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Based on interviews, and policy and medical record review, the facility failed to comply with (A2406) by failing to provide an appropriate medical screening examination within the capability of the hospital's emergency department to determine whether or not an emergency medical condition exists and failed to ensure a signed physician's certification for transfer form was completed (A2409) for transferred patients. The cumulative effect of this systemic practice resulted in the facility's inability to ensure that all patients presenting to the emergency department would receive a medical screening evaluation and a safe transfer.

Based on review of the medical record from Facility A and B, staff interview and policy review, the facility failed to provide an appropriate medical screening examination within the capability of the facility's emergency department to determine whether or not an emergency medical condition exists for one (Patient #21) of 21 emergency department medical records reviewed. The average monthly census of the Emergency Department is 3221 patients.

Findings include:

1. Patient #21 was listed as a "John Doe" on the facility's Emergency Department (ED) log from 03/21/15. Staff D (emergency room nurse) documented the following: "Patient #21 presented on 03/21/15 at approximately 4:00 AM via an unknown police department. The police officer was greeted by Staff R, who informed the officer that the ED department was on diversion. The officer questioned whether he/she should transport Patient #21 to Facility B and the nursing supervisor agreed to this question. Patient #21 was then transported to Facility B without being seen."

In an interview 03/30/15 at 8:21 AM Staff A (administrative staff) confirmed this finding.

2. Review of the medical record from Facility B revealed Patient #21 arrived on 03/21/15 at 4:16 AM by police for medical clearance. Documentation revealed the police officer stated he/she saw Patient #21 smoke from a crack pipe and swallow a white small shaped substance. Patient #21 was under arrest and denied swallowing anything. Patient #21 also refused all care and testing. Further review of documentation revealed the police officer stated he/she took Patient #21 to Facility A and was in the Emergency Department when told Facility A was on diversion. The police officer transported Patient #21 to Facility B.

3. The facility's EMTALA policy (LD-39) was reviewed. The policy stated if the facility is in "diversionary" status because it does not have the staff or facilities to accept additional emergency patients, the facility may divert patients. However, if an ambulance ignores the facility's instructions and brings the individual onto the facility's property, EMTALA applies and the facility will follow this policy to examine and treat the patient.

Based on medical record review and policy review, the facility failed to ensure a signed physician's certification for transfer form was completed for four (Patient #3, #4, #15 and #17) of five patient charts reviewed for transfers from the emergency department. The average monthly census of the Emergency Department is 3221 patients.

Findings include:

1. The medical record review for Patient #3 revealed Patient #3 was evaluated in the facility's Emergency Department on 03/18/15 with a diagnosis of suicide attempt and overdose and transferred to a different facility on 03/19/15. The medical record did not contain a physician's signed certification for the transfer.

2. The medical record review for Patient #4 revealed Patient #4 was evaluated in the facility's Emergency Department on 03/05/15 for a diagnosis of drug overdose and suicide attempt. Patient #4 was transferred to a different facility on 03/06/15. The medical record did not contain a physician's signed certification for the transfer.

3. The medical record review for Patient #15 revealed Patient #15 was evaluated in the facility's Emergency Department on 10/14/14 with a diagnosis of drug overdose and suicide attempt. Patient #15 was transferred to a different facility on 10/14/14. The medical record did not contain a physician's signed certification for the transfer.

4. The medical record review for Patient #17 revealed Patient #17 was evaluated in the facility's Emergency Department on 12/11/14 with a diagnosis of suicidal ideation. Patient #17 was transferred to a different facility on 12/12/14. The medical record did not contain a physician's signed certification for the transfer.

The facility's EMTALA policy revealed the physician signs a written certification stating that the medical benefits of the patient's receiving treatment at another facility outweigh the risks to the patient (or, in the case of labor, to the woman if unborn child) from being transferred.