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Based on record review the hospital failed to comply with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases for three of three sample patients (4, 12, and 14) that presented to the emergency room (ER) for treatment. Findings include:

1. Review of the ER record revealed a medical screening had not been completed for one of one sampled patient (13) after waiting approximately 59 minutes. The patient had left the hospital against medical advice (AMA). Review of the documented entrance complaint revealed the patient had requested he be sent for alcohol detoxification treatment. Review of the medical record revealed continuous monitoring of the patient had not been documented. Refer to C2406, finding 1.

2. Review of the ER record for one of one suicidal patient (4) revealed he had threatened suicide with a gun while intoxicated. The patient was discharged and transferred to a rehabilitation facility via private car by a family member. Review of the patient's alcohol level was 381 milliliters per deciliter (mg/dl) upon admission. The provider's plan of correction for the Emergency Medical Treatment and Active Labor Act (EMTALA) survey conducted on 7/10/12 revealed an alcohol level should have been 0.08 mg/dl at the time of discharge. Refer to C2409, finding A1.

3. Review of the ER records revealed an appropriate transfer had not been arranged for two of two sampled patients (12 and 14) that presented with alcohol withdrawal symptoms. After the emergency medical condition had been evaluated and medications administered for alcohol withdrawal symptoms both patients had been returned to jail to await transfer for aftercare at another healthcare facility. Refer to C2409, findings A2 and A3.

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Based on record review and interview, the provider failed to ensure a medical screening evaluation was conducted for one of one sampled patient (13) that left against medical advice. Findings include:

1. Review of the emergency room (ER) record for patient 13 revealed:
*He had presented to the ER on 11/29/12 at 10:26 a.m. requesting to be sent to a rehabilitation facility for detoxification. The patient had complaints of vomiting and abdominal pain. He stated he had "Drank beer this morning to get rid of shaky feeling" and "He was drinking very steady for last 2 weeks ate very little during that time."
*At 10:30 a.m. his vital signs were temperature 97.8 degrees Fahrenheit, pulse 80, respirations 20, blood pressure 158/101, and his oxygen saturation was 96 percent.
*At 10:40 a.m. the physician was notified of the patient's arrival.
*At 11:00 a.m. the patient's sister was making calls to Indian Health Service and Dakota Pride. No results of those phone calls were documented.
*At 11:25 a.m. AMA (against medical advice) had been documented. The patient and his sister were gone, the waiting areas were checked, and no one was present.
*The patient had been at the facility for approximately 59 minutes, and only one set of vital signs had been documented.
*The entrance complaint was the last documentation of the patient's condition noted in the ER record for the complaints stated above.
*There was no documentation in the medical record the patient had been advised of a waiting time, or why, and how much longer before the physician would have seen him.
*There was no documentation the provider had attempted to make transfer arrangements for detoxification for him.

Interview on 1/9/13 at 8:00 p.m. with the assistant director of nursing regarding patient 13 revealed:
*The patient had waited approximately 59 minutes without being examined by the physician.
*She did not know why the patient had waited that amount of time without being seen.
*A review of the emergency log book for that date revealed the ER was not busy during the patient's visit. From 10:50 a.m. until 11:32 a.m. a patient with a ruptured appendix had been transferred, but that did not explain the amount of time patient 13 had waited. The next patient had arrived at 11:34 a.m. which was after patient 13 had left AMA.
*AMA charts were reviewed monthly and the reason for the AMA identified was the long waiting time, the patient symptoms get better or had gone away, or they just left without staff knowledge.

A. Based on record review, interview, and policy review, revealed the provider failed to ensure:
*The plan of correction for the 7/10/12 Emergency Medical Treatment and Active Labor Act (EMTALA) survey was fully implemented for three of three sampled patients (4, 12, and 14).
*An appropriate transfer was arranged for two of two sampled patients (12 and 14) that presented with alcohol withdrawal symptoms and for one of one reviewed suicidal patient's (4) chart. Findings include:

1. Review of the emergency room (ER) note dated 1/6/13 for patient 4 revealed he had presented to the ER after drinking daily since Christmas and was very intoxicated. "He took out a gun tonight and wanted to shoot himself." "He has no other complaints."

Review of the ER record for patient 4 revealed:
*His alcohol level at 2:18 a.m. was 381; the normal range is 0.0 - 80.0 milligrams/deciliter (mg/dl).
*He was transferred on 1/6/13 at 3:20 a.m. to a treatment facility via private car by a family member.
*The mental health assessment form had not been completed by physician C.
*The Release of Responsibility Authorization/Certification for Transfer form had not been completed at the time of the transfer.

Review of a Release of Responsibility Authorization/Certification for Transfer form revealed it would have contained the physician's certification for transfer, the patient's consent to transfer, and identified which parts of the patient's medical record had been sent to the receiving facility.

Review of the provider's 7/10/12 EMTALA surveys plan of correction with a correction date of 11/15/12 revealed:
*"When patients present in the ER for suicide attempts due to alcohol and/or drug overdose a laboratory screening will be conducted. Prior to discharge the on-call medical staff member will also order another alcohol level to be conducted by the lab."
*The patients should have an alcohol level of 0.08 mg/dl at the time of their discharge.

Interview on 1/9/13 at 8:00 a.m. with the acting director of nursing (ADON) regarding patient 4 revealed:
*The provider's plan of correction (POC) dated 11/14/12 for the 7/10/12 EMTALA had not been fully implemented for the patient.
*There was no alcohol level obtained prior to the patient's discharge.
*The patient had been discharged prior to his alcohol level decreasing to 0.08 mg/dl.
*Having the patient's family member transport him to the rehabilitation facility might not have been the best method of transport. But she thought the patient's family member was in control of the situation.

Review of the provider's emergency management of psychiatric patients revised 11/14/12 revealed:
*The purpose of the policy was to establish guidelines for the emergency management of a patient with a serious disturbance of behavior, affect, or thought processes which makes the patient unable to cope with their life situation and interpersonal relationships."
*Suicidal patients were admitted to the unit for observation or transferred to a psychiatric unit.
*"If alcohol and/or drug use is suspected, screening on admit and discharge will need to be performed. The patient will be observed until ETOH level is below 0.08."
*"When patient presents to the hospital with a severe mental illness or behavioral issue, a mental health assessment form needs to be completed by a qualified mental health professional."

Review of the provider's EMTALA policy revised on 5/20/12 revealed "A release of Responsibility Authorization/Certification for Transfer will be filled out for all transferred patients from the emergency room."

2. Review of patient 12's medical record revealed on 11/26/12 at 4:50 p.m. he was brought to the ER by the county jailer. The patient had been in custody since 11/21/12. His diagnosis was listed as alcohol withdrawal symptoms.

Review of patient 12's documented entrance complaint revealed:
*The patient had been punching the wall last night.
*He answered questions appropriately.
*The right third knuckle was swollen and reddened.
*His last drink was on 11/21/12.
*The patient had started punching the walls at the jail yesterday when taken to Indian Health Services for "seizure medications."

Review of the physician's record/treatment documentation regarding patient 12 revealed:
*Nonsensical speech, talking to himself, knew Obama was president but did know the month, date, or year.
*He reported staying in his sister's basement the past week but in reality he had been in jail the entire time.
*An attempt was made to make arrangement for "detox" without success.
*The patient was stable and docile at the hospital.
*There was no assessment documented for the condition of the patient's right third knuckle.

Review of the instructions to the patient revealed:
*"Sent with Ativan 0.5 mg (milligram) #8 - to take 1 mg (2 tab) every 6 hours as needed for anxiety. May take extra dose in 4 hours if needed.
*Continue Keppra 500 mg twice daily."

Review of patient 12's laboratory results revealed the alcohol and drug screen completed had been negative.

Review of patient 12's ER assessment form dated 11/26/12 revealed:
*At 6:50 p.m. he had been moved to room 6 with the "jailer" at the bedside.
*At 7:40 p.m. the patient was fidgeting on the cot.
*At 8:15 p.m. the patient's tremors and/or fidgeting had increased, and he had been administered Ativan orally.
*At 9:00 p.m. the patient appeared "Calmer, eyes closed, lips moving as though speaking but no sound audible. Physician B was discussing the plan of care and patient's ____ (unable to read witting) safety needs with ____ (jailer's name). Nursing staff unable to provide one-on-one monitoring required. Jail would be able to provide safer environment and monitoring and able to administer medications."
*At 9:10 p.m. the patient left ambulatory accompanied by the jailer.

Review of physician B's progress note dated 11/27/12 at 9:30 a.m. revealed "Arrangements made for pt (patient) to go to Detox at _________ (hospital name). _______ (name of transporter) will transport him. Dr. ______ (doctor's name) accepting physician Will try to make arrangement for ______ (facility name) past Detox."

Review of the Release of Responsibility Authorization/Certification for Transfer form revealed:
*The form had originally been dated 11/26/12, and an unknown person had changed the date to 11/27/12.
*The accepting physician's name had been documented and the name of the accepting facility.
*The time of acceptance had not been documented.
*Vitals signs had been documented and were timed for 9:00 p.m. on 11/26/12, the day prior when he had been returned to the jail.
*The responsible person signing the form had been the county officer.
*Physician B had signed and dated the form on 11/27/12 at 9:32 a.m.
*A staff nurse had signed the form, but there was no date and time.

Interview on 1/9/13 at 8:00 a.m. with the ADON regarding patient 12 confirmed:
*The patient had been calm, noncombative, and cooperative while at the hospital.
*Physician B had documented the patient was calm and docile while in the hospital.
*The facility had the capacity and capability of caring for the patient until his transfer to the treatment facility the next morning.
*Physician B had documented in a progress note dated 11/27/12 transfer arrangement had been made.
*The county officer had signed the certificate of transfer form, but there was no date and time for the signature on that form.
*Physician B had signed the certificate of transfer form on 11/27/12 at 9:32 a.m.
*The patient had been sent back to jail on 11/26/12. He had never been returned to the facility for an evaluation by a physician and/or practitioner prior to his transfer to the treatment facility.
*Without that evaluation the condition of the patient at the time of the transfer would not be known.
*The certificate of transfer form had been incorrectly completed by hospital staff, there was no documentation what medical records had been sent with the patient, and maybe that form should not have been completed. The patient had been discharged from the facility the day before the staff had completed that form.

Interview on 1/9/13 at 11:45 a.m. with physician B regarding patient 12 revealed:
*The patient was calm and docile while in the hospital.
*The patient was stable and thought it was best to send the patient back to jail and wait for transfer.
*The county officer had called requesting additional medication for the patient, she had made arrangement for the patient transfer to the treatment facility, but had not evaluated the patient prior to the transfer.
*She trusted the county officer decision to transport the patient without being evaluated first; that was what they did all the time.
*It would not have been cost-effective for the county to keep the patient overnight until his transfer in the morning.

3. Review of patient 14's ER record revealed:
*On 12/04/12 at 6:07 p.m. he had presented to the ER stating "I think I'm having DTS [delirium tremens]. Nursing documentation indicated "Only had a couple beers today so I could get the voices out of my head. I left _______ (healthcare facility) and have been drinking 3 wks (weeks) straight maybe more."
*On 12/5/12 at 6:06 p.m. the patient was handcuffed and taken to jail.

Review of patient 14's physician's ER Note dated 12/5/12 revealed:
*The patient was homeless, involuntary commitment paperwork had been completed in the past, but the had patient voluntarily entered rehabilitation back in October 2012.
*He had been in the ER several times prior to last night and usually had alcohol levels in the 400s, 500s and 600s.
*He mumbled answers to questions and admitted to seeing things.
*Assessment indicated recurrent severe liver alcoholic probable hepatitis, long standing alcoholism, and homelessness.
*Plan was for involuntary commitment.

Review of the patient's laboratory summary dated 12/4/12 revealed the ethyl alcohol level was 402, normal range being 0.0 - 80.0 mg/dl. No additional ethyl alcohol level was obtained prior to the patient being transferred to the jail.

Review of patient 14's ER record revealed:
*The certification of qualified mental health professional or physician form had been completed.
*The petition for emergency commitment form had been completed.
*No progress notes were written for the patient. There was no documentation in the medical record why the patient had been transferred to the jail

Interview on 1/9/13 at 8:00 a.m. with the ADON regarding patient 14 revealed:
*The plan had been to transfer the patient to a treatment facility in the morning.
*Commital paperwork for the patient had been completed.
*The patient was calm and not combative.
*The patient had been at the hospital for approximately 24 hours, and there was no alcohol level obtained prior to the patient's discharge.
*She was not aware of a reason why the patient could not have been monitored in the hospital rather than going to the jail.

Interview on 1/9/13 at 1:30 p.m. with physician A did not reveal a reason why the patient had been sent to jail rather than to continue monitoring in the hospital. Physician A stated there were times when it was difficult to find placement for individuals requiring additional treatment after they were stable.

Review of patient 14's physician's orders dated 12/4/12 at 7:45 p.m. revealed:
*Ativan one milligram was to be administered "now" and then every six hours for withdrawal symptoms.
*Alcohol level, hemogram, complete metabolic panel, and an order to notify the attorney for protocol instructions.
*No further physician's orders were noted in the patient's medical record after 12/4/12.
*No order for the patient's discharge.

Review of patient 14's nurse's notes for 12/4/12 revealed:
*8:05 p.m. patient lying in bed with bible on chest stating he was seeing his "Grandma's ghost" and "his mind was racing." Ativan was administered orally as scheduled.
*10:00 p.m. patient stated he was seeing jack rabbits in his bed. Patient was sleeping upon staff entering room.

Review of patient 14's nurse's notes for 12/5/12 revealed:
*2:00 a.m. patient had complained his thoughts were racing again but denied hallucinations. Scheduled Ativan was administered.
*3:00 a.m. to 6:40 a.m. patient resting, eyes closed, and snoring respirations.
*8:02 a.m. patient complain "His insides are shaking," Ativan 1 mg administered.
*8:40 a.m. patient stating he felt better than last night, he had stopped taking his Seroquel one month ago because it had been affecting his sleep, denied suicidal tendency, and "Coming down after drinking."
*9:55 a.m. Chemical dependency placement attempted at ________ (facility name), but there was a waiting list. "We will need to file a petition for chemical dependency with the Clerk of Courts for committal."
*10:20 a.m. transport officer arrived, acknowledged need to deliver papers to Clerk of Courts and attorney for committal. Physician A stated "Alcohol level determined, pt (patient) will have level of 80 at 1430 (2:30 p.m.), sober at 2230 (10:30 p.m.) tonite." Physician A stated "Pt has had repeated dangerous alcohol levels, and may be a danger to self, will need to proceed with process of involuntary committal."
*11:10 unable to reach ______ (person name) for evaluation, she was out of town, and no one was covering.
*11:25 Physician A notified unable to reach individual to complete evaluation. Physician A stated "The jail will have to keep patient until next week if chemical dependency petition does not go through."
*11:33 a.m. musculoskeletal, psychosocial, and neurovascular findings abnormal - "Slight shakiness noted to hands, avoids eye contact, and left grip weak, right grip weak."
*11:35 a.m. patient eating, denied nausea, felt achy, and stated "This is not new as it happens when he has been drinking."
*2:01 p.m. complained of feeling "Anxious and shakey inside." Ativan 1 mg was administered as scheduled.
*3:57 p.m. patient stated "He was feeling better and not quite as jittery."
*6:06 p.m. officer arrived to transport patient from hospital to jail. "The current plan is for this patient to then be transported to _________ (treatment facility name) in the morning. Patient is calm and does not resist the handcuffs that are placed on his wrists and ankles. Vitals are taken on patient and are all within normal limits. Patient leaves with ofc. _____ (officer name) without confrontation."

B. Based on record review, interview, and policy review, revealed the provider failed to ensure:
*The plan of correction for the 7/10/12 Emergency Medical Treatment and Active Labor Act (EMTALA) survey was fully implemented for two of two sampled patients (1 and 4) presenting to the ER for treatment.
*The physician certification for transfer had been obtained and documented in one of one patient (1) transferred to another healthcare facility for detoxification treatment.
*The patient consent for transfer was obtained and documented for one of one patient (1) transferred to another healthcare facility for detoxification treatment.
*The risks associated with a transfer had been identified and documented for one of one patient (1) transferred to another healthcare facility for detoxification treatment.
*To ensure medical records relating to the emergency condition was sent to the receiving facility for two of two patients (1 and 4) transferred to another healthcare facility for detoxification treatment.
Findings include:

1. Review of patient 1's ER record revealed he had presented to the ER on 1/7/13 at 7:17 a.m. with complaints of shakiness and needing to go to "Detox" (detoxification). The patient was unable to recall when his last drink was, and he had been in a rehabilitation facility twice in the past.

Review of patient 1's physician's ER note dated 1/7/13 revealed diagnoses of alcoholism and a urinary tract infection. The ER note indicated "He has been drinking weekly and pretty heavy. Drank heavy for the last two days and he needs to get to Detox."

Review of the ER assessment form dated 1/7/13 revealed at 9:40 a.m. the patient had been accepted at a rehabilitation facility and transportation had been arranged.

Review of patient 1's ER record did not reveal the Release of Responsibility Authorization/Certification for Transfer form used by the facility to document:
*The physician certification of stability for transfer.
*The patient's consent for transfer.
*The risks and benefits of the transfer.
*What medical records had been sent with the patient at the time of the transfer.

2. Review of patient 4's ER record revealed the Release of Responsibility Authorization/Certification for Transfer form had been completed on 1/6/13. The section to document which medical records had been sent with the patient at the time of transfer had not been completed.

3. Review of patient 12's medical record revealed a Release of Responsibility Authorization/Certification for Transfer form had been signed on 11/27/12, the day after the patient had been discharged from the facility. Review of that form revealed:
*The date had been changed from 11/26/12 to 11/27/12.
*The time the receiving physician had accepted the patient had not been documented.
*The section to document what medical records had been sent with the patient at the time of discharge had not been completed.
*The section to document who the medical records had been sent with had not been completed.
*The date and time the provider staff had signed that form had not been completed.

4. Interview on 1/9/13 at 8:00 a.m. with the ADON confirmed:
*The Release of Responsibility Authorization/Certification for Transfer form
was not in patient 1's medical record. Without that form there would not be documentation of the physicians's transfer, the patient's consent for transfer, and the risks and benefits identified for the patient's transfer.
*There was no documentation on the Release of Responsibility Authorization/Certification for Transfer form identifying what medical records had been sent with patients 4 and 12 at the time of the transfers.
*The Release of Responsibility Authorization/Certification for Transfer form for patient 12 had been signed by the individual responsible for the patient on 11/27/12, the day after the patient had been discharged from the facility. That transfer form had been incorrectly completed or maybe should not have been completed for that patient.