HospitalInspections.org

Based on a review of the 2/21/2021 video recording, review of medical records, review of Medical Staff Rules and Regulations, review of policy and procedure, tour and observations, interviews, review of ED (Emergency Department) staffing schedule, review of the ED physicians' schedule, review of the current Medical Staff Roster, it was determined that the facility failed to provide appropriate treatment within its capacity and capability for one (1) out of 20 sampled patients (Patient #20) when Patient #20 presented to the ED on 2/21/2021 with a Crisis Counselor and Sheriff Officer for treatment for suicidal ideations.

Findings were:

Cross refer to A-2406, as it relates to the facility's failure to provide Patient #20 with an appropriate Medical Screening Examination.
Cross refer to A-2407, as it relates to the facility's failure to provide stabilizing treatment for Patient #20.
Cross refer to A-2409, as it relates to the facility's failure to provide an appropriate transfer for Patient #20.

Based on a review of the facility's ED (Emergency Department) Central Log, review of policy and procedure, and interviews, it was determined that the facility failed to make a Central Log entry for one (1) out of 20 sampled patients (Patient #20) when Patient #20 presented to the ED on 2/21/2021 with a Crisis Counselor and Sheriff Officer for treatment for suicidal ideations.

Findings were:

On 3/2/2021 at 8:35 a.m., in the ED lobby, ED Nurse Director CC stated that she was aware that a patient had been brought to the ED on a 1013 (form completed by a licensed Physician, licensed Psychologist, Licensed Clinical Social Worker, or Psychiatric Clinical Nurse Specialist that allows an individual to be transported to receive evaluation when the individual poses a threat to self or others), that this facility was not an Emergency Receiving Facility (ERF), that the patient had refused treatment, and that the facility could not treat the patient against his will.
A review of the facility's ED Central Log failed to reveal a log entry for Patient #20 on 2/21/2021. The ED Central Log revealed there were three (3) patients in the ED at the time Patient #20 arrived at the ED on 2/21/2021.

POLICIES AND PROCEDURES
Review of undated facility policy entitled "Registration of Emergency Patients Policy", policy number 900-001, policy number 900-011 revealed "all components of registration were to be completed when patients present for services. Patients presenting to the ED will be greeted by the Guest Service Technician or Outpatient Registration clerk or ED nurse and entered into the ED Tracker."

In an interview which occurred during a tour of the ED on 3/2/2021 at 9:30 a.m. the Guest Services Technician EE explained that when a Sheriff Officer brings a patient in, she enters the patient's name, date of birth, and chief complaint into the electronic record which initiates the medical record and enters the patient into the Central Log, and then she notifies the triage nurse.

During a telephone interview on 3/2/2021 at 11:45 a.m. RN FF explained that Patient #20 was not entered into the Central Log because Patient #20 refused treatment.

Based on a review of the facility's Emergency Department (ED) Central Log, review of the 2/21/2021 video recording, review of Medical Staff Rules and Regulations, review of policy and procedure, interviews, review of the ED physicians' schedule, review of the current Medical Staff Roster, and review of credential files, it was determined that the facility failed to provide an appropriate medical screening exam for one (1) of 20 patients (Patient #20) when Patient #20 presented to the ED on 2/21/2021 with a Crisis Counselor and Sheriff Officer for treatment for suicidal ideations.

Findings were:

On 3/2/2021 at 8:35 a.m., in the ED lobby, ED Nurse Director CC stated that she was aware that a patient had been brought to the ED on a 1013 (form completed by a licensed Physician, licensed Psychologist, Licensed Clinical Social Worker, or Psychiatric Clinical Nurse Specialist that allows an individual to be transported to receive evaluation when the individual poses a threat to self or others), that this facility was not an Emergency Receiving Facility (ERF), that the patient had refused treatment, and that the facility could not treat the patient against his will.

A review of the ED video recording for Patient #20 revealed the following:

--On 2/21/2021 at 1:12 a.m. Sheriff Officer JJ walked into the ED with patient #20 and Crisis Counselor KK. All three (3) men went to the registration desk. At 1:15 a.m., the ED waiting room was empty except for Sheriff Officer JJ who was standing across from the registration desk, Crisis Counselor KK who was pacing in the ED waiting room, and Patient #20 who was out of the view of the camera. At 1:19 a.m. Crisis Counselor KK sits down in the ED waiting room. At 2:20 a.m. Crisis Counselor KK and Sheriff Officer JJ go around the corner to the desk and speak with Registered Nurse (RN) GG. At 1:22 a.m. RN GG speaks with Patient #20, Crisis Counselor KK, and Sheriff Officer JJ. At 1:23 a.m. Crisis Counselor KK walks toward the ED exit and Sheriff Officer JJ paces the ED waiting room, both appear to be on their phones and Patient #20 sits down in the ED waiting room. At 1:24 a.m. Patient #20, Sheriff Officer JJ, and Crisis Counselor KK leave the ED. At 1:29 a.m. Crisis Counselor KK returns to the ED waiting room and paces. At 1:30 a.m., Sheriff Officer KK and Patient #20 go outside, Patient #20 gets into the Sheriff Officer JJ's car and Sheriff Officer JJ is observed standing outside the ED pacing and talking on his phone. At 1:32 a.m. RN FF is observed talking with Crisis Counselor KK. At 1:35 a.m. Sheriff Officer JJ gets into his car; Crisis Counselor KK is in the ED waiting room pacing and RN FF is standing at the ED desk. At 1:38 a.m. RN FF is talking with Crisis Counselor KK. At 1:39 a.m. Crisis Counselor KK leaves the ED. At 1:47 a.m. Crisis Counselor KK can be seen driving off in a red car and Sheriff Officer JJ gets into the patrol car and leaves with Patient #20.
A review of the Medical Staff Rules and Regulations approved 9/11/2018, revealed the following:
4.0 ARTICLE IV. EMERGENCY DEPARTMENT
4.1.4 An MSE (Medical Screening Examination) is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition (EMC) or not. The MSE can be performed by a licensed physician, mid-level provider (Nurse Practitioner or Physician's Assistant), or an RN that the facility has designated and identified as qualified to perform an MSE. These designated RN qualifications will be approved annually by the Medical Executive Committee.
Review of facility policy entitled "EMTALA (Emergency Medical Treatment and Labor Act): (Transfer Policy and Medical Screening Exam MSE) ", policy number 7325761, last approved 6/2020, revealed the purpose was to "establish clinical guidelines for MSE, stabilization, and safe appropriate transfer of patients to other facilities in compliance with EMTALA. This policy required any patient that presents to the ED or who developed an EMC to be provided with an appropriate MSE. The MSE and stabilization shall be performed in accordance with EMTALA regulations.
DEFINITIONS OF TERMS:
--EMC: A medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in:
A. Placing the health of the individual in serious jeopardy
B. Serious Impairment of bodily functions, and
C. Serious dysfunction of any bodily organ or part.
--PSYCHOLOGICAL:
With respect to psychiatric EMCs: Patients expressing suicidal or homicidal thoughts or deemed to be a danger to self or others, would be considered to have an EMC.
--MSE: All patients must receive an MSE within the capabilities of the hospitals' dedicated emergency department (DED) to determine whether or not an EMC existed.
Neither the MSE nor the necessary stabilizing treatments shall be delayed in order to inquire about the individuals' method of payment, insurance status, or in order to obtain prior authorization. The MSE will not be delayed by the registration process.
A. The purpose of the MSE is the process required to reach, with clinical confidence, whether the individual has an EMC or not. The MSE is an ongoing process and it determines the needs for services (i.e., labs, x-rays, or other ancillary services) as well as the presence or absence of an EMC.
B. If an individual presents to the DED and the nature of the individual's requests for treatment makes it clear that the condition is not an emergency, the hospital is required only to perform such screening as would be appropriate for any individual presenting in the manner to determine that the individual does not have an EMC.
C. The medical screening exam will be performed by Qualified Medical Personnel (QMP).
QMPs include physicians, Physicians Assistants, and Nurse Practitioners. Patients will be medically screened in the order of acuity of their symptoms as determined by triage.
D. All patients that have received an MSE and have been deemed as not having an EMC, shall be advised of the available treatment options for their appropriate level of care. Options include the convenient care center, the patient's primary care provider, or the ED.
E. In providing an MSE, the hospital shall not discriminate against any individual because of diagnosis, financial status, race, color, national origin, or handicap.

INTERVIEWS:
During a telephone interview on 3/2/2021 at 11:45 a.m. RN FF explained that on 2/21/2021 he was called to the waiting room to speak with Crisis Counselor KK.
RN FF said Patient #20 was not in the lobby at this time. He confirmed that RN GG had already spoken with Patient #20. RN FF said Crisis Counselor KK informed him (RN FF) that Patient #20 had a signed 1013 form prior to arrival in the ED. RN FF said that while he was speaking with Crisis Counselor KK the Counselor was on Speakerphone with a lady informing her that the facility was refusing to see Patient #20. RN FF said he was able to hear both sides of the conversation and that he replied loudly enough for the lady on the phone to hear that the facility was not refusing Patient #20, that this facility is not an ERF, and that they could not hold Patient #20 against his will. RN FF said the lady on the phone confirmed that this facility is not an ERF. RN FF said he informed Crisis Counselor KK a second time that Patient #20 was not being refused but that the facility is not an ERF and that they could not hold Patient #20 against his will but would provide services if Patient #20 would agree to be treated. RN FF said the lady on the phone then told Crisis Counselor KK that this facility is not an ERF and that she thought a nearby facility (the receiving facility) was an ERF. RN FF said Crisis Counselor KK turned and left the ED abruptly. RN FF said Patient #20 was not entered into the Central Log because the patient refused treatment. RN FF said that he usually has a patient or representative sign-in for further treatment if the patient agrees to be seen or has a refusal of care form signed. RN FF said he receives EMTALA training annually through HealthStream (the facility's electronic training system).
During a telephone interview on 3/2/2021 at 12:40 p.m., Supervisor LL of the Behavioral Health Liaison (BHL) company explained that Crisis Counselor KK called her from the facility's ED on 2/21/2021.
She explained that Crisis Counselor KK informed her that he could not leave Patient #20 because the facility reportedly was not an ERF. Supervisor LL went on to explain that she listed different places Crisis Counselor KK could take Patient #20 and it was decided that Patient#20 could be taken to a nearby hospital (the receiving facility) because she thought it was an ERF.

During a telephone interview on 3/2/2021 at 3:30 p.m., Sheriff Officer JJ explained that on 2/21/2021 he picked Patient #20 up at the patient's residence and transported the patient to the ED. Sheriff Officer JJ said Crisis Counselor KK had already filled out the 1013 form. Sheriff Officer JJ stated Crisis Counselor KK told him to take Patient #20 to the facility's ED and when they arrived at the hospital a nurse (RN GG) informed them that the hospital "does not take 1013 patients". Sheriff Officer JJ said RN GG told Patient #20 he "could stay and be treated if he wanted to but that the ED could not hold him against his will". Sheriff Officer JJ explained that Crisis Counselor KK called his Supervisor and was told to take Patient #20 to the receiving facility. Sheriff Officer JJ confirmed that this was his first 1013 transport to this facility but that he had transported other 1013 patients to other hospitals and those hospitals had always accepted 1013 patients. Sheriff Officer JJ said this was the first time a facility's ED staff had reported that they could not take a 1013 patient.

During a telephone interview on 3/3/2021 at 9:55 a.m. in the Board Room, Crisis Counselor KK explained that on 2/21/2021 he was called to Patient #20's residence. Crisis Counselor KK said that when he arrived Patient #20 had a knife and was threatening to kill himself. Crisis Counselor KK said Patient #20 had been hospitalized in January 2021 for psychiatric issues. He went on to explain that on 2/21/2021 Patient #20 had cuts on his wrist and cigarette burns on the back of his hands and that when he entered Patient #20's bedroom he observed tablets strewn on the floor and Patient #20 reported that he had taken an overdose the night before. Crisis Counselor KK said he filled out a 1013 on Patient #20 because the patient was not willing to go to the hospital on his own. Crisis Counselor KK explained that when he, Sheriff Officer JJ, and Patient #20 arrived at the hospital he introduced himself to the registrar at the front desk and was informed that she would get a nurse to talk with him. Crisis Counselor KK said that a nurse (RN GG) came out and spoke directly with Patient #20. Crisis Counselor KK said RN GG did not allow him to give his report. Crisis Counselor KK said RN GG asked Patient #20 if he was willing to sign himself in and Patient #20 replied no. Crisis Counselor KK said he informed RN GG that he was not used to staff addressing a patient that was brought in on a 1013 and RN GG replied that the hospital's attorney had advised the staff that they could not keep a patient if the patient is not willing to stay because it violates the patient's rights. Crisis Counselor KK said he had never heard that before from any facility.

Crisis Counselor KK said he asked RN GG what he was supposed to do with Patient #20, and RN GG replied that the facility could not keep Patient #20 against his will because doing so would violate Patient #20's rights. Crisis Counselor KK said he called the receiving facility and spoke with the receiving facility's ED Charge Nurse who informed him that it was against the law for any hospital to refuse to provide care for a patient. Crisis Counselor KK said the receiving facility's Charge Nurse also told him that the physician on duty could fill out another 1013. Crisis Counselor KK said he went back into the ED and spoke with a nurse (RN FF) who informed Counselor KK that the facility could not keep Patient #20. Crisis Counselor KK said he spoke back and forth between the two (2) EDs and the receiving facility finally agreed to accept Patient #20 and told him that they were going to file an EMTALA against the facility. Crisis Counselor KK went on to explain that Sheriff Officer JJ could not take Patient #20 all the way to the receiving facility because it was out of his jurisdiction and that the officer had wanted to take Patient #20 back to his residence. Crisis Counselor KK said he was able to get Sheriff Officer JJ to drive to the county line and meet a receiving Sheriff Officer who then transported Patient #20 to the receiving facility. Crisis Counselor KK said he was just trying to get Patient #20 the care that he needed.
Crisis Counselor KK said that he has never had an ED refuse to accept an individual for any reason or had a nurse speak directly with a patient before he could give his report. Crisis Counselor KK said he usually gives his report once a patient has been taken to a room and the ED staff then take it from there. He said that it seemed to him that the ED "staff did not take care of Patient #20". He went on to say that every psychiatric facility asks that patients be medically cleared, and that Patient #20 had reportedly taken an overdose of medication.
Crisis Counselor KK said he was never given a chance to report this because RN GG told the patient he could leave if he wanted to. Crisis Counselor KK further stated allowing the patient to leave would have invalidated the 1013.
Crisis Counselor KK said that he has not received EMTALA training for the position he is in now, but that he previously did consulting for hospital EDs in Oregon and that he was familiar with EMTALA.

During a telephone interview on 3/3/2021 at 11:10 a.m., RN GG said that on 2/21/2021 she was notified by the registrar that someone had a question. She said she went out and saw Crisis Counselor KK, Sheriff Officer JJ, and Patient #20. RN GG said she was told Patient #20 was a 1013 for suicidal ideations. RN GG said she told Crisis Counselor KK and Patient #20 that the ED would be happy to see the patient, but Patient #20 said he did not want to be seen. RN GG said that she understood from Administration that this facility does not recognize 1013s because the facility is not an ERF. RN GG said staff had been told that they cannot hold a patient against his/her will because it violates the patient's rights. RN GG said she asked Patient #20 if he wanted to be seen and he said no. RN GG stated she has worked at other hospitals including psychiatric hospitals and this hospital does not recognize a 1013 the same as other hospitals. She explained that she has worked at this facility for almost 2 years and has been a nurse for 20 years. RN GG said the facility doesn't generally have 1013s come in the front door because most people know the facility is not an ERF.

RN GG explained that if a patient walks in stating they are going to hurt themselves the patient is taken to the back, provided an MSE by a provider, receives a telepsychiatry consultation, and the provider then places the patient on a 1013 hold. She said once the provider fills out the 1013 and there is an accepting facility the patient cannot leave and the patient is transported to a receiving facility by the police, however, if there is not an accepting facility the patient can leave if they want to as long as the patient is alert to person, place, and time. RN GG said that when law officers bring in a patient and the patient refuses to be seen, as long as the patient is of sound mind the facility cannot hold the patient against his will. RN GG said that if a patient is signed in and refuses care the patient is asked to sign an Against Medical Advice (AMA) form. She said that in this instance Patient #20 had not been registered (entered in the Central Log) and he refused to be seen, so there was no reason to get an AMA form signed. RN GG confirmed that she did not ask Crisis Counselor KK if he wanted Patient #20 to be seen because the patient had refused to be seen.

Other Documentation
A review of the ED physicians' schedule revealed ED Physician HH was the sole provider in the ED from 6:00 p.m. on 2/20/2021 through 6:00 a.m. on 2/21/2021.

A review of the current Medical Staff Roster revealed physicians HH and II (ED Medical Director) were currently ED providers.

Based on a review of the facility's policies and procedure, ED physician's schedule, and interviews, it was determined that the facility failed to provide stabilizing treatment for Patient #20 when Patient #20 was brought to the facility's ED on a 1013 by a Counselor and Sheriff Officer on 2/21/2021.

Findings were:

Review of facility policy entitled "Assessment of ER Patient", policy number 5714897, last approved 12/2018, revealed the policy was to "establish criteria for all ED patients. This policy required all patients presenting to the ED to be provided with a medical screening and triage according to the ED triage policy.
Documentation was to include:
--Chief complaint including subjective data (what the patient reports) and objective data (what the staff can verify using their five [5] senses),
--Psychological status,
--Vital signs, critical patients were to have their vital signs taken every 15 minutes until stabilized and then as needed,
--Allergies and medications,
--Medical history,
--Response to medication,
--Condition prior to discharge,
--Tetanus status,
--Patient education, and
--Pain scale.

Review of facility policy entitled "EMTALA: (Transfer Policy and Medical Screening Exam MSE) ", policy number 7325761, last approved 6/2020, revealed the purpose was to "establish clinical guidelines for MSE, stabilization, and safe appropriate transfer of patients to other facilities in compliance with EMTALA. This policy required any patient that presents to the ED or who developed an EMC to be provided with an appropriate MSE. The MSE and stabilization shall be performed in accordance with EMTALA regulations.

On 3/2/2021 at 8:35 a.m., in the ED, the ED Nurse Director stated that she was aware that a patient had been brought to the ED on a 1013 (form completed by a licensed Physician, licensed Psychologist, Licensed Clinical Social Worker, or Psychiatric Clinical Nurse Specialist that allows an individual to be transported to receive evaluation when the individual poses a threat to self or others), that this facility was not an Emergency Receiving Facility (ERF), that the patient had refused treatment, and that the facility could not treat the patient against his will.

During a telephone interview on 3/2/2021 at 3:30 p.m. in the Board Room, Sheriff Officer JJ explained that on 2/21/2021 he picked Patient #20 up at the patient's residence and transported the patient to the ED. Sheriff Officer JJ said Crisis Counselor KK had already filled out the 1013 form. Sheriff Officer JJ stated Crisis Counselor KK told him to take Patient #20 to the facility's ED and when they arrived at the hospital a nurse (RN GG) informed them that the hospital "does not take 1013 patients". Sheriff Officer JJ said RN GG told Patient #20 he "could stay and be treated if he wanted to but that the ED could not hold him against his will". Sheriff Officer JJ explained that Crisis Counselor KK called his Supervisor and was told to take Patient #20 to the receiving facility. Sheriff Officer JJ confirmed that this was his first 1013 transport to this facility but that he had transported other 1013 patients to other hospitals and those hospitals had always accepted 1013 patients. Sheriff Officer JJ said this was the first time a facility's ED staff had reported that they could not take a 1013 patient.
During a telephone interview on 3/3/2021 at 11:10 a.m., RN GG said that on 2/21/2021 met with Crisis Counselor KK, Sheriff Officer JJ, and Patient #20 when Crisis Counselor KK and Sheriff Officer JJ brought Patient #20 to the Emergency Department under a 1013. RN GG said she was told Patient #20 was a 1013 for suicidal ideations.
RN GG said she told Crisis Counselor KK and Patient #20 that the ED would be happy to see the patient, but Patient #20 said he did not want to be seen. RN GG said that she understood from Administration that this facility does not recognize 1013s because the facility is not an ERF. RN GG said staff had been told that they cannot hold a patient against his/her will because it violates the patient's rights. RN GG said she asked Patient #20 if he wanted to be seen and he said no. RN GG stated she has worked at other hospitals including psychiatric hospitals and this hospital does not recognize a 1013 the same as other hospitals. She explained that she has worked at this facility for almost 2 years and has been a nurse for 20 years. RN GG said the facility doesn't generally have 1013s come in the front door because most people know the facility is not an ERF. RN GG explained that if a patient walks in stating they are going to hurt themselves the patient is taken to the back, provided an MSE by a provider, receives a telepsychiatry consultation, and the provider then places the patient on a 1013 hold. She said once the provider fills out the 1013 and there is an accepting facility the patient cannot leave and the patient is transported to a receiving facility by the police, however, if there is not an accepting facility the patient can leave if they want to as long as the patient is alert to person, place, and time. RN GG said that when law officers bring in a patient and the patient refuses to be seen, as long as the patient is of sound mind the facility cannot hold the patient against his will. RN GG said that if a patient is signed in and refuses care the patient is asked to sign an Against Medical Advice (AMA) form. She said that in this instance Patient #20 had not been registered (entered in the Central Log) and he refused to be seen, so there was no reason to get an AMA form signed. RN GG confirmed that she did not ask Crisis Counselor KK if he wanted Patient #20 to be seen because the patient had refused to be seen.

A review of the ED physicians' schedule revealed ED Physician HH was the sole provider in the ED from 6:00 p.m. on 2/20/2021 through 6:00 a.m. on 2/21/2021.

Based on a review of the facility's ED (Emergency Department) video recording of 2/21/2021, Medical Staff Rules and Regulations, ED/Emergency Medical Services (EMS) Committee Meeting Minutes,Policies and Procedures, Patient's medical records, and interviews, it was determined that the facility failed to provide an appropriate transfer for three (3) out of 20 sampled patients (Patient #1, Patient #17, and Patient #20).

Findings were:

A review of the ED video recording for Patient #20 revealed the following:
--On 2/21/2021 at 1:12 a.m. Sheriff Officer JJ walked into the ED with patient #20 and Crisis Counselor KK. All three (3) men went to the registration desk. At 1:15 a.m., the ED waiting room was empty except for Sheriff Officer JJ who was standing across from the registration desk, Crisis Counselor KK who was pacing in the ED waiting room, and Patient #20 who was out of the view of the camera. At 1:19 a.m. Crisis Counselor KK sits down in the ED waiting room. At 2:20 a.m. Crisis Counselor KK and Sheriff Officer JJ go around the corner to the desk and speak with Registered Nurse (RN) GG. At 1:22 a.m. RN GG speaks with Patient #20, Crisis Counselor KK, and Sheriff Officer JJ. At 1:23 a.m. Crisis Counselor KK walks toward the ED exit and Sheriff Officer JJ paces the ED waiting room, both appear to be on their phones and Patient #20 sits down in the ED waiting room. At 1:24 a.m. Patient #20, Sheriff Officer JJ, and Crisis Counselor KK leave the ED. At 1:29 a.m. Crisis Counselor KK returns to the ED waiting room and paces. At 1:30 a.m., Sheriff Officer KK and Patient #20 go outside, Patient #20 gets into the Sheriff Officer JJ's car and Sheriff Officer JJ is observed standing outside the ED pacing and talking on his phone.
At 1:32 a.m. RN FF is observed talking with Crisis Counselor KK. At 1:35 a.m. Sheriff Officer JJ gets into his car; Crisis Counselor KK is in the ED waiting room pacing and RN FF is standing at the ED desk. At 1:38 a.m. RN FF is talking with Crisis Counselor KK. At 1:39 a.m. Crisis Counselor KK leaves the ED.
At 1:47 a.m. Crisis Counselor, KK can be seen driving off in a red car and Sheriff Officer JJ gets into the patrol car and leaves with Patient #20.

A review of the facility's Medical Staff Rules and Regulations approved 9/11/2018, revealed the following:
"4.3 TRANSFER OF PATIENTS
4.3.1 The ED physicians shall follow federal law, rules, and regulations regarding the appropriate transfer of patients.
10.0 ARTICLE XII. GENERAL
10.5 TRANSFERS
If a patient is to be transferred to another facility for the continuum of care, the transferring physician must evaluate the patient and sign the EMTALA consent form unless the physician cannot reach the hospital within 30 minutes and the patient's condition could worsen due to the delay."

A review of the ED/Emergency Medical Services (EMS) Committee Meeting Minutes from 1/2021 to present included the following:
1/27/2020 The ED Nurse Director CC informed the Medical Staff of the name of the Psychiatric Hospital that would be used.
10/26/2020 EMS the ED Nurse Director CC informed the Medical Staff that the ED has a contract with Behavioral Health Connections to provide psychiatric services.

Policies and Procedures:
Review of facility policy entitled "Left Without Being Seen", policy number 9247285, last approved 2/2021, revealed the policy was to "establish guidelines for the process and documentation requirements of patients who have left without being seen (LWBS). This policy indicated that any patient that presents to the ED and signs in, or any patient that has been triaged and placed back in the waiting room, to be called three (3) times at 15-minute intervals, and if no answer the staff was to document this in the medical record."
Review of facility policy entitled "EMTALA: (Transfer Policy and Medical Screening Exam MSE) ", policy number 7325761, last approved 6/2020, revealed the following:
--PSYCHOLOGICAL:
With respect to psychiatric EMCs: Patients expressing suicidal or homicidal thoughts or deemed to be a danger to self or others, would be considered to have an EMC.
--TRANSFER:
APPROPRIATE TRANSFER: A transfer to another medical facility will be appropriate only in those cases in which;
The transferring hospital:
A. Will provide medical treatment within its capacity that minimizes the risks to the individual's health and in the case of a woman in labor, the health of the mother and unborn child.
If the physician determines, through the hospital policy, that any patient should be transferred to another facility for further care, Consolidated Omnibus Budget Reconciliation Act (COBRA) standards must be followed. The COBRA form (Patient Transfer to Another Facility) must be completed by the nurse and physician. The physician must sign the COBRA form certifying that based upon the information available at the time of transfer; the medical benefits reasonably expected from the treatment at another facility outweigh the risks to the individual.
B. Sends the receiving facility all medical records related to the emergency at the time of transfer including all test results, labs, observations, signs and symptoms, diagnosis, and copy of the COBRA form.
C. Acceptance to the receiving facility must be made physician to physician with proper documentation including the accepting physician's name and phone number. Nurse to nurse report must be given with the receiving facility's nurse's name and phone number. The patient is to be made aware of the reason for the transfer by the ED Physician, Nurse Practitioner, or Physician Assistant. Consent for treatment will be obtained. The hospital staff must ensure that the receiving facility has available capacity and has agreed to accept the patient.
E. Documentation shall include but is not limited to; condition of the patient prior to transfer, vital signs prior to transfer, and documentation of whom the report was given.
F. The physician will determine the mode of transport, 911 will be contacted for all acute care transfers. The physician will determine the personnel and equipment needed for transport.
G. If the ambulance is currently unavailable to transport, the ED physician will be notified immediately and will determine if alternate means of transportation need to be implemented or if the patient is safe to wait for county ambulance transport. This information will be documented in the nurses' notes.
--Transfer of Patients Who Have Not Been Stabilized:
1. If a patient at the hospital has an EMC that has not been stabilized, the hospital may transfer the individual if the individual requests transfer or the expected benefits of the transfer to a facility with a higher level of care outweigh the increased risks of the transfer.
2. The receiving hospital must have the capability and capacity to treat the patient's EMC. The consent of the receiving hospital must be obtained and documented in the patient's medical record before transfer. The doctor to doctor and nurse to nurse contact must be made and documented along with their phone numbers on the COBRA form.
3. The hospital shall provide all available medical records to the receiving facility. The COBRA form must be completed and accompany the patient on transfer."
A hospital's EMTALA obligation ends when it has been determined that no EMC exists when the individual is appropriately transferred, the individual has been admitted as an inpatient, or when the EMC has been stabilized and the individual discharged home.

A review of sampled medical records revealed the following:

--Patient #1's medical record revealed the patient presented to the facility with suicidal ideations. Patient #1 received a Medical Screening Examination (MSE), stabilizing treatment, and was transferred to a Psychiatric facility. An RN signed the transfer form but there was no physician's signature.
--Patient #17's medical record revealed an adolescent patient was brought in for "cutting self". Patient #17 received an MSE, and stabilizing treatment, and she was transferred to a Psychiatric facility. The medical record failed to reveal a Transfer Form, and the facility was unable to locate the form. Documentation revealed Patient #17's record was faxed to the receiving facility.
Nurses' notes indicated that there was an accepting facility, accepting physician, nurse to nurse report and that the patient was transported by ambulance. The record failed to reveal evidence that the risks and benefits of transfer were addressed and provided to the patient prior to the transport.

Interviews:
During a telephone interview on 3/2/2021 at 11:45 a.m. RN FF explained that on 2/21/2021 he was called to the waiting room to speak with Crisis Counselor KK.
RN FF said Patient #20 was not in the lobby at this time. He confirmed that RN GG had already spoken with Patient #20. RN FF said Crisis Counselor KK informed him (RN FF) that Patient #20 had a signed 1013 form prior to arrival in the ED. RN FF said that while he was speaking with Crisis Counselor KK the Counselor was on Speakerphone with a lady informing her that the facility was refusing to see Patient #20. RN FF said he was able to hear both sides of the conversation and that he replied loudly enough for the lady on the phone to hear that the facility was not refusing Patient #20, that this facility is not an ERF, and that they could not hold Patient #20 against his will. RN FF said the lady on the phone confirmed that this facility is not an ERF. RN FF said he informed Crisis Counselor KK a second time that Patient #20 was not being refused but that the facility is not an ERF and that they could not hold Patient #20 against his will but would provide services if Patient #20 would agree to be treated. RN FF said the lady on the phone then told Crisis Counselor KK that this facility is not an ERF and that she thought a nearby facility (the receiving facility) was an ERF. RN FF said Crisis Counselor KK turned and left the ED abruptly. RN FF said Patient #20 was not entered into the Central Log because the patient refused treatment. RN FF said that he usually has a patient or representative sign in for further treatment if the patient agrees to be seen or has a refusal of care form signed. RN FF said he receives EMTALA training annually through HealthStream (the facility's electronic training system).

During a telephone interview on 3/3/2021 at 11:10 a.m. in the Board Room, RN GG said that on 2/21/2021 she met Crisis Counselor KK, Sheriff Officer JJ, and Patient #20 in the facility's ED. RN GG said she was told Patient #20 was 1013 for suicidal ideations. RN GG said she told Crisis Counselor KK and Patient #20 that the ED would be happy to see the patient, but Patient #20 said he did not want to be seen. RN GG said that she understood from Administration that this facility does not recognize 1013s because the facility is not an ERF. RN GG said staff had been told that they cannot hold a patient against his/her will because it violates the patient's rights. RN GG said she asked Patient #20 if he wanted to be seen and he said no. RN GG stated she has worked at other hospitals including psychiatric hospitals and this hospital does not recognize a 1013 the same as other hospitals. She explained that she has worked at this facility for almost 2 years and has been a nurse for 20 years. RN GG said the facility doesn't generally have 1013s come in the front door because most people know the facility is not an ERF.
RN GG explained that if a patient walk in stating they are going to hurt themselves the patient is taken to the back, provided an MSE by a provider, receives a telepsychiatry consultation, and the provider then places the patient on a 1013 hold. She said once the provider fills out the 1013 and there is an accepting facility the patient cannot leave and the patient is transported to a receiving facility by the police, however, if there is not an accepting facility the patient can leave if they want to as long as the patient is alert to person, place, and time. RN GG said that when law officers bring in a patient and the patient refuses to be seen, as long as the patient is of sound mind the facility cannot hold the patient against his will. RN GG said that if a patient is signed in and refuses care the patient is asked to sign an Against Medical Advice (AMA) form. She said that in this instance Patient #20 had not been registered (entered in the Central Log) and he refused to be seen, so there was no reason to get an AMA form signed. RN GG confirmed that she did not ask Crisis Counselor KK if he wanted Patient #20 to be seen because the patient had refused to be seen.