patient was diagnosed with rhabdomyolysis, the breakdown of muscle fibers, resulting in the release of muscle fiber content into the bloodstream, which may cause kidney damage.

2. Physician A stated during an interview that he used the hospital's T computer system (used only by the ED) instead of the MediTech system (the computer system used by all units of the hospital) to check on laboratory results for Patient 4 on 1/10/10. The T system did not indicate the status of all ordered laboratory tests.

On 2/3/10, the Director of Quality stated the Meditech system was the system staff should use when reviewing laboratory test results because it would reflect if any lab tests were pending. The T system did not include pending results.

Based on record review and interviews, the hospital failed to provide appropriate stabilizing medical treatment for one of 35 sampled patients (Patient 4). The physician failed to review abnormal laboratory test results before Patient 4 was transferred to another hospital. Findings:

Patient 4's record was reviewed on 2/3/10. Patient 4 was seen in the emergency department (ED) four times from 1/5/10 to 1/10/10. He was hospitalized on 1/6/10 and discharged home on 1/7/10. On 1/10/10, he was transferred to a psychiatric unit at another hospital.

On 1/5/10 at 7:02 p.m., Patient 4 was brought by ambulance to the emergency department after falling and loss of consciousness at home. The patient was examined for trauma, laboratory tests were drawn, and a CT procedure (computed tomography, a diagnostic procedure used to visualize the patient's brain and spine) was performed. The laboratory test results included an elevated white cell count 11.8 (reference range 4.8-11.0), low potassium 3.4 (normal 3.5- 5.1), low sodium 135 (normal 136-145), low carbon dioxide 15 (normal 21-32) and a high anion gap of 21 (normal 3-11). Patient 4 was diagnosed with a concussion and sent home at 7 p.m.

Patient 4 returned to the ED on 1/6/10 at 1:30 a.m. with complaints of dizziness. He was examined, a blood sample was drawn, and the CT scan was repeated. He was discharged home at 4:32 a.m. No reference to the 1/5/10 visit or laboratory results were noted in the physician's notes.

Patient 4 returned to the ED on 1/6/10 at 5:35 a.m. after having a seizure at home. He was admitted to the hospital. The patient's treatment included additional laboratory tests, a repeat CT scan and observation. A lactic acid test result was abnormally high at 5.7 (normal range 0.4-2.0). According to the Merck Manual Eighteen Edition, very high levels of lactic acid cause lactic acidosis which occurs during tissue hypoperfusion in hypovolemic, cardiac, or septic shock and is worsened by decreased lactate metabolism in the poorly perfused liver. It may also occur with primary hypoxia from lung disease and with various hemoglobinopathies.

Patient 4 was discharged on 1/7/10 with instructions to follow-up with a neurologist in six weeks. His discharge diagnoses included altered mental status secondary to concussion.

The patient returned by ambulance on 1/10/10 at 12:25 p.m. because of altered mental status and loss of consciousness. Patient 4 was triaged by a nurse at 12:25 p.m. The physician (A) examined the patient, ordered a repeat CT scan and ordered several laboratory tests, including a CPK (creatinine phosphokinase). CPK is an enzyme found mainly in the heart, brain and skeletal muscle. The record review indicated the results of the CPK test were available at 4:26 p.m. and were abnormal at 23,349 U/L (units per liter). The normal range is 35-232 U/L.

Physician A's notes indicated there was no treatable medical condition identified. The physician ordered a 72 hour psychiatric hold (California Welfare and Institutions Code (WIC), Section 5150) because Patient 4 had been agitated, confused for the past one to two days, was gravely disabled, and his family refused to take him home.

According to the WIC, Section 5150, "When any person, as a result of mental disorder, is a danger to others, or to himself or herself, or gravely disabled, a peace officer, member of the attending staff, as defined by regulation, of an evaluation facility designated by the county, designated members of a mobile crisis team provided by Section 5651.7, or other professional person designated by the county may, upon probable cause, take, or cause to be taken, the person into custody and place him or her in a facility designated by the county and approved by the State Department of Mental Health as a facility for 72-hour treatment and evaluation."

Physician A advised Patient 4 of the order for 72-hour hold at 3:40 p.m. and arranged for his transfer to a psychiatric facility at another hospital for a mental evaluation.

Physician A was interviewed on 2/3/10 at 1:30 p.m. He stated he did not review all the laboratory tests he had ordered before the patient was discharged to another facility on 1/10/10. The test results he did review indicated the patient required no further medical treatment. Physician A stated he would have admitted the patient to the hospital if he had seen the CPK test results.

Patient 4's condition deteriorated when he arrived at the psychiatric facility and he was sent to the emergency department for an examination. He was admitted to the coronary care unit for further treatment. The patient was diagnosed with rhabdomyolysis, the breakdown of muscle fibers, resulting in the release of muscle fiber content into the bloodstream, which may cause kidney damage.

Based on interview and record review, the emergency department (ED) physician, or other qualified staff, failed to complete the certification on the EMTALA Memorandum of Transfer form prior to the patient transfer to another facility for one of sampled patients (6). Findings:

Patient 6 was admitted to the ED on 12/8/09 at 12:56 p.m. The patient was transferred to a psychiatric facility at 3:20 p.m. There was no EMTALA Memorandum of Transfer form in the patient's medical record.

The EMTALA Memorandum of Transfer form was revised on 7/28/09. The instructions indicated after the form was signed, "make two copies; original goes to the medical record, copy to the patient and copy to receiving facility."