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Based on record review, review of the facility Emergency Treatment and Labor Act (EMTALA) policies, staff and provider interviews the facility failed to provide 1 (Patient 20) of 30 sampled patients an appropriate medical screening examination to evaluate/address the patient's extremely elevated blood pressure to ensure the patient did not have an Emergency Medical Condition (EMC); and failed to provide 1 (Patient 12) an appropriate safe transfer. Patient 12 who was actively suicidal was transported by private vehicle for direct admission to an inpatient psychiatric facility for stabilization and treatment of her EMC. The total sample size was 30. Findings are:

A. Record review of Patient 12's medical record revealed the patient, a minor adolescent, was brought to the ED on 7/10/16 at 8:35 PM. The nursing documentation on arrival reveals the mother told the nurse the patient had been overdosing with an insulin pump. The patient is a diabetic and uses the insulin pump to infuse insulin through a subcutaneous site on a continual basis. The pump is programmed to deliver a continual rate of insulin and also a bolus or extra insulin to cover the consumption of carbohydrates to keep blood sugars in normal range. The American Diabetes Association defines target blood glucose (sugar) goals as 70-130 before meals and less that 180 after meals. The infusion of too much insulin can result in hypoglycemia (low blood glucose) that can result in a variety of symptoms ranging from clumsiness, trouble talking, confusion, loss of consciousness, seizures or death. The mother reported the patient had a history of suicidal intention. Humulog was identified as the insulin used by the patient. Humulog is used in insulin pumps to infuse insulin into the subcutaneous tissue by an infusion site. Humulog is a fast acting insulin beginning to lower blood sugar in 15 minutes and its effects last 6-8 hrs.
The physician assessed the patient at 8:47 PM. Chief complaint in physician notes include "suicide attempt." The time of ingestion (insulin) was identified as 8 PM. The ingestion was intentional and the amount of insulin was 'Unknown." The patient's psychiatric assessment by the physician identified the patient was depressed with suicidal thoughts and hopelessness.
Blood sugars performed in the ED were: 118 at 8:55 PM by fingerstick; 153 with lab draw at 9:25 PM and the last one done at 9:49 PM, a fingerstick with 152 blood sugar.
Record review of the psychiatric assessment performed by Licensed Mental Health Practitioner (LMHP) "J" at 10:49 PM revealed the patient stated "I just want to die" and that the patient "took too much insulin." The patient revealed that there had been a previous attempt to harm self the same way in the past. The patient lives with the mother. Suicide risk score was "High." The patient confirmed having suicidal thoughts, intent and had a specific plan to end their life by overdosing on insulin. Judgement was identified as 'Poor." The LMHP reported the findings to the Psychiatrist on call who wanted the patient transferred and admitted to an inpatient acute psychiatric hospital that treats adolescents.
Record review of the form titled "Certificate of Transfer" dated 7/10/16 at 11:15 PM notes the patient was to be transferred by "POV" Privately Owned Vehicle. Vital signs at 11:00 PM before transfer were: BP 108/65; Pulse 70; Respirations 16 and Temperature 98.2 Fahrenheit. A blood sugar before transfer was not documented. Risks of transfer identified on the form include only "MVC" (motor vehicle collision) and benefits "definitive care." Under the section Patient condition the form has checked the box stating "There is not reasonable likelihood of deterioration from or during transport". The physician and the mother signed the transfer form.
Interview with LMHP "J" on 9/27/16 at 10:35 AM confirmed Patient #12 was suicidal and had a plan using insulin. The The patient told the LMHP they "wanted to die".The patient reported using insulin in the past for a suicide attempt. LMHP discussed the assessment with the psychiatrist on call who felt the patient needed acute inpatient care and hospitalization. The LMHP stated the patient had an Emergency Medical Condition based on the fact that Patient 12 was "actively suicidal." The LMHP did not know how the patient used insulin if by shot or insulin pump or know if the pump was still in the patient's possession.
Interview with Registered Nurse "G" on 9/27/16 at 5:00 PM. RN G confirmed being Patient 12's ED nurse on 7/10/16. The nurse was asked about the lack of documentation regarding the patient's insulin pump. The record does not contain what the settings were, infusion history evaluation or if the pump was still infusing into the patient. The nurse stated the patient "almost had to have had the pump on". The nurse thought the mom had shut it off before arrival. The nurse stated that the patient refused to talk to her or answer questions. The nursing information came from the mother. RN G confirmed a blood sugar was not done prior to transfer with the last one done at 9:49 PM. RN G confirmed the patient was suicidal and had an EMC requiring transfer. RN G recalled discussing with the Mother the method of transfer. The Mother related that the last time the patient went in the ambulance he/she was uncooperative, taking off monitors and hitting staff. The nurse stated the mother wanted to transport in her car. RN G stated the doctor makes the ultimate decision on the method to transfer. The nurse related that there is a place on the Against Medical Advice form that is used to document refusal of ambulance transfer. The nurse confirmed the record does not contain a refusal of ambulance transfer or any discussion with the patient regarding ambulance transfer.
Interview with Medical Doctor (MD) "C" who is the ED Medical Director on 9/28/16 at 9:05 AM regarding the ED record from the 7/10/16 visit for Patient 12 revealed confirmation that the patient had an EMC related to a psychiatric condition. Regarding transfer with the patient's insulin pump the physician responded that can be "tricky." Insulin is necessary to maintain normal insulin levels. It can be lethal if you leave it on or lethal if you take it off. MD C stated that it is a judgement call regarding whether the patient can be safely transferred by the mother and it depends on if they can be reliable and reasonable it "may be ok." MD C stated that the physician determines the method of transfer and verbally discusses it with the nurse. The physician signature on the transfer form verifies that it is a safe method to transfer.
Phone interview with MD "A" on 9/29/16 at 2:00 PM confirmed MD A was Patient 12's ED MD on 7/10/16. MD A related that he medically cleared the patient by doing repeat blood sugars to ensure they were not showing decline and that her laboratory results were negative. MD A determined the patient was stable for transfer to treat psychiatric emergency. MD A did not know if the patient's insulin pump was infusing and with the patient or not. MD A reported a discussion with mom regarding transport to the psychiatric hospital by ambulance. The mom wanted to transport the patient as she felt an ambulance would cause increased stress. The mother did transport the patient by private vehicle. MD A confirmed the discussion regarding transfer and refusal of transfer by ambulance was not documented in the record.
Record review of the receiving hospital admission documentation reveals the patient was admitted on 7/11/16. The attending psychiatrist documented the patient presented voluntary by guardian "after overdosed on her insulin pump and having to be taken to a hospital where she was medically cleared." The physician also noted that "upon her admission was taken off her insulin pump". The patient transferred by private vehicle with the insulin pump, method of suicide per patient, in their possession.
Record review of the facility policy titled "EMTALA- Emergency Medical Treatment and Active Labor Act" effective date 2/1/16 identified a psychiatric patient with potential harm to self or others would always be considered an emergency medical condition to be screened and treated. The policy defines an "Appropriate Transfer" is a transfer in which the physician has certified the patient condition for transfer, the destination facility and physician have accepted the care of the patient, the patient, or responsible party has agreed to the transfer and the needed equipment, level of staff and mode of transport is available. The transfer is to be provided through qualified personnel and transportation equipment as required and as determined by the transferring physician.
The section titled "Transfer by Private Vehicle": Patients being transferred for a hospital to hospital transfer who may be at risk of deterioration "shall be transferred by appropriate medical vehicle."; Patients requesting to utilize their private vehicle who are deemed capable of making such a decision by the responsible physician may do so upon meeting the documentation requirements for private vehicle transfer.; The requirements are discussion of risk/benefit and documentation of the risks discussed. The responsible persons understanding and capability of making an informed decision are to be documented.; The risks discussed will be inserted into the Ambulance Refusal Form in the section labeled "Risks." The Ambulance Refusal Form will be signed by the patient or responsible decision maker or if signature is refused that is to be noted on the form in the area provided for patient signature. The refusal form is to be signed by the physician or ED provider and witnessed on the form.; Where the physician or ED provider deems it appropriate they may further document the refusal and warnings provided through the use of an "Against Medical Advice" form. The record for Patient 12 does not include this documentation for transfer by private vehicle as required by facility policy.


B. Medical Record Review of the ED visit on 6/14/16 for Patient 20 revealed the patient came to the ED at 9:18 AM. The Triage Notes identified that the patient reported "thoughts of paranoia, and feeling disconnected with thoughts of suicide with no plan." Initial vital signs were: BP 187/119, Temperature (T) 98.2 oral, Pulse (P) 106, Respirations (R) 24 and oxygen saturation 96% on room air, and currently takes no medications. The record identified Patient 20's past medical history of: Psychiatric-Personality disorder and Medical-history of knee surgery. Patient 20 reported being homeless and living in (gender) car.

The MSE (Medical Screening Exam) was completed by the Doctor of Osteopathic Medicine (DO)-B. The exam noted that Patient 20 presented with a chief complaint of psychiatric problems. The onset was one week prior to arrival. The patient denied any hallucinations, had unclear thinking, denied suicidal or homicidal thoughts. The patient is not uncooperative. The review of symptoms included: Respiratory: lungs clear and breath sounds were equal bilaterally, CV (Cardiovascular): Tachycardia (fast heart beat), the rhythm was regular. Neurological: oriented to person, place and time. The patient was awake and alert, memory was intact. Psychiatric: no visual or auditory hallucinations. The orders included:
Blood Alcohol, CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), Lipid Panel, Protime/INR, TSH (Thyroid Stimulating Hormone), UA and UA for drug screen (unable to void before discharge), Hgb A1C, BP monitor per protocol, Mental health consult per protocol and Suicidal precautions per protocol. IMPRESSION: PSYCHOSIS (a lack of understanding with reality). DO-B documented "The patient was discharged to Home. The patient's condition upon discharge was good. Education was provided to the patient in reference to the impressions, diagnostic study results, treatment, prognosis and need for follow up. Instructions given to the patient: Psychosis. Follow up: As recommended by psych."
DO-B's documentation lacked mention of the elevated blood pressures.

The evaluation for Mental Health was completed by LMHP (Licensed Mental Health Practitioner)-I on 6/14/16 at 10:45 AM. Patient 20 was identified as denying suicidal thoughts or thoughts of hurting others, denied hallucinations, does experience paranoia related to minorities and homosexuals, and delusions "Gotta be alive in 2029 for the asteroids." Is homeless and resides in (gender) car, travels the United States, is on disability and has a medical history of knee replacement and HBP (high blood pressure). The LMHP performed a suicide severity rating scale that identified Patient 20 as Low level risk for suicide. The evaluation was then reviewed with the Psychiatrist on call and the ED doctor. An evaluation by the Psychiatrist/LMHP and in coordination with the ED doctor is completed to determine if an Emergency Medical Condition (EMC) for Mental Health exists. For Patient 20, it was felt that Patient 20 did not have an EMC for Mental Health and it was recommended to follow up with out patient psychiatric referrals (address and phone number provided) upon dismissal.

Review of Patient 20's "Tabular Trend" form with BP's and Pulses recorded while in the ED revealed:
09:17 AM- BP 187/119, P 106
09:20 AM- BP 214/153, P 100
09:21 AM- BP 228/145, P 102
09:30 AM- BP 221/145, P 101
09:40 AM- BP 202/141, P 97
09:50 AM- BP 202/123, P 85
09:52 AM- BP 205/125, P 87
10:00 AM- BP 206/159, P 96
10:20 AM- BP 196/138, P 92

An interview with Registered Nurse (RN) H on 9/27/16 at 11:35 AM confirmed being the nurse caring the for Patient 20 during the 6/14/16 ED visit. Upon request of reviewing the documented BP's on Patient 20's record, RN H verified that the record lacked documentation of physician notification of the elevated BP's and lacked any dismissal instructions regarding following up about the BP's or printed information given about elevated BP's. RN H stated, "I usually chart if there is a high BP that I notified the doctor before they are discharged. But I don't see it anywhere in here." RN H verified that no medications were administered to Patient 20 during the ED visit. When RN H was asked if (gender) felt that it appeared Patient 20 had a hypertensive EMC? RN H stated, "Yeah" When asked if (gender) felt that Patient 20 was safe to send home when discharged, RN H stated, "No, I don't see it on the health history or a history of high BP." Do you feel Patient 20 then had an EMC at the time of Discharge? RN H stated, "Yes, due to the high blood pressure and without being on meds or a history."

An interview with The Medical Director of ED (MD)-C on 9/28/16 at 9:05 AM regarding Patient 20, (due to DO-B is no longer employed at the facility and not available for interview) revealed the opportunity to review the 6/14/16 record. When asked if MD-C felt Patient 20 had an EMC for Mental Health, MD-C stated "No." When asked about the elevated BP's ranging from 187/119-214/153 during the ED visit if MD-C felt that Patient 20 had an EMC Medically related to the BP's, MD-C stated, "No." MD-C stated, "With (gender) labs (essentially normal), no chest pain, no shortness of breath and (gender) renal function was fine, the patient can follow up as an outpatient. According to the ACEP (American College of Emergency Physicians) it says if the patient is asymptomatic they can follow up as an outpatient. So on discharge give the outpatient information for blood pressure and outpatient information." MD-C verified that the discharge instructions lacked paperwork about blood pressure and there was not a follow up for the blood pressure issues mentioned. "I do see the discharge instructions say to follow up with psychiatric treatment." An address and phone number was listed for that on the discharge paperwork. When asked if MD-C felt that Patient 20 had a Medical EMC related to the elevated blood pressures at discharge, MD-C stated, "No, (gender) was asymptomatic and per ACEP (Patient 20) could follow up as an outpatient. However the discharge instructions should have had follow up referral information about the blood pressure on it."

Record review of the facility policy titled "EMTALA" effective 2/1/2016 identified under title "A medical screening examinations is provided to any person presenting themselves anywhere on the campus who is seeking emergency services to determine whether that person has an emergency medical condition. An Emergency Medical Condition is defined in the policy as "As defined by law is a condition manifesting itself with acute symptoms of sufficient severity including severe pain, that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the person in serious jeopardy; serious impairment to any bodily functions; serious dysfunction of any bodily organ or part; or, a pregnant woman having contractions, that there is inadequate time to effect a safe transfer to another hospital before delivery; or that the transfer may pose a threat to the health or safety of the woman or unborn child. Emergency medical conditions always include women in labor, patients with substance abuse or current intoxication, patients with severe pain, and psychiatric patients that might or could ultimately be at risk to self or others."

Review of the ACEP website -Current Clinical Policies Management- Asymptomatic Elevated Blood Pressure Volume 62 No 1 dated July 2013 revealed:
-In patients with asymptomatic markedly elevated blood pressure, does ED medical intervention reduce rates of adverse outcomes? For patient management recommendations, Level A and Level B recommendatins- none specified; Level C recommendation was:
(1) In patients with asymptomatic markedly elevated blood pressure, routine ED Medical intervention is not required.
(2) IN SELECT PATIENT POPULATIONS (EG. POOR FOLLOW-UP), EMERGENCY PHYSICIANS MAY TREAT MARKEDLY ELEVATED BLOOD PRESSURE IN THE ED AND/OR INITIATE THERAPY FOR LONG-TERM CONTROL. [CONSENSUS REMMENDATION]
(3) PATIENTS WITH ASYMPTOMATIC MARKEDLY ELEVATED BLOOD PRESSURE SHOULD BE REFERRED FOR OUTPATIENT FOLLOW-UP. [CONSENSUS RECOMMENDATION]
Patient 20 is homeless and lives in (gender) car and travels the United States.

Review of the Mayo Clinic website- High Blood Pressure article dated 9/9/2016 revealed the following categories to classify blood pressure:
-Normal blood pressure- when the blood pressure is normal if below 120/80 mmHg (millimeters of mercury)
-Prehypertension- Prehypertension is a systolic (top number-measures your arteries when your hear beats) pressure ranging from 120-139 mmHg or a diastolic (lower number-measures the pressure in your arteries between beats).
-Stage 1 hypertension- Stage 1 hypertension is a systolic pressure ranging from 140-159 mmHG or a diastolic pressure ranging from 90-99 mmHg.
-Stage 2 hypertension- More severe hypertension, stage 2 hypertension is a systolic pressure of 160 mmHG or higher or a diastolic pressure of 100 mmHg or higher.

Uncontrolled high blood pressure can lead to: heart attack or stroke, aneurysm, heart failure, weakened and narrowed blood vessels in the kidneys, thinkened, narrowed or torn blood vessels of the eyes, metabolic syndrome, trouble with memory or understanding.

An unannounced onsite EMTALA (Emergency Medical Treatment and Labor Act) investigation began on 9/22/16 and continued through 9/28/16. Based on record review, review of the facility EMTALA policies, staff interview and medical staff interviews the facility failed to perform an adequate Medical Screening Examination (MSE) for 1 (Patient 20) of 30 sampled patients to determine if the patient had an Emergency Medical Condition which required stabilizing treatment before a safe discharge. This failure posed an immediate and serious threat to Patient 20's health and safety. Patient 20 came to the Emergency Department (ED) on 6/14/16 due to psychiatric problems. During the initial screening of Patient 20's vital signs the blood pressure (BP) was elevated with a finding of 187/119, the blood pressure remained extremely elevated throughout the stay without the facility staff making mention of the elevated blood pressure. The facility discharged the patient with a blood pressure of 196/138 without providing treatment or education prior to dismissal related to the elevated blood pressure and the need to follow up with a health care practitioner. The lack of providing the patient with treatment and/or education regarding the elevated blood pressure put the patient at risk for the side effects of an extremely high blood pressure.

Findings are:

A. Medical Record Review of the ED visit on 6/14/16 for Patient 20 revealed the patient came to the ED at 9:18 AM. The Triage Notes identified that the patient reported "thoughts of paranoia, and feeling disconnected with thoughts of suicide with no plan." Initial vital signs were: BP 187/119, Temperature (T) 98.2 oral, Pulse (P) 106, Respirations (R) 24 and oxygen saturation 96% on room air, and currently takes no medications. The record identified Patient 20's past medical history of: Psychiatric-Personality disorder and Medical-history of knee surgery. Patient 20 reported being homeless and living in (gender) car.

The MSE (Medical Screening Exam) was completed by the Doctor of Osteopathic Medicine (DO)-B. The exam noted that Patient 20 presented with a chief complaint of psychiatric problems. The onset was one week prior to arrival. The patient denied any hallucinations, had unclear thinking, denied suicidal or homicidal thoughts. The patient is not uncooperative. The review of symptoms included: Respiratory: lungs clear and breath sounds were equal bilaterally, CV (Cardiovascular): Tachycardia (fast heart beat), the rhythm was regular. Neurological: oriented to person, place and time. The patient was awake and alert, memory was intact. Psychiatric: no visual or auditory hallucinations. The orders included:
Blood Alcohol, CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), Lipid Panel, Protime/INR, TSH (Thyroid Stimulating Hormone), UA and UA for drug screen (unable to void before discharge), Hgb A1C, BP monitor per protocol, Mental health consult per protocol and Suicidal precautions per protocol. IMPRESSION: PSYCHOSIS (a lack of understanding with reality). DO-B documented "The patient was discharged to Home. The patient's condition upon discharge was good. Education was provided to the patient in reference to the impressions, diagnostic study results, treatment, prognosis and need for follow up. Instructions given to the patient: Psychosis. Follow up: As recommended by psych."
DO-B's documentation lacked mention of the elevated blood pressures.

The evaluation for Mental Health was completed by LMHP (Licensed Mental Health Practitioner)-I on 6/14/16 at 10:45 AM. Patient 20 was identified as denying suicidal thoughts or thoughts of hurting others, denied hallucinations, does experience paranoia related to minorities and homosexuals, and delusions "Gotta be alive in 2029 for the asteroids." Is homeless and resides in (gender) car, travels the United States, is on disability and has a medical history of knee replacement and HBP (high blood pressure). The LMHP performed a suicide severity rating scale that identified Patient 20 as Low level risk for suicide. The evaluation was then reviewed with the Psychiatrist on call and the ED doctor. An evaluation by the Psychiatrist/LMHP and in coordination with the ED doctor is completed to determine if an Emergency Medical Condition (EMC) for Mental Health exists. For Patient 20, it was felt that Patient 20 did not have an EMC for Mental Health and it was recommended to follow up with out patient psychiatric referrals (address and phone number provided) upon dismissal.

B. Review of Patient 20's "Tabular Trend" form with BP's and Pulses recorded while in the ED revealed:
09:17 AM- BP 187/119, P 106
09:20 AM- BP 214/153, P 100
09:21 AM- BP 228/145, P 102
09:30 AM- BP 221/145, P 101
09:40 AM- BP 202/141, P 97
09:50 AM- BP 202/123, P 85
09:52 AM- BP 205/125, P 87
10:00 AM- BP 206/159, P 96
10:20 AM- BP 196/138, P 92

C. An interview with Registered Nurse (RN) H on 9/27/16 at 11:35 AM confirmed being the nurse caring the for Patient 20 during the 6/14/16 ED visit. Upon request of reviewing the documented BP's on Patient 20's record, RN H verified that the record lacked documentation of physician notification of the elevated BP's and lacked any dismissal instructions regarding following up about the BP's or printed information given about elevated BP's. RN H stated, "I usually chart if there is a high BP that I notified the doctor before they are discharged. But I don't see it anywhere in here." RN H verified that no medications were administered to Patient 20 during the ED visit. When RN H was asked if (gender) felt that it appeared Patient 20 had a hypertensive EMC? RN H stated, "Yeah" When asked if (gender) felt that Patient 20 was safe to send home when discharged, RN H stated, "No, I don't see it on the health history or a history of high BP." Do you feel Patient 20 then had an EMC at the time of Discharge? RN H stated, "Yes, due to the high blood pressure and without being on meds or a history."

D. An interview with The Medical Director of ED (MD)-C on 9/28/16 at 9:05 AM regarding Patient 20, (due to DO-B is no longer employed at the facility and not available for interview) revealed the opportunity to review the 6/14/16 record. When asked if MD-C felt Patient 20 had an EMC for Mental Health, MD-C stated "No." When asked about the elevated BP's ranging from 187/119-214/153 during the ED visit if MD-C felt that Patient 20 had an EMC Medically related to the BP's, MD-C stated, "No." MD-C stated, "With (gender) labs (essentially normal), no chest pain, no shortness of breath and (gender) renal function was fine, the patient can follow up as an outpatient. According to the ACEP (American College of Emergency Physicians) it says if the patient is asymptomatic they can follow up as an outpatient. So on discharge give the outpatient information for blood pressure and outpatient information." MD-C verified that the discharge instructions lacked paperwork about blood pressure and there was not a follow up for the blood pressure issues mentioned. "I do see the discharge instructions say to follow up with psychiatric treatment." An address and phone number was listed for that on the discharge paperwork. When asked if MD-C felt that Patient 20 had a Medical EMC related to the elevated blood pressures at discharge, MD-C stated, "No, (gender) was asymptomatic and per ACEP (Patient 20) could follow up as an outpatient. However the discharge instructions should have had follow up referral information about the blood pressure on it."

E. Record review of the facility policy titled "EMTALA" effective 2/1/2016 identified under title "A medical screening examinations is provided to any person presenting themselves anywhere on the campus who is seeking emergency services to determine whether that person has an emergency medical condition. An Emergency Medical Condition is defined in the policy as "As defined by law is a condition manifesting itself with acute symptoms of sufficient severity including severe pain, that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the person in serious jeopardy; serious impairment to any bodily functions; serious dysfunction of any bodily organ or part; or, a pregnant woman having contractions, that there is inadequate time to effect a safe transfer to another hospital before delivery; or that the transfer may pose a threat to the health or safety of the woman or unborn child. Emergency medical conditions always include women in labor, patients with substance abuse or current intoxication, patients with severe pain, and psychiatric patients that might or could ultimately be at risk to self or others."

F. Review of the ACEP website -Current Clinical Policies Management- Asymptomatic Elevated Blood Pressure Volume 62 No 1 dated July 2013 revealed:
-In patients with asymptomatic markedly elevated blood pressure, does ED medical intervention reduce rates of adverse outcomes? For patient management recommendations, Level A and Level B recommendatins- none specified; Level C recommendation was:
(1) In patients with asymptomatic markedly elevated blood pressure, routine ED Medical intervention is not required.
(2) IN SELECT PATIENT POPULATIONS (EG. POOR FOLLOW-UP), EMERGENCY PHYSICIANS MAY TREAT MARKEDLY ELEVATED BLOOD PRESSURE IN THE ED AND/OR INITIATE THERAPY FOR LONG-TERM CONTROL. [CONSENSUS REMMENDATION]
(3) PATIENTS WITH ASYMPTOMATIC MARKEDLY ELEVATED BLOOD PRESSURE SHOULD BE REFERRED FOR OUTPATIENT FOLLOW-UP. [CONSENSUS RECOMMENDATION]
Patient 20 is homeless and lives in (gender) car and travels the United States.

G. Review of the Mayo Clinic website- High Blood Pressure article dated 9/9/2016 revealed the following categories to classify blood pressure:
-Normal blood pressure- when the blood pressure is normal if below 120/80 mmHg (millimeters of mercury)
-Prehypertension- Prehypertension is a systolic (top number-measures your arteries when your hear beats) pressure ranging from 120-139 mmHg or a diastolic (lower number-measures the pressure in your arteries between beats).
-Stage 1 hypertension- Stage 1 hypertension is a systolic pressure ranging from 140-159 mmHG or a diastolic pressure ranging from 90-99 mmHg.
-Stage 2 hypertension- More severe hypertension, stage 2 hypertension is a systolic pressure of 160 mmHG or higher or a diastolic pressure of 100 mmHg or higher.

Uncontrolled high blood pressure can lead to: heart attack or stroke, aneurysm, heart failure, weakened and narrowed blood vessels in the kidneys, thinkened, narrowed or torn blood vessels of the eyes, metabolic syndrome, trouble with memory or understanding.

An unannounced onsite Emergency Treatment and Labor Act (EMTALA) investigation began on 9/22/2016 and continued through 9/20/2016. Based on medical record review, review of the facility EMTALA policies, staff interviews and physician interview the facility failed to ensure 1 (#12) of 7 sampled patients who were transferred for further stabilizing treatment were transferred by an appropriate method with qualified personnel present to prevent potential further risk to the patient's health and safety. This failure posed an immediate threat to Patient 12's health and safety. Patient 12, a minor was brought to the Emergency Department (ED) on 7/10/16 and was found to have an Emergency Medical Condition related to suicidal attempt. The patient was transported by parent's private vehicle for direct admission to an acute care hospital providing adolescent psychiatric services. The total sample size was 30. Findings are:

A. Record review of Patient 12's medical record revealed the patient, a minor adolescent, was brought to the ED on 7/10/16 at 8:35 PM. The nursing documentation on arrival reveals the mother told the nurse the patient had been overdosing with an insulin pump. The patient is a diabetic and uses the insulin pump to infuse insulin through a subcutaneous site on a continual basis. The pump is programmed to deliver a continual rate of insulin and also a bolus or extra insulin to cover the consumption of carbohydrates to keep blood sugars in normal range. The American Diabetes Association defines target blood glucose (sugar) goals as 70-130 before meals and less that 180 after meals. The infusion of too much insulin can result in hypoglycemia (low blood glucose) that can result in a variety of symptoms ranging from clumsiness, trouble talking, confusion, loss of consciousness, seizures or death. The mother reported the patient had a history of suicidal intention. Humulog per Drug.com at www.drugs.com/humalog.html is identified as the insulin used by the patient. Humulog is used in insulin pumps to infuse insulin into the subcutaneous tissue by an infusion site. Humulog is a fast acting insulin beginning to lower blood sugar in 15 minutes and its effects last 6-8 hrs. The patient was also on Ambilify, and antipsychotic and Lexapro, and antidepressant/antianxiety medication.
The physician assessed the patient at 8:47 PM. Chief complaint in physician notes include "suicide attempt." The time of ingestion (insulin) was identified as 8 PM. The ingestion was intentional and the amount of insulin was 'Unknown." The patient's psychiatric assessment by the physician identified the patient was depressed with suicidal thoughts and hopelessness.
The Medical Screening Examination (MSE) included a Complete Blood Count, Complete Metabolic Profile and EKG. The potassium level was low at 3.2 (lab normal 3.5-5.0). Blood sugars performed in the ED were: 118 at 8:55 PM by fingerstick; 153 with lab draw at 9:25 PM and the last one done at 9:49 PM, a fingerstick with 152 blood sugar. EKG was normal. Aspirin and Tylenol blood levels were within normal limits.
Record review of the psychiatric assessment performed by Licensed Mental Health Practitioner (LMHP) "J" at 10:49 PM revealed the patient stated "I just want to die" and that the patient "took too much insulin." The patient revealed that there had been a previous attempt to harm self the same way in the past. The patient lives with the mother. Suicide risk score was "High." The patient confirmed having suicidal thoughts, intent and had a specific plan to end their life by overdosing on insulin. Judgement was identified as 'Poor." The LMHP reported the findings to the Psychiatrist on call who wanted the patient transferred and admitted to an inpatient acute psychiatric hospital that treats adolescents.
Record review of the form titled "Certificate of Transfer" dated 7/10/16 at 11:15 PM notes the patient was to be transferred by "POV" Privately Owned Vehicle. Vital signs at 11:00 PM before transfer were: BP 108/65; Pulse 70; Respirations 16 and Temperature 98.2 Fahrenheit. A blood sugar before transfer was not documented. Risks of transfer identified on the form include only "MVC" (motor vehicle collision) and benefits "definitive care." Under the section Patient condition the form has checked the box stating "There is not reasonable likelihood of deterioration from or during transport". The physician and the mother signed the transfer form.

B. Interview with LMHP "J" on 9/27/16 at 10:35 AM confirmed Patient #12 was suicidal and had a plan using insulin. The The patient told the LMHP they "wanted to die".The patient reported using insulin in the past for a suicide attempt. LMHP discussed the assessment with the psychiatrist on call who felt the patient needed acute inpatient care and hospitalization. The LMHP stated the patient had an Emergency Medical Condition based on the fact that Patient 12 was "actively suicidal." The LMHP did not know how the patient used insulin, if by shot or insulin pump, or know if the pump was still in the patient's possession.

C. Interview with Registered Nurse "G" on 9/27/16 at 5:00 PM. RN G confirmed being Patient 12's ED nurse on 7/10/16. The nurse was asked about the lack of documentation regarding the patient's insulin pump. The record does not contain what the settings were, infusion history evaluation or if the pump was still infusing into the patient. The nurse stated the patient "almost had to have had the pump on". The nurse thought the mom had shut it off before arrival. The nurse stated that the patient refused to talk to her or answer questions. The nursing information came from the mother. RN G confirmed a blood sugar was not done prior to transfer with the last one done at 9:49 PM. RN G confirmed the patient was suicidal and had an EMC requiring transfer. RN G recalled discussing with the Mother the method of transfer. The Mother related that the last time the patient went in the ambulance Patient 12 was uncooperative, taking off monitors and hitting staff. The nurse stated the Mother wanted to transport in her car. RN G stated the doctor makes the ultimate decision on the method to transfer. The nurse related that there is a place on the "Against Medical Advice" form that is used to document refusal of ambulance transfer. The nurse confirmed the record does not contain a refusal of ambulance transfer or any discussion with the patient regarding ambulance transfer.

D. Interview with Medical Doctor (MD) "C" who is the ED Medical Director on 9/28/16 at 9:05 AM regarding the ED record from the 7/10/16 visit for Patient 12 revealed confirmation that the patient had an EMC related to a psychiatric condition. Regarding transfer with the patient's insulin pump the physician responded that can be "tricky." Insulin is necessary to maintain normal insulin levels. It can be lethal if you leave it on or lethal if you take it off. MD C stated that it is a judgement call regarding whether the patient can be safely transferred by the mother and it depends on if they can be reliable and reasonable it "may be ok." MD C stated that the physician determines the method of transfer and verbally discusses it with the nurse. The physician signature on the transfer form verifies that it is a safe method to transfer.

E. Phone interview with MD "A" on 9/29/16 at 2:00 PM confirmed MD A was Patient 12's ED MD on 7/10/16. MD A related that he medically cleared the patient by doing repeat blood sugars to ensure they were not showing decline and that her laboratory results were negative. MD A determined the patient was stable for transfer to treat a psychiatric emergency. MD A did not know if the patient's insulin pump was infusing and with the patient or not. MD A reported a discussion with mom regarding transport to the psychiatric hospital by ambulance. The mom wanted to transport the patient as she felt an ambulance would cause increased stress. The mother did transport the patient by her private vehicle. MD A confirmed the discussion regarding transfer and refusal of transfer by ambulance was not documented in the record.

F. Record review of the receiving hospital admission documentation reveals the patient was admitted on 7/11/16. The attending psychiatrist documented the patient presented voluntary by guardian "after overdosed on her insulin pump and having to be taken to a hospital where she was medically cleared." The physician also noted that "upon her admission was taken off her insulin pump". The patient transferred by private vehicle with the insulin pump, method of suicide per patient, in their possession.

G. Record review of the facility policy titled "EMTALA- Emergency Medical Treatment and Active Labor Act" effective date 2/1/16 identified a psychiatric patient with potential harm to self or others would always be considered an emergency medical condition to be screened and treated. The policy defines an "Appropriate Transfer" is a transfer in which the physician has certified the patient condition for transfer, the destination facility and physician have accepted the care of the patient, the patient, or responsible party has agreed to the transfer and the needed equipment, level of staff and mode of transport is available. The transfer is to be provided through qualified personnel and transportation equipment as required and as determined by the transferring physician.
The section titled "Transfer by Private Vehicle": Patients being transferred for a hospital to hospital transfer who may be at risk of deterioration "shall be transferred by appropriate medical vehicle."; Patients requesting to utilize their private vehicle who are deemed capable of making such a decision by the responsible physician may do so upon meeting the documentation requirements for private vehicle transfer.; The requirements are discussion of risk/benefit and documentation of the risks discussed. The responsible persons understanding and capability of making an informed decision are to be documented.; The risks discussed will be inserted into the Ambulance Refusal Form in the section labeled "Risks." The Ambulance Refusal Form will be signed by the patient or responsible decision maker or if signature is refused that is to be noted on the form in the area provided for patient signature. The refusal form is to be signed by the physician or ED provider and witnessed on the form.; Where the physician or ED provider deems it appropriate they may further document the refusal and warnings provided through the use of an "Against Medical Advice" form. The record for Patient 12 does not include this documentation for transfer by private vehicle as required by facility policy.