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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in §489.24, related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

Findings:

1. The facility failed to meet the following requirements under the EMTALA regulation:

Tag A2406 - Medical Screening Exam - The facility failed to ensure an appropriate Medical Screen Exam (MSE) as required by EMTALA regulation was provided by qualified medical personnel (QMP) in 1 of 5 records reviewed for patients who presented to the facility for an emergency evaluation and were not admitted. (Patient #30).

Tag A2409 - Appropriate Transfer - The facility failed to ensure patients requiring a higher or specialized level of care were transferred appropriately pursuant to EMTALA for 3 of 5 patients transferred reviewed (Patients #8, #29 and #30).

Based on interviews and record review, the facility failed to ensure an appropriate Medical Screen Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided by qualified medical personnel (QMP) in 1 of 5 records reviewed for patients who presented to the facility for an emergency evaluation and were not admitted. (Patient #30). This failure resulted in the delay of care for patients with emergency medical conditions.

Findings include:

Facility policy:

According to the policy, Compliance with Emergency Medical Treatment EMTALA, EMTALA is applicable to anyone who presents on any area or department of the hospital for primary assessment and treatment. The EMTALA requirements are applicable to anyone who is on hospital property, including parking lots, sidewalks, and driveways.

The policy, Transfer Acceptance Policy for Psychiatric Patient read, Medical Screening Examination (MSE): the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition (EMC) exists. With respect to an individual with psychiatric symptoms, an MSE consists of both a medical and psychiatric screening.

According to the policy, Pre-Admission Screening and Admission Process, the Assessment and Referral (A & R) Department will provide clinical assessments of all potential patients and referral for the appropriate level of care.

Qualified Medical Personnel (QMP) provide Initial Assessment/Medical Screening for patients by completing the Medical Screening Form by reviewing self-complete section and taking patient vitals and administering breathalyzer to obtain blood alcohol level.

If there are medical outliers, as indicated on the Medical Screening form, the QMP will notify the RN (Registered Nurse) and/or the physician as indicated on the Medical Screening form. The physician, in making level of care decisions, consults the QMP who has assessed the patient and the RN responding for further medical assessment. For patients not appropriate for admission due to medical outliers, an appropriate referral and appropriate transfer (per medical condition) will be arranged.

1. The facility failed to ensure all patients who arrived at the facility seeking emergency medical treatment received a medical screening examination by a QMP to determine if an emergency medical condition existed.

a. Review of the Call Log (the document the facility used to track incoming calls, referrals and walk-in appointments) showed that Patient #30 arrived at the facility on 2/1/18 as an unscheduled walk-in. The patient's specific arrival time is uncertain, as according to the Call Log, the A & R team was not advised of his arrival. However, the first entry on the Call Log for Patient #30 was made on 2/1/18 at 4:25 p.m. After an unspecified wait period, he was found asleep in the main lobby at 6:25 p.m. Patient #30 was then brought back to the A & R department for an assessment.

Review of the Initial Medical Screening Assessment Information form (which included areas to document vital signs, medical history and pain assessment), dated 2/1/18 at 6:42 p.m., revealed Assessor #5 administered a breathalyzer test to Patient #30. The result was a blood alcohol level (BAL) of 0.29, which indicated alcohol intoxication (with values greater than 0.08 considered intoxicated). The rest of the medical screening form was left blank, including the vital signs portion, and no further documentation was found showing that an assessment was completed.

During an interview conducted with the Director of Quality (Director #6) on 5/3/18 at 2:41 p.m., she stated she considered a BAL of 0.29 a medical emergency.

An interview was conducted with a house supervisor (RN #7) on 5/2/18 at 10:16 a.m. He stated if a patient had medical issues in A & R, the procedure would be for a nurse from the inpatient unit to come and evaluate the patient and administer aid within the facility's capabilities until the patient could be transferred.

There was no documentation in the medical record indicating an RN or physician was requested to evaluate the patient and determine whether an emergent medical condition related to the patient's intoxication existed.

An interview with the Director of Assessment and Referral (Director #9) was conducted on 5/3/18 at 1:15 p.m. in which she confirmed a complete medical screen, as described in the facility's policy, was not completed for Patient #30.

According to the call log, Assessor #5 called Physician #4 at 7:01 p.m. regarding the patient's elevated BAL. He recommended transferring the patient to an emergency department (ED) of an acute care facility. At 7:26 p.m., the patient was transferred to the ED via ambulance.

b. An interview with the Medical Director (Physician #3) was conducted on 5/3/18 at 8:03 a.m. He stated the A & R staff could not "technically" do a full medical screening examination, as they were Master's prepared clinicians. He stated in instances of medical emergencies, he expected the staff to gather information and then ask the medical team for further guidance.

c. During an interview, on 5/2/18 at 4:04 p.m., Assessor #2 stated the A & R staff were responsible for completing the initial assessment on all individuals presenting to the A&R department for possible inpatient treatment. She stated an initial assessment consisted of taking vital signs, performing a breathalyzer test and completing the initial medical screening form. She stated if anything in the patient's presentation or medical history was concerning, or if the vital signs were outside the parameters listed on the medical screening form, she would ask a registered nurse (RN) to come up to the A & R area to evaluate the patient and make recommendations.

d. An interview with RN #11 was conducted on 5/3/18 at 10:15 a.m. She stated she had been called up to A & R previously to assess and assist with unstable patients. She stated she was expected to complete an assessment in these instances, and administer first aid within the capabilities of the facility and her scope of practice.

Based on interviews and record review, the facility failed to ensure patients requiring a higher or specialized level of care were transferred appropriately pursuant to EMTALA (Emergency Medical Treatment And Labor Act) for 3 of 5 patients transferred (Patients #8, #29 and #30).

Findings include:

Facility policy:

According to the policy, Compliance with Emergency Medical Treatment EMTALA, EMTALA is applicable to anyone who presents in any area or department of the hospital for primary assessment and treatment. The EMTALA requirements are applicable to anyone on hospital property, including parking lots, sidewalks and driveways.

A patient with an unstabilized emergency medical condition may be transferred only if the hospital complies with all of the following standards:

The hospital provides treatment within its capacity to minimize risks to the individual's health. The patient's record shall reflect vital signs and the condition of the patient at the time of transfer.

The receiving hospital has available space and qualified personnel for the treatment of the patient, and the receiving hospital and physician have agreed to accept the patient and provide appropriate medical treatment.

The hospital sends to the receiving facility all medical records (or copies thereof) available at the time of transfer related to the emergency condition of the patient including: records related to the emergency condition; observations of signs and symptoms, preliminary diagnosis, treatment provided, results of any tests at the time of transfer; other records (including pending test results or records not available at the time of transfer) must be forwarded as soon as practicable after the transfer; and the patient's informed, written consent to transfer or the physician's certification (or copy thereof).

1. The facility failed to complete an appropriate transfer for patients requiring a higher or specialized level of care.

a. Review of the facility's Call Log (the document the facility used to track incoming calls, referrals and walk-in appointments) revealed Patient #8 arrived at the facility as an unscheduled walk-in on 2/18/18 at 1:23 p.m. According to the Comprehensive/Psychosocial Assessment Tool, completed by Assessor #2 and dated 2/18/18 at 2:57 p.m., Patient #8 reported paranoia about leaving her home and expressed suicidal ideation. Patient #8's medical record revealed an Emergency Mental Illness Report and Application (M-1) was completed by Assessor #2. In the M1 application, Assessor #2 documented the patient had written several suicide letters to family while waiting at the facility, was "gravely disabled" and "highly escalated."

During an interview with Assessor #2, on 5/2/18 at 4:04 p.m., she stated she had spoken with a representative from Patient #8's insurance company who instructed Assessor #2 to transfer the patient to the emergency room (ER) at an acute care hospital for medical clearance for another facility.

An Emergency Medical Services (EMS) consent form, provided by an ambulance company contracted by the facility, showed Patient #8 was transferred to the ED of an acute care hospital via ambulance on 2/18/18 at 10:01 p.m. Patient #8 did not sign the form, nor did any facility staff or physicians.

Review of Patient #8's chart revealed no facility initiated transfer forms were provided or completed regarding her transfer to the the acute care hospital. Additionally, there was no documentation of risks or benefits of the transfer or signature of a transferring physician. There was no documentation the facility communicated with the receiving facility regarding Patient #8 prior to her transfer. This was in contrast to the facility's policy which stated the facility should have sent all records with the patient, and should have called in advance to ensure the receiving hospital had the capacity to accept the transfer.

b. Review of the Call Log showed Patient #29 was dropped off at the facility by a family member on 2/2/18 at 1:00 p.m. According to the Call Log, the patient was having suicidal ideation with "some thoughts on different plans." On 2/2/18 at 2:57 p.m., Assessor #5 completed an M1 application. The M1 application stated the patient had suicidal thoughts. Assessor #5 documented on the Call Log she spoke with Patient #29's insurance company, who requested the patient be sent to the ED for an assessment of level of care. Patient #29 was transferred at 3:35 p.m. via non-emergency ambulance to the emergency department of an acute care hospital.

Assessor #5 documented the facility received a call from the recipient ED after Patient #29's arrival, in which the recipient facility asked why the patient was sent to the ED. In response to this phone call, Assessor #5 documented in the Call Log on 2/2/18 at 5:34 p.m., she faxed Patient #29's assessment to the recipient facility, "as the patient was on M1 hold from us." There was no documentation in the medical record the facility notified or communicated with the receiving facility of Patient #29's transfer prior to the phone call. Additionally, there was no documentation of risks or benefits of the transfer and signature or certification from the transferring physician.

Physician #3, who was the medical director of the facility, was interviewed on 5/3/18 at 8:03 a.m. During the interview, he stated when patients were transferred to acute care facilities, the medical records should have been sent with the patient. He also stated an order for transfer should have been obtained and documented prior to transferring the patient to another facility.

c. Review of the Call Log showed that Patient #30 arrived at the facility on 2/1/18 as an unscheduled walk-in. The actual time of his arrival was uncertain; however, the first entry on the Call Log for Patient #30 was made on 2/1/18 at 4:25 p.m. According to the Call Log, the the A & R team was not advised of his arrival. After an unspecified wait period, he was found asleep in the main lobby at 6:25 p.m. He was then taken to the A & R area for vital signs and a breathalyzer test. The breathalyzer revealed Patient #30 had a blood alcohol level (BAL) 0.29, which indicated alcohol intoxication (values greater than 0.08 considered intoxicated).

Review of the Initial Medical Screening Assessment Information form revealed Assessor #4 documented Patient #30's BAL; however no vital signs or any other assessment information was documented.

Assessor #5 documented at 7:01 p.m. on the Call Log she called Physician #4 who advised her to transfer Patient #30 to the ED via non-emergent transport. At 7:26 p.m., Patient #30 left the facility. There was no documentation the facility notified the receiving hospital of Patient #30's transfer nor was any documentation found the patient was informed of the risks and benefits of transfer.

During an interview conducted with the Director of Quality (Director #6) on 5/3/18 at 2:41 p.m., she stated a BAL of 0.29 would be a medical emergency. However, there was no documentation Patient #30 was assessed or stabilized by a physician or registered nurse while awaiting transport to an acute care facility. Further, there was no documentation that staff at the facility communicated with the recipient facility regarding the transfer.

d. An interview with Assessor #1 was conducted on 5/2/18 at 12:58 p.m., in which he stated it was a courtesy to contact the acute care hospital before transferring a patient for medical reasons. He stated sometimes he would call the psychiatric assessment team prior to transfer, but never the nurses' station or attending ED physician. He also stated he would not send the patient's records with the patient when transferring to another facility. He stated he did not believe he was allowed to send medical records with the patient, since they had not been admitted as inpatient by the facility.

e. An interview with the Director of A & R (Director #8) was conducted on 5/3/18 at 1:15 p.m. She stated she expected staff to notify the receiving facility, and then document that notification and what documents were sent with the patient. She stated a complete medical screening or refusal should have been included with the documents sent to the facility.

f. An interview with the medical director (Physician #3) was conducted 5/3/18 at 8:03 a.m. He stated he expected staff to follow EMTALA regulations. He stated staff should have sent medical records with the patients, or any documentation regarding the patient from the facility.