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Based on interview, policy review and record review, the hospital failed to provide an appropriate medical screening examination (MSE) to determine the presence of an emergency medical condition (EMC) and maintain an appropriate Emergency Department (ED) central log for one patient (#12); failed to accept one patient (#27) from another hospital; and failed to appropriately transfer one patient (#21) out of 30 ED records reviewed. The hospital's ED average monthly census over the past six months was 1,016.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," dated 07/2021, showed:
- A MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists. Such screening must be performed by qualified medical personnel and within the hospital's capacity and capability. The MSE is an ongoing process, and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized, admitted to inpatient care, or appropriately transferred.
- The central log must contain the name of the individual seeking assistance, and the disposition of the patient. If the patient leaves the ED at any time without notifying hospital staff, hospital staff shall document in the central log the time the staff discovered that the patient had left.
- A hospital that is not in diversionary status may not refuse or fail to accept a request for an appropriate transfer or admission of an individual with an EMC if the individual requires a specialized service, if the hospital has the capacity to treat the individual, and the transferring facility does not have the specialized services needed.
- An appropriate transfer occurs when the receiving hospital has the appropriate space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual.

Review of Patient #12's ED record showed:
- She was a 41-year-old female who presented to the ED by ambulance with psychiatric (relating to mental illness) abnormal behavior and suicide (to cause one's own death) attempt on 12/03/22 at 11:17 PM.
- She had a history of bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows) and when EMS arrived, she refused to sit on the cot or allow EMS staff to take her vital signs or touch her.
- During transport to the hospital, she began taking her seat belts off and then her shoes and then asked EMS staff to put them back on and when they arrived at the hospital, she stated she was refusing. When asked what that meant, she told them she said nothing.
- Upon arrival to the hospital, the patient threw her shoes on the ground outside of the ambulance and started screaming. The patient was then placed in an ED room and started washing her shoes in the sink in the room. She then took the pillow case off the pillow and was saying items in the room and spelling them out loud.

Review of Patient #21's ED record, dated 12/14/22 at 8:51 PM, showed:
- He was a 28-year-old male who presented to the ED with law enforcement for medical clearance for psychiatric treatment.
- He was being transferred on a 96-hour hold (court ordered evaluation by behavioral specialists to determine is a person is safe to themselves and others) to psychiatric assessment at Hospital B via local sheriff's department for continued suicidal ideation (SI, thoughts of causing one's own death) and plan. The court approved 96-hour hold was obtained prior to arrival at the ED.
- Lab tests were completed as well as an electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions).
- The patient was assessed by a physician and was determined to be medically stable for discharge.

Patient #27 was a 27-year-old female patient diagnosed with an overdose who was requested an Intensive Care Unit (ICU, a unit where critically ill patients are cared for) bed by Hospital D, and was denied.

Please refer to 2405, 2406, 2407, and 2411.

Based on interview, policy review and record review, the hospital failed to enter one patient (#12) into the Emergency Department (ED) central log of 30 ED records reviewed. The hospital's ED average monthly census over the last six months was 1,016.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," dated 07/2021, showed the central log must contain the name of the individual seeking assistance, and the disposition of the patient. If the patient leaves the ED at any time without notifying hospital staff, hospital staff shall document in the central log the time the staff discovered that the patient had left.

Review of the hospital's ED central log from 08/27/22 through 02/27/23, showed Patient #12 arrived on 12/03/22 at 5:43 PM, arrival mode was documented as ground Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) and disposition was documented as against medical advice (AMA) on 12/04/22 at 1:55 AM.

Review of Patient #12's 12/03/22 ED record, showed the face sheet with a documented arrival date and time of 12/03/22 at 5:43 PM, for a blood pressure problem, and the ambulance report showed they arrived at the hospital on 12/03/22 at 11:17 PM, with a report of psychiatric (relating to mental illness) abnormal behavior and suicide (to cause one's own death) attempt.

During an interview on 03/01/23 at 8:05 AM, Staff L, Patient Access Director, stated that Patient #21 presented to the ED on 12/03/22 at 5:43 PM, and didn't finish registering. The patient left and the account should have been deleted. When Patient #21 presented with EMS, registration staff pulled the account from earlier in the day. She stated that this should not have occurred. Each time a patient presented to the ED, they should receive a new account number.

Based on interview, record review and policy review, the hospital failed to provide an appropriate medical screening examination (MSE) to determine the presence of an emergency medical condition (EMC) for one patient (#12) out of 30 Emergency Department (ED) records reviewed. The hospital's ED average monthly census over the past six months was 1,016.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," dated 07/2021, showed a MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists. Such screening must be performed by qualified medical personnel and within the hospital's capacity and capability. The MSE is an ongoing process, and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized, admitted to inpatient care, or appropriately transferred.

Review of the police report dated, 12/03/22 at 10:47 PM, showed when police arrived, Patient #12 was knocking on neighbor's doors and acting strange. When asked how she was doing, she stated not well. She told the police she was bipolar (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), her medication was not working, tonight she was very manic and she needed to see a doctor.

Review of Patient #12's ED record showed:
- She was a 41-year-old female who presented to the ED by ambulance with psychiatric (relating to mental illness), abnormal behavior and suicide (to cause one's own death) attempt on 12/03/22 at 11:17 PM.
- She had a history of bipolar disorder and when Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) arrived, she refused to sit on the cot or allow EMS staff to take her vital signs or touch her.
- During transport to the hospital, she began taking her seat belts off and then her shoes and then asked EMS staff to put them back on and when they arrived at the hospital, she stated she was refusing. When asked what that meant, she told them she said nothing.
- Upon arrival to the hospital, the patient threw her shoes on the ground outside of the ambulance and started screaming. The patient was then placed in an ED room and started washing her shoes in the sink in the room. She then took the pillow case off the pillow and was saying items in the room and spelling them out loud.
- She told the nurse that she felt like she was having contractions and that she was no longer pregnant because she had an abortion. She stated that it was a boy and his name was Zane.
- She was talking nonsensical and making no sense but just kept saying, "batman batman" and then told the ED staff different last names that she had.
- Her behavior was documented as anxious, restless, and uncooperative. The patient used the medication bar code scanner to scan her belly button. Then, the patient walked out of her ED room and wanted to go into another patient's room.
- Security was standing by and assisted the patient to the bathroom.
- She remained uncooperative, alternated between crying and screaming in her room, and continued to talk about batman.
- She refused to give a urine sample and continued to scream and be verbally abusive to the ED staff.
- Staff R, ED Physician, spoke to the patient and she was unwilling to cooperate with any of the doctor's orders and wanted to go home. She wanted to leave against medical advice (AMA).
- Staff R, ED Physician, was aware the patient wanted to leave AMA and told Staff C, Chief Nursing Officer (CNO), that if the patient was unwilling to cooperate she could go.
- The patient was escorted out with security.

During an interview on 03/01/23 at 10:10 AM, Staff C, CNO, stated that she was staffing in the ED on the night of 12/03/22. She reviewed the medical record and stated that Patient #12 should have had a behavioral health examination. The hospital should have called Facility C, the local community resource used for behavioral health patients, to have the patient assessed. She stated that Staff R, ED Physician, told her that Patient #12 could leave AMA and so she had her sign the paperwork and security escorted the patient out of the hospital. She also stated that they could have restrained the patient.

During a telephone interview on 03/06/23, Staff R, ED Physician, stated that he had reviewed the ED record for Patient #12 and remembered that she had presented to the ED with a manic episode, speaking nonsensically about an abortion, however, she was not suicidal (SI, thoughts of causing one's own death) or homicidal (HI, thoughts or attempts to cause another's death). A patient should have a behavioral health exam as part of the MSE if they were SI or HI. He was not sure what else to do for this patient at that time and she wanted to leave AMA.

During a telephone interview on 03/07/23 at 8:35 AM, Staff Q, ED Medical Director, stated that she had reviewed the ED record for Patient #12 and Staff R, ED Physician, had performed a MSE. A behavioral health evaluation would be completed if the patient were SI or HI, or at the request of the patient. A nurse performed a behavioral health evaluation on every patient, and in this case it looked like that would have been difficult.

Based on interview, record review and policy review the hospital failed to appropriately transfer one patient (#21) out of 30 Emergency Department (ED) records reviewed. The hospital's ED average monthly census over the past six months was 1,016.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," dated 07/2021, showed an appropriate transfer occurs when the receiving hospital has the appropriate space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual.

Review of Patient #21's ED record, dated 12/14/21 at 8:51 PM, showed:
- He was a 28-year-old male who presented to the ED with law enforcement for medical clearance for psychiatric (relating to mental illness) treatment.
- He was being transferred on a 96-hour hold (court ordered evaluation by behavioral specialists to determine is a person is safe to themselves and others) for a psychiatric assessment at Hospital B via local Sheriff's Department for continued suicidal ideation (SI, thoughts of causing one's own death) and plan. The court approved 96 hour hold was obtained prior to arrival to the ED.
- Lab tests were completed as well as an electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions).
- The patient was assessed by a physician and was determined to be medically stable for discharge.
- The ED nurse called Hospital B at 10:11 PM, to notify them that Patient #21 had been medically cleared and explained that the 96-hour hold was completed prior to the patient's arrival at the ED.
- Hospital B Registered Nurse (RN) stated she knew nothing of Patient #21 and she would call back when she could.
- The ED nurse contacted Staff M, Facility C (Outpatient Mental Health Agency) Provider, and was told by her to send the lab work and the chart and to tell the Sheriff Deputy to get on the road because the judge ordered the 96-hour hold. Staff M told the ED nurse that Hospital B did in fact know about Patient #21 because she had sent them a fax.
- Hospital B RN, Psych center, called very upset asking, "Who authorized this patient to be transferred to our hospital?"
- The ED nurse explained that Patient #21 had a 96-hour hold by a local county Sheriff's Department; and the arrangement was between them and Facility C; and Northeast Regional Medical Center was only involved for medical clearance.
- Hospital B RN, requested to speak with the ED Director.
- The patient was discharged to Hospital B in the custody of the sheriff's department.

During a telephone interview on 03/01/23 at 8:45 AM, Staff M, Facility C Provider, stated that:
- When a 96-hour hold was obtained outside of a hospital, they would try to have the patient transported directly to Hospital B. However, they have received "flack" for not having a medical clearance completed prior to the patient's arrival to Hospital B.
- She called ahead to Hospital B on 12/14/21, regarding Patient #21, and Hospital B told her that she would need to get medical clearance before they would accept the patient.
- She then called Northeast Regional Medical Center ED to notify them that the sheriff's staff would be stopping by for a medical clearance.
- She faxed paperwork to Hospital B for Patient #21.
- She received a call from Hospital B but she did not remember what day, and they told her that they were going to file a complaint related to EMTALA.

During a telephone interview on 03/01/23 at 9:12 AM, Staff N, Former Risk Manager in 2021, stated that the ED Director was contacted by Hospital B and let the Chief Nursing Officer (CNO) know about Patient #21 being transferred without any communication from Northeast Regional Medical Center. She did not know who had told the sheriff's office that they would need to stop by and get a medical clearance for Patient #21, prior to transporting to Hospital B.

During a telephone interview on 03/01/23 at 9:30 AM, Staff K, Former ED Director, stated that:
- There was a 96-hour hold in place with Hospital B when Patient #21 presented to Northeast Regional Medical Center ED for medical clearance.
- Nursing staff tried to contact Hospital B multiple times during Patient #21's ED visit on 12/14/21, in an attempt to give them report and send them lab work.
- There was a misunderstanding about how a 96-hour hold worked.
- Hospital B called her on 12/14/21, and yelled at her about Patient #21 being sent to them without any notification.
- Hospital B told her that they did file an EMTALA complaint, but did not feel that Northeast Regional Medical Center had been malicious in any way.

During an interview on 03/01/23 at 10:10 AM, Staff C, CNO, stated that she was not sure if a 96-hour hold was still in effect when a patient presented to the ED for a medical clearance.

During a telephone interview on 03/01/23 at 1:48 PM, Staff O, Sheriff Schuyler County, stated that he was not sure who had told them to take Patient #21 to Northeast Regional Medical Center on 12/14/21, for medical clearance before they transported Patient #21 to Hospital B. He also stated that there was confusion as to why Hospital B wanted medical clearance before the patient arrived.

During a telephone interview on 03/01/23 at 3:30 PM, Staff P, ED Physician, stated that she did not understand why the Sheriff's staff stopped at Northeast Regional Medical Center for a medical clearance on 12/14/21, for Patient #21. When there is a 96-hour hold in place, it would not be necessary for a patient to stop at another hospital for medical clearance.

During a telephone interview on 03/01/23 at 2:09 PM, Staff Q, ED Medical Director, stated that
- When there was a 96-hour hold in place, the patient was in police custody, and the police had made arrangements, they would take the patient to the accepting hospital.
- If she saw a patient for medical clearance and the 96-hour hold was obtained by the hospital, she would call the accepting hospital.
- The ED nurses would call report to the accepting hospital.

Based on interview, policy review and record review, the hospital failed to accept one patient (#27) from another hospital out of 30 Emergency Department (ED) records reviewed. The hospital's ED average monthly census over the past six months was 1,016.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," dated 07/2021, showed a hospital that is not in diversionary status may not refuse or fail to accept a request for an appropriate transfer or admission of an individual with an EMC if the individual requires a specialized service, if the hospital has the capacity to treat the individual, and the transferring facility does not have the specialized services needed.

Review of the ED log from Hospital D, dated 06/04/21, showed Patient #27 presented to the ED with a chief complaint of "I took a hand full of pills", and was transferred to a higher level of care in poor condition for further treatment.

During an interview on 02/28/23 at 12:05 PM, Staff H, Nurse Practitioner, Hospital D, stated that when she called Northeast Regional Medical Center on 06/04/21, and requested an Intensive Care Unit (ICU, a unit where critically ill patients are cared for) bed for a female patient who had an overdose, she was told that because the patient would need psychiatric (relating to mental illness) care, they could not accept the patient.

During a telephone interview on 02/28/23 at 2:10 PM, Staff J, Registered Nurse (RN), House Supervisor, stated that when a hospital called and requested a transfer, she would not always discuss her decision with a physician.

During an interview on 02/28/23 at 12:27 PM, Staff I, Inpatient Services Director, stated that when another hospital called and requested a bed for a patient, there would be a three way call between the other hospital, the House Supervisor, and the physician, and she would expect that a House Supervisor should not make the decision to accept a patient without contacting a physician.

During an interview on 03/01/23 at 10:10 AM, Staff C, CNO, stated that the House Supervisor would have a three way call with the requesting hospital and a physician when a transfer request was made. She would expect that the House Supervisor would not make that decision on her own.