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Based on records reviewed the Hospital failed to ensure that the Physician On-Call List consisted of individual physician names and not physician group names, which was not consistent with the Hospital policy.

Findings included:

The policy titled Emergency Medical Treatment & Active Labor Act (EMTALA), dated 3/12/13, indicated that the physician on-call list must consist of individual physician names and not physician group names.

The Physician On-Call List, dated February 2015, December 2015, January 2016, April 2016, and May 2016 indicated an Ears, Nose and Throat Service (ENT) was on-call, the individual physician name was not listed on the On-call list as required.

The Physician On-Call List, dated February 2015, December 2015, January 2016, April 2016, and May 2016 indicated the neurology service listed the neurology group as the on-call physician for the Neurology Service, the individual physician name was not listed on the On-call list as required.

The Physician On-Call List, dated February 2015, December 2015, January 2016, April 2016, and May 2016 indicated the Gastroenterology service was on-call, the individual physician name was not listed on the On-call list as required.

Based on records reviewed for 10 of 10 Hospital's behavioral health services vendor practitioners the Hospital failed to ensure that the behavioral health services vendor practitioners performed Medical Screening Examinations only after they were determined to be qualified by the Hospital Bylaws and rules and regulations.

Findings included:

The policy titled Emergency Medical Treatment & Active Labor Act, dated 3/12/13, indicated every patient who presented to the Hospital's Emergency Department and requested an examination or treatment of a potential Emergency Medical Condition would receive an appropriate Medical Screening Examination to determine if the patient was experiencing an Emergency Medical Condition.

The policy titled Emergency Medical Treatment & Active Labor Act, dated 3/12/13, indicated an Emergency Medical Condition was defined as a medical condition manifested by acute symptoms of sufficient severity (including psychiatric disturbances) that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy. The policy indicated a Medical Screening Examination was a screening process required to determine with reasonable clinical confidence if an Emergency Medical Condition existed. The policy indicated Qualified Medical Personnel were individuals, in addition to physicians, authorized by the Hospital in accordance with its Medical Staff Bylaws and or Governing Body and approved Hospital policies to perform a Medical Screening Examination within their scope of practice. The policy indicated Qualified Medical Personnel included Licensed Independent Clinical Social Workers for the limited purpose of performing psychosocial assessments, which included a past and current history of psychiatric problems, medications, assessment of suicide or homicide attempt or risk, assessment of assaultive or violent behavior that indicated danger to self or others, i.e. a mental status examination only.

The policy titled Evaluation of Crisis Patients in the Emergency Department (ED), dated 2/22/16, indicated the disposition decision (i.e. admission to a psychiatric hospital or discharge to home) for the patient was made by the ED physician, based on information obtained from the Crisis team (behavioral health services vendor) Staff.

Patient #1's ED Medical Record, dated 5/9/16, indicated Hospital's behavioral health services vendor Staff #1, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation and based the evaluation recommendation Patient #1 was discharged.

Patient #2's ED Medical Record, dated 5/11/16, indicated Hospital's behavioral health services vendor Staff #3, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation.

Patient #5's ED Medical Record, dated 4/28/15, indicated Hospital's behavioral health services vendor Staff #4, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation and based the evaluation recommendation Patient #5 was discharged.

Patient #6's ED Medical Record, dated 5/1/16, indicated Hospital's behavioral health services vendor Staff #5, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation and based the evaluation recommendation Patient #6 was discharged.

Patient #7's ED Medical Record, dated 5/9/16, indicated Hospital's behavioral health services vendor Staff #6, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation.

Patient #8's ED Medical Record, dated 5/9/16, indicated Hospital's behavioral health services vendor Staff #5, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation.

Patient #9's ED Medical Record, dated 5/10/16, indicated Hospital's behavioral health services vendor Staff #3, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation.

Patient #10's ED Medical Record, dated 5/10/16, indicated Hospital's behavioral health services vendor #7, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation.

Patient #14's ED Medical Record, dated 5/12/16, indicated Hospital's behavioral health services vendor Staff #7, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation and based the evaluation recommendation Patient #14 was discharged.

Patient #15's ED Medical Record, dated 5/11/16, indicated Hospital's behavioral health services vendor Staff #7, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation.

Patient #16's ED Medical Record, dated 5/11/16, indicated Hospital's behavioral health services vendor Staff #6, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation and based the evaluation recommendation Patient #16 was discharged.

Patient #19's ED Medical Record, dated 3/27/16, indicated Hospital's behavioral health services vendor Staff #6, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation.

Patient #20's ED Medical Record, dated 4/6/16, indicated Hospital's behavioral health services vendor Staff #8, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation.

Patient #21's ED Medical Record, dated 12/5/15, indicated Hospital's behavioral health services vendor Staff #6, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation and based the evaluation recommendation Patient #21 was discharged.

Based on records reviewed and interviews the Hospital failed for 5 (Patients #2, 12, 13, 15 and 20) of 14 transferred patients from a21 total sampled patient medical records the Hospital failed to ensure that Emergency Department physicians documented in the patient's medical record whether or not the patients' Emergency Medical Condition was stabilized at the time of transfer.

Findings included:

The policy titled Emergency Medical Treatment & Active Labor Act, dated 3/12/13, indicated stabilized meant that the Emergency Department physician determined that no significant deterioration of the Emergency medical Condition was likely to result from or occur during transfer of the patient from the Hospital

Patient #2's Authorization for Transfer Form, undated, indicated that the physician did not document of Patient #2's condition was stabilized at the time of transfer.

Patient #12's Authorization for Transfer Form, dated 5/16/16 at 11:25 A.M., indicated that the physician did not document of Patient #12's condition was stabilized at the time of transfer.

Patient #13's Authorization for Transfer Form, dated 5/15/16 at 1:45 P.M., indicated that the physician did not document of Patient #13's condition was stabilized at the time of transfer.

Patient #15's Authorization for Transfer Form, dated 5/14/16 at 11:24 A.M., indicated that the physician did not document of Patient #15's condition was stabilized at the time of transfer.

Patient #20's Authorization for Transfer Form, dated 4/7/16 at 2:23 P.M., indicated that the physician did not document of Patient #20's condition was stabilized at the time of transfer.

Based on records reviewed for 5 of 12 (Patients #2, 12, 15, 19 and 20) of a total sample of 21 sampled patient medical records the Hospital failed to document that appropriate medicals records from the medical screening examination were sent to the receiving hospital.

Findings included:

The Authorization for Transfer Form, undated and for Patient #2, indicated that the physician did not document that the receiving facility was provided with appropriate medical records of the examination and treatment of the patient.

The Authorization for Transfer Form, dated 5/16/16 at 11:25 A.M. for Patient #12, indicated that the physician did not document that the receiving facility was provided with appropriate medical records of the examination and treatment of the patient.

The Authorization for Transfer Form, dated 5/14/16 at 11:42 A.M. for Patient #15, indicated that the physician did not document that the receiving facility was provided with appropriate medical records of the examination and treatment of the patient.

The Authorization for Transfer Form, dated 3/29/16 at 8:00 P.M. for Patient #19, indicated that the physician did not document that the receiving facility was provided with appropriate medical records of the examination and treatment of the patient.

The Authorization for Transfer Form, dated 4/7/16 at 2:23 P.M. for Patient #20, indicated that the physician did not document that the receiving facility was provided with appropriate medical records of the examination and treatment of the patient.

Based on records reviewed the Hospital failed to ensure that the Physician On-Call List consisted of individual physician names and not physician group names, which was not consistent with the Hospital policy.

Findings included:

The policy titled Emergency Medical Treatment & Active Labor Act (EMTALA), dated 3/12/13, indicated that the physician on-call list must consist of individual physician names and not physician group names.

The Physician On-Call List, dated February 2015, December 2015, January 2016, April 2016, and May 2016 indicated an Ears, Nose and Throat Service (ENT) was on-call, the individual physician name was not listed on the On-call list as required.

The Physician On-Call List, dated February 2015, December 2015, January 2016, April 2016, and May 2016 indicated the neurology service listed the neurology group as the on-call physician for the Neurology Service, the individual physician name was not listed on the On-call list as required.

The Physician On-Call List, dated February 2015, December 2015, January 2016, April 2016, and May 2016 indicated the Gastroenterology service was on-call, the individual physician name was not listed on the On-call list as required.

Based on records reviewed for 10 of 10 Hospital's behavioral health services vendor practitioners the Hospital failed to ensure that the behavioral health services vendor practitioners performed Medical Screening Examinations only after they were determined to be qualified by the Hospital Bylaws and rules and regulations.

Findings included:

The policy titled Emergency Medical Treatment & Active Labor Act, dated 3/12/13, indicated every patient who presented to the Hospital's Emergency Department and requested an examination or treatment of a potential Emergency Medical Condition would receive an appropriate Medical Screening Examination to determine if the patient was experiencing an Emergency Medical Condition.

The policy titled Emergency Medical Treatment & Active Labor Act, dated 3/12/13, indicated an Emergency Medical Condition was defined as a medical condition manifested by acute symptoms of sufficient severity (including psychiatric disturbances) that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy. The policy indicated a Medical Screening Examination was a screening process required to determine with reasonable clinical confidence if an Emergency Medical Condition existed. The policy indicated Qualified Medical Personnel were individuals, in addition to physicians, authorized by the Hospital in accordance with its Medical Staff Bylaws and or Governing Body and approved Hospital policies to perform a Medical Screening Examination within their scope of practice. The policy indicated Qualified Medical Personnel included Licensed Independent Clinical Social Workers for the limited purpose of performing psychosocial assessments, which included a past and current history of psychiatric problems, medications, assessment of suicide or homicide attempt or risk, assessment of assaultive or violent behavior that indicated danger to self or others, i.e. a mental status examination only.

The policy titled Evaluation of Crisis Patients in the Emergency Department (ED), dated 2/22/16, indicated the disposition decision (i.e. admission to a psychiatric hospital or discharge to home) for the patient was made by the ED physician, based on information obtained from the Crisis team (behavioral health services vendor) Staff.

Patient #1's ED Medical Record, dated 5/9/16, indicated Hospital's behavioral health services vendor Staff #1, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation and based the evaluation recommendation Patient #1 was discharged.

Patient #2's ED Medical Record, dated 5/11/16, indicated Hospital's behavioral health services vendor Staff #3, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation.

Patient #5's ED Medical Record, dated 4/28/15, indicated Hospital's behavioral health services vendor Staff #4, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation and based the evaluation recommendation Patient #5 was discharged.

Patient #6's ED Medical Record, dated 5/1/16, indicated Hospital's behavioral health services vendor Staff #5, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation and based the evaluation recommendation Patient #6 was discharged.

Patient #7's ED Medical Record, dated 5/9/16, indicated Hospital's behavioral health services vendor Staff #6, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation.

Patient #8's ED Medical Record, dated 5/9/16, indicated Hospital's behavioral health services vendor Staff #5, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation.

Patient #9's ED Medical Record, dated 5/10/16, indicated Hospital's behavioral health services vendor Staff #3, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation.

Patient #10's ED Medical Record, dated 5/10/16, indicated Hospital's behavioral health services vendor #7, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation.

Patient #14's ED Medical Record, dated 5/12/16, indicated Hospital's behavioral health services vendor Staff #7, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation and based the evaluation recommendation Patient #14 was discharged.

Patient #15's ED Medical Record, dated 5/11/16, indicated Hospital's behavioral health services vendor Staff #7, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation.

Patient #16's ED Medical Record, dated 5/11/16, indicated Hospital's behavioral health services vendor Staff #6, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation and based the evaluation recommendation Patient #16 was discharged.

Patient #19's ED Medical Record, dated 3/27/16, indicated Hospital's behavioral health services vendor Staff #6, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation.

Patient #20's ED Medical Record, dated 4/6/16, indicated Hospital's behavioral health services vendor Staff #8, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation.

Patient #21's ED Medical Record, dated 12/5/15, indicated Hospital's behavioral health services vendor Staff #6, not determined to be qualified by Hospital Bylaws, provided a behavioral health screening evaluation and based the evaluation recommendation Patient #21 was discharged.

Based on records reviewed and interviews the Hospital failed for 5 (Patients #2, 12, 13, 15 and 20) of 14 transferred patients from a21 total sampled patient medical records the Hospital failed to ensure that Emergency Department physicians documented in the patient's medical record whether or not the patients' Emergency Medical Condition was stabilized at the time of transfer.

Findings included:

The policy titled Emergency Medical Treatment & Active Labor Act, dated 3/12/13, indicated stabilized meant that the Emergency Department physician determined that no significant deterioration of the Emergency medical Condition was likely to result from or occur during transfer of the patient from the Hospital

Patient #2's Authorization for Transfer Form, undated, indicated that the physician did not document of Patient #2's condition was stabilized at the time of transfer.

Patient #12's Authorization for Transfer Form, dated 5/16/16 at 11:25 A.M., indicated that the physician did not document of Patient #12's condition was stabilized at the time of transfer.

Patient #13's Authorization for Transfer Form, dated 5/15/16 at 1:45 P.M., indicated that the physician did not document of Patient #13's condition was stabilized at the time of transfer.

Patient #15's Authorization for Transfer Form, dated 5/14/16 at 11:24 A.M., indicated that the physician did not document of Patient #15's condition was stabilized at the time of transfer.

Patient #20's Authorization for Transfer Form, dated 4/7/16 at 2:23 P.M., indicated that the physician did not document of Patient #20's condition was stabilized at the time of transfer.

Based on records reviewed for 5 of 12 (Patients #2, 12, 15, 19 and 20) of a total sample of 21 sampled patient medical records the Hospital failed to document that appropriate medicals records from the medical screening examination were sent to the receiving hospital.

Findings included:

The Authorization for Transfer Form, undated and for Patient #2, indicated that the physician did not document that the receiving facility was provided with appropriate medical records of the examination and treatment of the patient.

The Authorization for Transfer Form, dated 5/16/16 at 11:25 A.M. for Patient #12, indicated that the physician did not document that the receiving facility was provided with appropriate medical records of the examination and treatment of the patient.

The Authorization for Transfer Form, dated 5/14/16 at 11:42 A.M. for Patient #15, indicated that the physician did not document that the receiving facility was provided with appropriate medical records of the examination and treatment of the patient.

The Authorization for Transfer Form, dated 3/29/16 at 8:00 P.M. for Patient #19, indicated that the physician did not document that the receiving facility was provided with appropriate medical records of the examination and treatment of the patient.

The Authorization for Transfer Form, dated 4/7/16 at 2:23 P.M. for Patient #20, indicated that the physician did not document that the receiving facility was provided with appropriate medical records of the examination and treatment of the patient.