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Based on review of the facility's electronic Central Log/Medical Record system, Bylaws of the Medical Staff and Rules and Regulations, Professional Services Agreement Emergency Department, policies and procedures, Local Hospital Diversion Status, and staff interviews, it was determined that the facility failed to provide treatment within its capacity that minimize the risk to the individual's health for one (1) individual (patient #5) out of twenty (20) sampled patients with services that the facility was capable of providing when patient #5 was brought to the Emergency Department on 12/19/18 by adjacent law enforcement officers.

Findings include:

Cross refer to A-2406, as it relates to failure to provide patient #5 with an appropriate Medical Screening Examination.

Cross refer to A-2407, as it relates to failure to provide stabilizing treatment for patient #5.

Cross refer to A-2409, as it relates to failure to provide an appropriate transfer for patient #5.

Based on review of the facility's electronic ED Central Log/Medical Record system, policies and procedures, and staff interview, it was determined that the facility failed to ensure that all patients presenting for treatment are entered into the Emergency Department Central Log, for one (1) individual (patient #5) out of twenty (20) sampled patients, when patient #5 was brought to the Emergency Department on 12/19/18 by adjacent law enforcement officers.

Findings were:

Review of the facility's electronic ED Central Log revealed patient #5 was not entered into the facility's electronic Central Log/Medical Record system when the patient was brought into the ED on 12/19/18 by law enforcement officers from an adjacent county.

Review of facility policies included but was not limited to the following:
I. Policy entitled HHC (Houston Health Care)- Emergency Department - Standards: Guidelines for Patient Care, no policy number, effective 09/13/18, revealed all patients will routinely have the following interventions for care:
a. Triage
b. Vital signs
c. Medical Screening Exam
d. Reassessment
e. Disposition

On 1/23/19 at 1:00 p.m., an interview was conducted with the ED Quality Improvement/Performance Improvement Manager (QIPI). The QIPI Manager confirmed that patient #5 was not entered into the ED Central Log on 12/19/18 which would have generated the patient's medical record.

Based on review of medical records, Medical Staff Bylaws and Medical Staff Rules and Regulations, Professional Services Agreement Emergency Department, policies and procedures, Local Hospital Diversion Status, and staff interviews, it was determined that the facility failed to provide an appropriate Medical Screening Examination for one (1) individual (patient #5) out of twenty (20) sampled patients, when patient #5 was brought to Hospital A's Emergency Department for a psychiatric evaluation on 12/19/18 by adjacent law enforcement officers.

Findings were:

Patient #5's medical record from Hospital B was reviewed. The medical record revealed that patient #5 arrived at Hospital B via County Sheriff Department on 12/19/2018 at 6:45 p.m. Medical record review revealed the patient presented to the emergency department in handcuffs verbalizing "I don't know why I am here, they broke my door down and came in and drug me out of my bed, handcuffed me and me here. . ."Per SO (Security Officer) they took pt. (Patient) #5 to Houston Medical Center, walked into the facility and was turned around due to Psych (psychiatric) diversion and told to take patient to Hospital B ...pt. had a gun in hand and held it to his head and pulled the trigger, gun was jammed and did not go off. Wife was able to get the gun and called for help." Further review revealed at 6:52 p.m., Patient #5 was given 20 mg (milligrams) of Geodon (Antipsychotic-medication used to treat certain mental /mood disorders) in right hip per verbal orders from Emergency Room Physician. At 7:00 P.M., a 1:1 sitter was at the patient's bed side, and urine and blood work was sent for laboratory work-up. At 7:33 p.m., the ED medical doctor was at the patient's bedside. At 7:49 p.m., ED Registered (RN) documented the patient's wife was called via telephone and was informed that Pt. #5 tried to take his life, by loading a gun. The wife called 911, and patient barricaded himself in the bedroom. The SWAT (Special weapons and Tactics-law enforcement team) team called and the patient was removed from the premises. At 7:56 p.m., the patient's behavior escalated and he was placed in seclusion and restrained, The ED physician signed a 10-13 form (a certificate legally authorizing transportation of a person that appears mentally ill requiring involuntary inpatient treatment). At 8: 50 p.m., X-rays were completed on the patient's right wrist and knees. On 12/20/2018 at 12:04 a.m., the patient received a psychiatric evaluation by a psychiatric assessor. The assessor recommended patient #5 required inpatient psychiatric treatment, and was currently looking for placement. Patient #5 was transferred to Hospital C via ambulance on 12/20/2018 at 3:50 a.m. The facility failed to ensure that their policies and procedures were followed as evidenced by failing to ensure that on 12/19/2018, that when a request (County Sheriff) is made on the behalf of the individual (Patient#5) for an examination and treatment, the hospital must provide an appropriate medical screening examination within the capability of the hospital's ED to include ancillary services (on-call physician, laboratory and diagnostic testing) routinely available to ED to determine whether or not an emergency medical condition exists. Additionally, the facility also failed to triage patient #5 on 12/19/2018 as stated in their policy.


Review of Houston Medical Center (Hospital A) facility's Bylaws of the Medical Staff, approved by the Board of Trustees on 6/27/12, revealed the following:
Rules and Regulations,
Section V. Emergency Room,
F. Patients presenting to the facility will have a Medical Screening Exam consistent with EMTALA (Emergency Medical Treatment and Labor Act) regulations performed by a Physician, Registered Nurse (RN), Nurse Practitioner (NP), or Physician Assistant (PA) credentialed by the Medical Staff. This section was approved on 8/5/15 by the Chairman of the Board.

Review Hospital A's facility's Professional Services Agreement Emergency Department, effective 1/31/14, revealed the contractors agreed to comply with the professional standards established by the Joint Commission and specialty societies of which the Physicians are members, including any accrediting boards, with all applicable federal and state regulatory agencies, the then current Bylaws, Policies and Procedures of the Hospital, and the then standards of medical practice.

Review of facility policies included but was not limited to the following:
I. Policy entitled HHC (Houston Health Care)- Emergency Department - Standards: Guidelines for Patient Care, no policy number, effective 09/13/18, revealed all patients will routinely have the following interventions for care:
a. Triage
b. Vital signs
c. Medical Screening Exam
d. Reassessment
e. Disposition

II. Policy entitled Emergency Medical Screening, Treatment and Transfer Policy, no policy number, effective 1/16/18, revealed:
A. Definitions:
1. "Emergency Medical Condition" means: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
a. Placing the health of the individual (or, with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy"
b. Serious impairment to any bodily function_; or,
c. Serious dysfunction of any bodily organ or part."

Medical Screening Exam means examination by a physician, physician assistant, or nurse practitioner, to include diagnostic studies, interventions or treatment needed to confirm or rule out an emergency medical condition.

B. Admission of patients to the ED.
1. Upon arrival in the ED all patients will be assessed by a nurse, who determines the severity of the complaint and prioritizes the patient ...d. All patients will be triaged (Triage is a process of assigning priority of patients' treatment based on the severity of their illness) and treated in the same manner.

B. MEDICAL SCREENING EXAM
1. Special responsibilities of Medicare hospitals in emergency cases require that if any individual presents to a hospital's emergency department, and a request is made on the individual's behalf for examination or treatment of a medical condition, the hospital must provide an appropriate medical screening examination within the capability of the hospital' s emergency department, to determine if an emergent medical condition exists.

C. Any lab test, x-ray other screening or study deemed necessary by the ED physician or Advance Provider to confirm or rule out an emergency medical condition.

Review of the facility's Local Hospital Diversion Status from 12/18/18 at 2:00 p.m. through 12/20/18 at 6:00 a.m. revealed the facility was on Psychiatric Diversion.

On 1/22/19 at 11:30 a.m., an interview was conducted with the Police Officer (AA) on duty in the ED. Police Officer (AA) explained that he did not know what EMTALA was and had never heard the word. The Police Officer (AA) said that he covers the ED six (6) nights a week and was only helping the day shift. The Officer stated he never tells patients anything because the hospital staff are responsible for discussing medical issues with the patients. The Officer said that if another officer brought a patient in for medical care the hospital staff would determine what needed to be done and that he was only in the ED to provide security.

On 1/22/19 at 11:40 a.m., an interview was conducted with the facility's Security Officer (BB) on duty in the ED. The Security Officer (BB) stated he had been working at the facility for 6-7 months. The Security Officer (BB) said he did not know what EMTALA meant. When questioned as to what the procedure is for patients brought in by law enforcement, the Security Officer (BB) explained that these patients are usually brought in through the ambulance bay and placed in a quiet/secure room. When questioned as to what the procedure was if a law enforcement officer brought in a psychiatric patient and the facility was on Psychiatric Diversion, Security Officer (BB) explained the patient would be placed in a quiet/secure room until seen by a physician. Security Officer (BB) said that he had been informed that patients were never to be turned away from the ED.

On 1/22/19 at 11:50 a.m., an interview was conducted with the facility's Security Supervisor (CC) in the Security Office. The Supervisor explained he has been the Security Supervisor for five (5) years. The Supervisor explained that ED video recordings are kept for two (2) weeks and there are no video recordings available for December 2018. The Supervisor said that he didn't think he had received any EMTALA training. When questioned as to how a behavioral health patient presenting to the facility when the facility is on psychiatric diversion, he stated the patient would be placed in a quiet/secure room until seen by a physician. The Supervisor said that Security Officers are informed that they are not to send patients away.

On 1/22/19 at 2:00 p.m., an interview was conducted with the ED Director (GG) in the Conference Room. The Director said she became aware of the situation on 12/19/18 near the end of the 7:00 a.m. to 7:00 p.m. shift. The ED Director explained that the Assistant Nurse Manager (DD) informed her that an incident had occurred. The ED Director stated she was informed that on 12/19/18 the Police Officer (FF) on duty in the ED asked the Assistant Nurse Manager (DD) if the facility was still on Psychiatric Diversion and the Assistant Nurse Manager (DD) confirmed that the facility was still on Psychiatric Diversion. The ED Director said that at the time the Assistant Nurse Manager (DD) reported that she was unaware that the patient (#5) was already in the ED. The ED Director confirmed that the Police Officer (FF) then told the adjacent county Officers to take the patient somewhere else. The ED Director said that after being notified of the incident she notified the Chief Nursing Officer (II).

On 1/22/19 at 2:10 p.m., an interview was conducted with Police Officer (FF) in the Conference Room. The Officer explained that he is a local city Police Officer that works at the facility part-time. The Officer stated that on 12/19/18 he was not aware of EMTALA regulations but was aware that patients have a right to come into the facility and be seen for treatment. The Officer explained that in his mind there is a difference between patients and someone presenting to a facility in handcuffs. The Officer said that people in handcuffs have been seized/arrested and no longer have the right to freedom. The Officer said the attending officer is in responsible for a person in handcuffs. The Officer said that when he sees someone in handcuffs being accompanied by an officer, that person is under arrest. The Officer explained that usually law enforcement officers bring people in for medical clearance or for a mental evaluation. The Officer went on to explain that on 12/19/18 the patient (#5) was in handcuffs and was being brought into the ED by two (2) adjacent county deputies. The Officer stated the ED deals with people in custody all the time, and that when a detainee is combative the law enforcement officers bring them in through the back/ambulance entrance to a holding/secure area. The Officer said that law enforcement officers don't usually bring combative patients through the main ED because those patients are dangerous. The Officer said that when the facility goes on Psychiatric Diversion all 911 centers are called and dispatchers informed. The Officer said that on 12/19/18 he checked to ensure that the Psychiatric Diversion notifications had been performed. The Officer explained that when the patient (#5) was brought in by the adjacent county officers he asked the officers why they were bringing the patient to Houston Medical Center's ED when they were from an adjacent county that had a hospital. The Officer said the two (2) adjacent county Officers explained that their Major informed them to bring the patient to Houston Medical Center. The Officer said he went and asked the Assistant Nurse Manager (DD) if the facility was still on Psychiatric Diversion and was informed that the diversion status was still in place. The Officer said he made the decision to have the adjacent county Officers take the patient somewhere else because the patient was in custody and not from this County. The Officer said he has since learned about the 250 yards rule and received EMTALA training in December. In addition, the Officer said he met with the local Sheriff to discuss the issue of other counties bringing their troubled cases to this county and had also asked the local Chief of Police and Assistant Chief of Police to contact the adjacent county and come to some type of understanding. The Officer repeated that he did not want the hospital to get in trouble because of a decision he made as a Police Officer.

On 1/22/19 at 5:30 p.m., a telephone interview was conducted with the adjacent county Deputy (JJ). The Deputy stated he remembered taking patient (#5) to the Houston Medical Center ED on 12/19/18. The Deputy said that his Major informed him and another Deputy to take the patient to Houston Medical Center ED because the facility was an Emergency Receiving Emergency Treatment facility for behavioral health patients. The Deputy explained that when they arrived in the ED with patient (#5), the Officer (FF) on duty informed us that the facility was on Psychiatric Diversion and that we should take the patient back to the adjacent county.

On 1/23/19 at 9:30 a.m., an interview was conducted with the Chief Nursing Officer (CNO - II) in the Conference Room. The CNO stated that on 12/19/18 she was notified by the ED Director (GG) that there was an incident in the ED. The CNO said that it was first reported that the adjacent county Officer was on the radio and was told that the hospital was on Psychiatric Diversion. The CNO explained that the investigation revealed that the adjacent county Officer and the patient (#5) were in the ED lobby when our Officer (FF) told the adjacent county Officers that we were on Psychiatric Diversion and that the patient was to be taken somewhere else. In addition, the CNO said that the investigation revealed the Officer (FF) went to the back to talk to the Assistant Nurse Manager (DD) to confirm that the facility was still on Psychiatric Diversion.

On 1/23/19 at 10:10 a.m., an interview was conducted with the Assistant Nurse Manager (DD) in the Conference Room. The nurse explained that on 12/19/18 she was in the back of the ED when Police Officer (FF) approached her and reported that an adjacent county Sheriff Officer was attempting to bring in a behavioral health patient. The nurse said that the Officer (FF) asked if the facility was still on Psychiatric Diversion and that she advised the Officer that the facility was still on Psychiatric Diversion "but that if the patient was on the premises they were ours". The nurse said the Officer (FF) told her that the patient was enroute and that he (FF) would handle it if it was alright. The nurse said she told the officer that was fine as long as the patient had not presented to the ED. The nurse said that 15-20 minutes later she found out that the patient had actually been in the ED lobby. The nurse said that near the end of her shift she notified the ED Director (GG).

On 1/23/19 at 1:00 p.m., an interview was conducted with the ED Quality Improvement/Performance Improvement Manager (QIPI). The QIPI Manager also confirmed that patient #5 did not receive a medical screening examination, or stabilizing treatment.

Based on review of medical records, policies and procedures, and staff interview, it was determined that the facility failed to provide stabilizing treatment as required for one (1) individual (patient #5) out of twenty (20) sampled patients.

Findings were:

Patient #5's medical record from Hospital B was reviewed. The medical record revealed that patient #5 arrived at Hospital B via County Sheriff Department on 12/19/2018 at 6:45 p.m. Medical record review also revealed the ED physician signed a 10-13 form (a certificate legally authorizing transportation of a person that appears mentally ill requiring involuntary inpatient treatment. The patient received a psychiatric evaluation by a psychiatric assessor. On 12/20/2018 at 12:04 a.m., the assessor recommended patient #5 required inpatient psychiatric treatment, and he/she was currently looking for placement. Patient #5 was transferred to Hospital C via ambulance on 12/20/2018 at 3:50 a.m. Patient #5 was not stabilized prior to his leaving Hospital A, and was not evaluated by a Qualified Medical Personnel. Hospital A failed to ensure that their EMTALA stabilization policy and procedure was followed for Patient #5 on 12/19/2018.

A review of the policy titled, "Policy entitled Emergency Medical Screening, Treatment and Transfer Policy", no policy number, effective 1/16/18, revealed:
A. Definitions: ...
The term "stabilization" means, with respect to an emergency medical condition, to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during the transfer or discharge of the individual from a facility.


B. MEDICAL SCREENING EXAM
2. If the hospital determines that such individual has an emergent medical condition, the hospital is further obligated to provide either necessary stabilizing treatment or an appropriate transfer to a facility that has the capability to deliver definitive treatment.
a. If the hospital determines that an emergent medical condition exists, the hospital must provide for further medical examination and treatment as required to stabilize the individual.

On 1/23/19 at 1:00 p.m., an interview was conducted with the ED Quality Improvement/Performance Improvement Manager (QIPI). The QIPI Manager confirmed that patient #5 did not receive stabilizing treatment on 12/19/2018.

Based on review of medical records, policies and procedures, and staff interview it was determined that the facility failed to provide an appropriate EMTALA transfer for one (1) individual (patient #5) out of twenty (20) sampled patients reviewed
Findings were:

Patient #5's medical record from Hospital B was reviewed. The medical record revealed that patient #5 arrived at Hospital B via County Sheriff Department on 12/19/2018 at 6:45 p.m. On 12/20/2018 at 12:04 a.m., the patient received a psychiatric evaluation by a psychiatric assessor. The assessor recommended patient #5 required inpatient psychiatric treatment, and was currently looking for placement. Patient #5 was transferred to Hospital C via ambulance on 12/20/2018 at 3:50 a.m. The patient was inappropriately transferred to another facility without a certification of transfer and without an evaluation. Hospital A failed to ensure that their own policy and procedure was followed as evidenced by failing to ensure that on 12/19/2018 Patient #5 was appropriately transferred to an inpatient psychiatric unit or psychiatry hospital to receive the psychiatric care he needed.

A review of the facility's policy titled " Policy entitled Emergency Medical Screening, Treatment and Transfer Policy, no policy number, effective 1/16/18, revealed:
A. Definitions:

The term "transfer" means the movement (including the discharge) of an individual outside a hospital's facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital, but does not include such a movement of an individual who (A) has been declared dead, or (B) leaves the facility without the permission of any such person.

D. Transfer of Patients from the ED to another Facility
1. Patients will be transferred to another facility if they require more definitive or specialized treatment that is not available at the hospital. When the patient has had stabilization to the best capabilities of the hospital, the patient may be transferred to receiving facility. The private physician will be contacted and will accept the patient prior to transfer.
a. Patients are to be stabilized before the patient leaves the hospital, unless a delay in transfer will compromise the patient's condition (i.e., severe head trauma).
b. The physician in attendance will provide a signed statement in the medical record attesting that the medical benefits of the transfer outweigh the risks to the individual. (Transfer Record)
2. The patient and/or his family will be fully informed by the attending physician of the need for the transfer, the hospital's obligation to treat, and the risk of the transfer. The patient and/or family will sign a written consent for the transfer.
3. The ED physician or specialist in attendance will appropriately refer the patient to a physician at the receiving facility.
a. The physician at the hospital will call the physician specialist needed and give a full and detailed report of the patient's condition and reason for requesting the transfer.
b. The physician will wait for confirmation of acceptance by the receiving physician and hospital before the patient leaves.
c. The primary nurse will give the receiving primary nurse a detailed report.
4. When the patient is transferred to another facility, a copy of all records will be sent with the patient, (or promptly faxed) to include the ED record, all consultation notes from physicians, nurse's notes, lab reports, electrocardiograms (heart rate and rhythm), x-rays, and transfer form.
5. The patient will be transferred to the receiving facility by the ambulance or other service based on need. (Helicopter).
6. The patient may make a request for transfer as outlined in the Transfer Record.


B. MEDICAL SCREENING EXAM
c. A transfer is appropriate when the medical benefits of the transfer outweigh the medical risks of the transfer and other requirements specified in the regulation are met.
d. The hospital may provide appropriate transfer of an unstable patient to another medical facility if:
i. The individual (or person acting on his or her behalf), after being informed of the potential risks of transfer and the hospital ' s EMTALA duty to provide stabilizing care, requests a transfer.
ii. A physician has signed a certification that the benefits of the transfer of the patient to another facility outweigh the risks and documented and supported by the patient ' s medical record.
iii. A qualified medical person (as determined by the hospital in its by-laws or rules and regulations) has signed the certification after a physician, in consultation with that qualified medical person, has made the determination that the benefits of the transfer outweigh the risks and the physician countersigns the certification in a timely manner. (This last criterion applies if the responsible physician is not physically present in the emergency department at the time the individual is transferred).
iv. Provide treatment to minimize the risks of transfer.
v. Send all pertinent records to the receiving hospital.
vi. Obtain the consent of the receiving hospital to accept the transfer.
vii. Ensure that the transfer of an unstable individual is affected through the use of qualified personnel and transportation equipment, including the use of medically appropriate life support measures.

On 1/23/19 at 1:00 p.m., an interview was conducted with the ED Quality Improvement/Performance Improvement Manager (QIPI). The QIPI Manager confirmed that patient #5 did not receive an appropriate transfer.