HospitalInspections.org

Based on review of hospital policy, ambulance trip report, dedicated emergency department (DED) log, DED meeting minutes, closed medical record review, and staff and physician interviews the facility failed to ensure compliance with 42 CFR 489.24.

The findings included:

1. The hospital failed to ensure an appropriate medical screening examination was completed for 1 of 28 sampled patients (Patient #12) with an emergency medical condition that presented to the hospital's dedicated emergency department (DED).

~cross refer to 489.24(r)(c) Medical Screening Exam - Tag A2406

2. The hospital failed to provide stabilizing treatment within its capability and capacity for 1 of 25 sampled patients (Patient #23) that presented to the hospital's dedicated emergency department with an emergency medical condition.

~ cross refer to 489.24(d) (1-3) Stabilizing Treatment- Tag A2407

3. The hospital's dedicated emergency department (DED) failed to ensure an appropriate transfer by failing to ensure physician certification that the medical benefits expected at the time of transfer outweighed the risks of transfer, failing to ensure the receiving facility had accepted the transfer and failing to send related medical records to the receiving facility for 1 of 7 patients transferred with an emergency medical condition (Patient #12).

~ cross refer to 489.24(e)(3) Appropriate Transfer - Tag A2409

Based on review of hospital policy, ambulance trip report, dedicated emergency department (DED) log and staff interviews, the hospital failed to ensure that each individual presenting to the DED seeking care for an emergency medical condition was included on the central DED log for 1 of 28 DED patients reviewed (Patient #12).

The findings include:

Review of the "Transfer of Patients To and From An Acute Care Facility" revised 09/2012 revealed "Policy: ... A Central Log is maintained by the Admissions Department listing all individuals who present for emergency services or receive a medical screening examination. The log includes the disposition of all patients whether admitted, treated, transferred, stabilized and transferred, discharged and/or refused treatment and/or voluntary withdrawals/walkouts...."

Review of an ambulance trip report from (local) County EMS confirmed that Patient #12 was taken to Hospital A's (receiving hospital) DED on 01/30/2013. Review of the trip report recorded the ambulance crew arrived at Hospital A (receiving hospital) at 0435. The report revealed the ambulance crew entered the DED with the patient and reported to the nurse that the patient was suicidal. Review revealed the nurse told the ambulance crew that the patient was "banned" from the hospital and told them to take the patient to Hospital B (transferring hospital). Review of the report recorded that the ambulance crew departed and took the patient to Hospital B where she was accepted.

Telephone interview on 03/07/2013 at 1425 with the Charge Nurse (RN #7) working on 01/30/2013 when Patient #12 was brought into the DED revealed Patient #12 walked into the DED entrance behind EMS staff. The staff member stated "I recognized her voice. I said to EMT 'She is only to be here if life threatening emergency like chest pain or something like that.' She said 'I want to go to (Hospital B) now.' We never established care. They turned around and walked out. I was aware of a restraining order. She had been there a few days before and had threatened staff. (Physician name) told me there was a restraining order. They said she was having suicide thoughts. I didn't take that as a life threatening emergency. I never assumed care of the patient."

Review of Hospital A's DED log on 03/06/2013 revealed no evidence Patient #12 had presented to the hospital's DED on 01/30/2013. Review of Patient #12's DED visits for the past year revealed no evidence of a DED visit or medical record on 01/30/2013.

Interview on 03/06/2013 at 1755 with administrative staff confirmed Patient #12 presented to the DED on 01/30/2013 via ambulance. Interview confirmed that Patient #12 was not on the DED log and should have been.

Based on review of hospital policy, ambulance trip report, dedicated emergency department (DED) log, DED meeting minutes, closed medical record review, and staff and physician interviews, the hospital failed to ensure an appropriate medical screening examination was completed for 1 of 28 sampled patients (Patient #12) with an emergency medical condition that presented to the hospital's dedicated emergency department (DED).

The findings include:

A policy related to EMTALA procedures was requested on 03/06/2013. Hospital administrative staff presented an "Emergency Medical Treatment and Active Labor Act (EMTALA)" policy that was approved February 26, 2013. Administrative staff reported on 03/06/2013 at 1755 that the hospital had a policy entitled "Transfer of Patients To and From An Acute Care Facility" revised 09/2012 that was used for EMTALA guidelines prior to the approval in February of this EMTALA policy. Review of the "Transfer of Patients To and From An Acute Care Facility" revised 09/2012 revealed no procedure for provision of a medical screening examination to patients presenting to the hospital's DED.

Review of an ambulance trip report from (local) County EMS confirmed that Patient #12 was taken to Hospital A's (receiving hospital) DED on 01/30/2013. Review of the trip report recorded the ambulance crew arrived at the patient's residence at 0413 and found the patient, a 49 year-old female "sitting on the couch saying she needed help with DTs (delirium tremors) from medication she has been abusing. Patient wanted to go to (Hospital B). I stated that (Hospital A) could help her and that was where we were going. I did not see any danger in patient not going to (Hospital B), so I assisted patient walk to the ambulance and once we were on the ambulance patient sit on stretcher in fowler position. 0423: (heart rate) 102, (Blood Pressure) 128/69, (Oxygen sat) 94% while on the ambulance as I talked with patient about her problems and obtained these vitals. 0432: (heart rate) 95, (BP) 122/70, (O2 sat) 92% these are the vital signs I obtained right before arriving at (Hospital A) ER. Patient was still talking and doing fairly well other than her problems in life. 0435: We arrived at (Hospital A) ER and took patient into the ER and (staff member name) I think was the last name, as I started to give report this nurse stated that our patient has to go to (Hospital B). I ask why and (nurse name) said that our patient cussed everyone there out and unless its life or death she is banned from this hospital. I said OK now this patient is saying she is gonna commit suicide. He said well life or death is the only way we will treat her. She has to go to (Hospital B). I said ok then let's go to the patient and we left on our way to (Hospital B - transferring hospital). 0445: (heart rate) 95, (BP) 114/75, (O2 sat) 94% while enroute to (Hospital B), patient was still doing the same, however her O2 sat was a little low so I administered O2 4 liters by NC (nasal cannula) to bring her O2 sats up. 0452: (heart rate) 92, (BP) 111/75, (O2 sat) 94% 0515: (heart rate) 90, (BP) 107/75, (O2 sat) 100% we arrived at (Hospital B) and walked our patient inside and placed patient in Room 6 and gave report to the nurse on duty. I told her the Hospital that (Hospital A) denied treatment of this patient and that she said she was suicide prone and needed help. I then transferred care."

Review on 03/06/2013 of Patient #12's DED visits for the past year revealed no evidence of a DED visit or medical record on 01/30/2013. Interview 03/06/2013 at 1755 with administrative staff confirmed there was no medical record for Patient #12 for 01/30/2013.

Review of Emergency Department Service Meeting minutes dated 02/06/2013 revealed "... New Business A. EMTALA - Discussion ensued regarding EMTALA and patients with no-trespass orders. Education of staff regarding no-trespass orders vs. restraining orders and emergency medical screening/EMTALA discussed. Documentation by ED staff in abusive patient situations discussed. (DED contract physician group) to forward initial/yearly EMTALA education/competency/refresher records for all providers/midlevels. Additional education/training to providers offered ...."

Interview on 03/06/2013 at 1755 with administrative staff revealed Hospital B had notified the facility on 01/30/2013 of a potential EMTALA violation related to Patient #12. Interview revealed an investigation was initiated immediately after notification of the possible EMTALA violation. The investigation consisted of DED staff and physician interviews, discussion with local County EMS staff and police. Interview revealed it was discovered that there was a document issued by the local Police Department that stated that Patient #12 was not allowed on the property of Hospital A and she would be charged with trespassing if the patient came onto the property. Interview revealed administrative staff were not aware of such a document prior to the incident on 01/30/2013. The investigation revealed the document was issued on 05/15/2012 when the patient was cursing and threatening staff after discharge. The patient reportedly would not leave the property and the local police were called. The police issued the written notice as a result of the incident and gave a copy of the written notice to hospital security who shared the information with emergency department staff. Interview revealed the patient was a "frequent flyer" and was well known to the DED staff and physicians. Administrative staff members stated the DED Charge Nurse stated he told EMS staff upon arrival that the patient was "banned" from the premises and could not be treated unless it was a life or death situation.

Interview on 03/07/2013 at 1215 with the DED nursing manager (RN #3) revealed she was notified about the event from a written letter from the involved nurse (RN #7). The letter stated Patient #12 was brought by EMS for treatment and the staff member recognized her. Review of the letter revealed the nurse told EMS staff that the patient was "banned from the hospital unless she was having life threatening illness I.E. chest or something like that because of her abusive nature to staff. (Patient #12) then stated to EMS 'I told you to take me to (Hospital B)' then she cursed a couple of times and they left. I advised (DED physician) after they left. We never registered her in, and she was always in the company of EMS." Further review of the letter revealed (Hospital B) staff called back to the DED nurse to notify the staff of a possible EMTALA violation. Interview with the nursing manager revealed several administrative staff meetings were held related to this incident and it had been determined that the patient should have been offered a medical screening examination and was not. The staff member stated the paperwork documenting that the patient was banned from the facility issued by the police had been discussed during these meetings.

Telephone interview on 03/07/2013 at 1425 with the Charge Nurse (RN #7) working on 01/30/2013 when Patient #12 was brought into the DED revealed Patient #12 walked into the DED entrance behind EMS staff. The staff member stated "I recognized her voice. I said to EMT 'She is only to be here if life threatening emergency like chest pain or something like that.' She said 'I want to go to (Hospital B) now.' We never established care. They turned around and walked out. I was aware of a restraining order. She had been there a few days before and had threatened staff. (Physician name) told me there was a restraining order. They said she was having suicide thoughts. I didn't take that as a life threatening emergency. I never assumed care of the patient."

Telephone interview on 03/07/2013 at 1505 with hospital security (staff #8) revealed he was working on 01/30/2013 when Patient #12 was brought into the DED. The staff member stated the charge nurse told EMS staff that she was "banned" from the DED because of abusive language to doctors and nurses. The patient said she didn't want to come here. She wanted to go to Hospital B. The staff member stated EMS took her to Hospital B.

Interview on 03/07/2013 at 1400 with hospital security staff (staff #5) revealed he knew Patient #12 because she came into the DED frequently. Interview revealed he was present on 01/30/2013 when the patient was brought into the DED. Interview revealed the staff member heard the patient say "I didn't want to come here" and EMS left and took the patient to Hospital B. Interview revealed the staff member was aware of the police department paperwork that stated that the patient was not to be on the hospital property. Interview revealed the staff member had been told that the hospital couldn't refuse to see the patient, but that she had to leave when she was discharged.

Telephone interview on 03/07/2013 at 1410 with the local Police Chief (police #6) revealed the document issued by the police department is not a restraining order. Interview revealed the document was a first step in notifying the identified person that trespassing charges will be pursued if they are found on the property creating a disturbance. Interview revealed the document for Patient #12 had been issued on 05/15/2012 at the request of hospital security after the patient caused a disturbance at the hospital after being discharged. Interview further revealed that these written notices are primarily issued for businesses like apartment complexes and it was understood that it would exclude any person seeking medical treatment.

Interview on 03/07/2013 at 1545 with an EMS staff member (EMS #10) that brought Patient #12 to the DED on 01/30/2013 revealed the patient was picked up at home and was having suicidal thoughts. The staff member stated upon arrival in the DED, the charge nurse told him that the patient was "banned and we would need to take her to (Hospital B). The patient wasn't agitated until that was said, then she got agitated. She had agreed to come to (Hospital A). She walked in for treatment." Interview revealed the nurse refused treatment so they EMS crew took the patient to Hospital B.

Interview on 03/07/2013 at 1520 with local County EMS Director (EMS #9) revealed he was aware of the incident involving Patient #12 on 01/30/2013. Interview revealed he had received a telephone call from Hospital B and had investigated this incident. Interview revealed it was the policy of EMS to transport locally whenever possible to maximize the availability of EMS transport trucks and to support the local hospital. The Director stated his investigation revealed the patient initially requested to go to Hospital B and then agreed to go to Hospital A. Upon arrival at Hospital A, the EMS crew were told that the patient was "banned" and the patient was refused treatment. EMS then transported the patient to Hospital B. Further interview revealed the Director had talked with hospital administration after the incident regarding improving communication and diversion issues.

Telephone interview on 03/07/2013 at 1600 with the DED physician (Physician #11) that was on duty on 01/30/2013 when Patient #12 arrived revealed he had no idea the patient was there. Interview revealed the physician was notified after the patient left and was told that she was taken to Hospital B. Interview revealed the physician was not aware that the patient had been "banned" and stated "I didn't know you could do that."

Review of Patient #12's DED record from Hospital B revealed the patient, a 49 year-old female arrived via EMS on 01/30/2013 at 0520 with a chief complaint of "I need psychiatric help." Record review revealed the patient was having suicidal thoughts and wanted help for withdrawal symptoms. Review revealed a medical screening examination was completed that included laboratory tests. Further review revealed the patient was placed on suicide precautions with a sitter at bedside and medications were administered. Record review revealed a psychiatric screening consult was conducted with recommendations for inpatient treatment. Record review revealed the patient was not an involuntary commitment and was transferred via EMS to another facility for inpatient treatment on 01/30/2013 at 1245.

Consequently, Patient #12 presented via EMS to the Hospital A's DED on 01/30/2013 for suicidal thoughts. DED nursing staff told EMS that the patient was banned and would not be seen and treated. EMS staff took the patient to Hospital B's DED where the patient was treated and subsequently transferred to another facility.

Based on review of hospital policy, ambulance trip report, dedicated emergency department (DED) log, DED meeting minutes, closed medical record review, and staff and physician interviews, the hospital failed to provide stabilizing treatment within its capability and capacity for 1 of 25 sampled patients (Patient #12) that presented to the hospital's dedicated emergency department with an emergency medical condition.

The findings include:

A policy related to EMTALA procedures was requested on 03/06/2013. Hospital administrative staff presented an "Emergency Medical Treatment and Active Labor Act (EMTALA)" policy that was approved February 26, 2013. Administrative staff reported on 03/06/2013 at 1755 that the hospital had a policy entitled "Transfer of Patients To and From An Acute Care Facility" revised 09/2012 that was used for EMTALA guidelines prior to the approval in February of this EMTALA policy. Review of the "Transfer of Patients To and From An Acute Care Facility" revised 09/2012 revealed "Policy: It is the policy of (hospital name) to provide care for all patients based on the patient's need for service and (hospital name) capability to provide those services and/or patient request for transfer."

Review of an ambulance trip report from (local) County EMS confirmed that Patient #12 was taken to Hospital A's (receiving hospital) DED on 01/30/2013. Review of the trip report recorded the ambulance crew arrived at the patient's residence at 0413 and found the patient, a 49 year-old female "sitting on the couch saying she needed help with DTs (delirium tremors) from medication she has been abusing. Patient wanted to go to (Hospital B). I stated that (Hospital A) could help her and that was where we were going. I did not see any danger in patient not going to (Hospital B), so I assisted patient walk to the ambulance and once we were on the ambulance patient sit on stretcher in fowler position. 0423: (heart rate) 102, (Blood Pressure) 128/69, (Oxygen sat) 94% while on the ambulance as I talked with patient about her problems and obtained these vitals. 0432: (heart rate) 95, (BP) 122/70, (O2 sat) 92% these are the vital signs I obtained right before arriving at (Hospital A) ER. Patient was still talking and doing fairly well other than her problems in life. 0435: We arrived at (Hospital A) ER and took patient into the ER and (staff member name) I think was the last name, as I started to give report this nurse stated that our patient has to go to (Hospital B). I ask why and (nurse name) said that our patient cussed everyone there out and unless its life or death she is banned from this hospital. I said OK now this patient is saying she is gonna commit suicide. He said well life or death is the only way we will treat her. She has to go to (Hospital B). I said ok then let's go to the patient and we left on our way to (Hospital B - transferring hospital). 0445: (heart rate) 95, (BP) 114/75, (O2 sat) 94% while enroute to (Hospital B), patient was still doing the same, however her O2 sat was a little low so I administered O2 4 liters by NC (nasal cannula) to bring her O2 sats up. 0452: (heart rate) 92, (BP) 111/75, (O2 sat) 94% 0515: (heart rate) 90, (BP) 107/75, (O2 sat) 100% we arrived at (Hospital B) and walked our patient inside and placed patient in Room 6 and gave report to the nurse on duty. I told her the Hospital that (Hospital A) denied treatment of this patient and that she said she was suicide prone and needed help. I then transferred care."

Review on 03/06/2013 of Patient #12's DED visits for the past year revealed no evidence of a DED visit or medical record on 01/30/2013. Interview on 03/06/2013 at 1755 with administrative staff confirmed there was no medical record for Patient #12 for 01/30/2013.

Review of Emergency Department Service Meeting minutes dated 02/06/2013 revealed "... New Business A. EMTALA - Discussion ensued regarding EMTALA and patients with no-trespass orders. Education of staff regarding no-trespass orders vs. restraining orders and emergency medical screening/EMTALA discussed. Documentation by ED staff in abusive patient situations discussed. (DED contract physician group) to forward initial/yearly EMTALA education/competency/refresher records for all providers/midlevels. Additional education/training to providers offered ...."

Interview on 03/06/2013 at 1755 with administrative staff revealed Hospital B had notified the facility on 01/30/2013 of a potential EMTALA violation related to Patient #12. Interview revealed an investigation was initiated immediately after notification of the possible EMTALA violation. The investigation consisted of DED staff and physician interviews, discussion with local County EMS staff and police. Interview revealed it was discovered that there was a document issued by the local Police Department that stated that Patient #12 was not allowed on the property of Hospital A and she would be charged with trespassing if the patient came onto the property. Interview revealed administrative staff were not aware of such a document prior to the incident on 01/30/2013. The investigation revealed the document was issued on 05/15/2012 when the patient was cursing and threatening staff after discharge. The patient reportedly would not leave the property and the local police were called. The police issued the written notice as a result of the incident and gave a copy of the written notice to hospital security who shared the information with emergency department staff. Interview revealed the patient was a "frequent flyer" and was well known to the DED staff and physicians. Administrative staff members stated the DED Charge Nurse stated he told EMS staff upon arrival that the patient was "banned" from the premises and could not be treated unless it was a life or death situation.

Interview on 03/07/2013 at 1215 with the DED nursing manager (RN #3) revealed she was notified about the event from a written letter from the involved nurse (RN #7). The letter stated Patient #12 was brought by EMS for treatment and the staff member recognized her. Review of the letter revealed the nurse told EMS staff that the patient was "banned from the hospital unless she was having life threatening illness I.E. chest or something like that because of her abusive nature to staff. (Patient #12) then stated to EMS 'I told you to take me to (Hospital B)' then she cursed a couple of times and they left. I advised (DED physician) after they left. We never registered her in, and she was always in the company of EMS." Further review of the letter revealed (Hospital B) staff called back to the DED nurse to notify the staff of a possible EMTALA violation. Interview with the nursing manager revealed several administrative staff meetings were held related to this incident and it had been determined that the patient should have been offered a medical screening examination and was not. The staff member stated the paperwork documenting that the patient was banned from the facility issued by the police had been discussed during these meetings.

Telephone interview on 03/07/2013 at 1425 with the Charge Nurse (RN #7) working on 01/30/2013 when Patient #12 was brought into the DED revealed Patient #12 walked into the DED entrance behind EMS staff. The staff member stated "I recognized her voice. I said to EMT 'She is only to be here if life threatening emergency like chest pain or something like that.' She said 'I want to go to (Hospital B) now.' We never established care. They turned around and walked out. I was aware of a restraining order. She had been there a few days before and had threatened staff. (Physician name) told me there was a restraining order. They said she was having suicide thoughts. I didn't take that as a life threatening emergency. I never assumed care of the patient."

Telephone interview on 03/07/2013 at 1505 with hospital security (staff #8) revealed he was working on 01/30/2013 when Patient #12 was brought into the DED. The staff member stated the charge nurse told EMS staff that she was "banned" from the DED because of abusive language to doctors and nurses. The patient said she didn't want to come here. She wanted to go to Hospital B. The staff member stated EMS took her to Hospital B.

Interview on 03/07/2013 at 1400 with hospital security staff (staff #5) revealed he knew Patient #12 because she came into the DED frequently. Interview revealed he was present on 01/30/2013 when the patient was brought into the DED. Interview revealed the staff member heard the patient say "I didn't want to come here" and EMS left and took the patient to Hospital B. Interview revealed the staff member was aware of the police department paperwork that stated that the patient was not to be on the hospital property. Interview revealed the staff member had been told that the hospital couldn't refuse to see the patient, but that she had to leave when she was discharged.

Telephone interview on 03/07/2013 at 1410 with the local Police Chief (police #6) revealed the document issued by the police department is not a restraining order. Interview revealed the document was a first step in notifying the identified person that trespassing charges will be pursued if they are found on the property creating a disturbance. Interview revealed the document for Patient #12 had been issued on 05/15/2012 at the request of hospital security after the patient caused a disturbance at the hospital after being discharged. Interview further revealed that these written notices are primarily issued for businesses like apartment complexes and it was understood that it would exclude any person seeking medical treatment.

Interview on 03/07/2013 at 1545 with an EMS staff member (EMS #10) that brought Patient #12 to the DED on 01/30/2013 revealed the patient was picked up at home and was having suicidal thoughts. The staff member stated upon arrival in the DED, the charge nurse told him that the patient was "banned and we would need to take her to (Hospital B). The patient wasn't agitated until that was said, then she got agitated. She had agreed to come to (Hospital A). She walked in for treatment." Interview revealed the nurse refused treatment so they EMS crew took the patient to Hospital B.

Interview on 03/07/2013 at 1520 with local County EMS Director (EMS #9) revealed he was aware of the incident involving Patient #12 on 01/30/2013. Interview revealed he had received a telephone call from Hospital B and had investigated this incident. Interview revealed it was the policy of EMS to transport locally whenever possible to maximize the availability of EMS transport trucks and to support the local hospital. The Director stated his investigation revealed the patient initially requested to go to Hospital B and then agreed to go to Hospital A. Upon arrival at Hospital A, the EMS crew were told that the patient was "banned" and the patient was refused treatment. EMS then transported the patient to Hospital B.

Telephone interview on 03/07/2013 at 1600 with the DED physician (Physician #11) that was on duty on 01/30/2013 when Patient #12 arrived revealed he had no idea the patient was there. Interview revealed the physician was notified after the patient left and was told that she was taken to Hospital B. Interview revealed the physician was not aware that the patient had been "banned" and stated "I didn't know you could do that."

Review of Patient #12's DED record from Hospital B revealed the patient, a 49 year-old female arrived via EMS on 01/30/2013 at 0520 with a chief complaint of "I need psychiatric help." Record review revealed the patient was having suicidal thoughts and wanted help for withdrawal symptoms. Review revealed a medical screening examination was completed that included laboratory tests. Further review revealed the patient was placed on suicide precautions with a sitter at bedside and medications were administered. Record review revealed a psychiatric screening consult was conducted with recommendations for inpatient treatment. Record review revealed the patient was not an involuntary commitment and was transferred via EMS to another facility for inpatient treatment on 01/30/2013 at 1245.

Consequently, Patient #12 presented via EMS to the Hospital A's DED on 01/30/2013 for suicidal thoughts. DED nursing staff told EMS that the patient was banned and would not be seen and treated. EMS staff took the patient to Hospital B's DED where the patient was treated and subsequently transferred to another facility.

Based on review of hospital policy, ambulance trip report, dedicated emergency department (DED) log, DED meeting minutes, closed medical record review, and staff and physician interviews, the hospital's dedicated emergency department (DED) failed to ensure an appropriate transfer by failing to ensure physician certification that the medical benefits expected at the time of transfer outweighed the risks of transfer, failing to ensure the receiving facility had accepted the transfer and failing to send related medical records to the receiving facility for 1 of 7 patients transferred with an emergency medical condition (Patient #12).

The findings include:

A policy related to EMTALA procedures was requested on 03/06/2013. Hospital administrative staff presented an "Emergency Medical Treatment and Active Labor Act (EMTALA)" policy that was approved February 26, 2013. Administrative staff reported on 03/06/2013 at 1755 that the hospital had a policy entitled "Transfer of Patients To and From An Acute Care Facility" revised 09/2012 that was used for EMTALA guidelines prior to the approval in February 2013 of this EMTALA policy. Review of the "Transfer of Patients To and From An Acute Care Facility" revised 09/2012 revealed "Policy: ... When the physician, in consultation with the patient and family, has determined transfer to another facility to be appropriate, in the best interest of the patient, and the patient is medically stable, the order will be given by the physician and necessary transfer forms completed. The receiving organization must agree to accept the patient. The physician will contact, provide clinical information to the receiving physician and complete the Authorization Consent for Transfer form.... Process: 1. B. Acceptance of patient must be verified by receiving physician and facility. Document name of person verifying acceptance of patient and to whom the report was given...F. Copy medical record as requested by the attending physician. Copied portion of the record is to accompany patient...."

Review of an ambulance trip report from (local) County EMS confirmed that Patient #12 was taken to Hospital A's (receiving hospital) DED on 01/30/2013. Review of the trip report recorded the ambulance crew arrived at the patient's residence at 0413 and found the patient, a 49 year-old female "sitting on the couch saying she needed help with DTs (delirium tremors) from medication she has been abusing. Patient wanted to go to (Hospital B). I stated that (Hospital A) could help her and that was where we were going. I did not see any danger in patient not going to (Hospital B), so I assisted patient walk to the ambulance and once we were on the ambulance patient sit on stretcher in fowler position. 0423: (heart rate) 102, (Blood Pressure) 128/69, (Oxygen sat) 94% while on the ambulance as I talked with patient about her problems and obtained these vitals. 0432: (heart rate) 95, (BP) 122/70, (O2 sat) 92% these are the vital signs I obtained right before arriving at (Hospital A) ER. Patient was still talking and doing fairly well other than her problems in life. 0435: We arrived at (Hospital A) ER and took patient into the ER and (staff member name) I think was the last name, as I started to give report this nurse stated that our patient has to go to (Hospital B). I ask why and (nurse name) said that our patient cussed everyone there out and unless its life or death she is banned from this hospital. I said OK now this patient is saying she is gonna commit suicide. He said well life or death is the only way we will treat her. She has to go to (Hospital B). I said ok then let's go to the patient and we left on our way to (Hospital B - transferring hospital). 0445: (heart rate) 95, (BP) 114/75, (O2 sat) 94% while enroute to (Hospital B), patient was still doing the same, however her O2 sat was a little low so I administered O2 4 liters by NC (nasal cannula) to bring her O2 sats up. 0452: (heart rate) 92, (BP) 111/75, (O2 sat) 94% 0515: (heart rate) 90, (BP) 107/75, (O2 sat) 100% we arrived at (Hospital B) and walked our patient inside and placed patient in Room 6 and gave report to the nurse on duty. I told her the Hospital that (Hospital A) denied treatment of this patient and that she said she was suicide prone and needed help. I then transferred care."

Review on 03/06/2013 of Patient #12's DED visits for the past year revealed no evidence of a DED visit or medical record on 01/30/2013. Interview with administrative staff confirmed there was no medical record for Patient #12 for 01/30/2013.

Interview on 03/06/2013 at 1755 with administrative staff revealed Hospital B had notified the facility on 01/30/2013 of a potential EMTALA violation related to Patient #12. Interview revealed an investigation was initiated immediately after notification of the possible EMTALA violation. The investigation consisted of DED staff and physician interviews, discussion with local County EMS staff and police. Interview revealed it was discovered that there was a document issued by the local Police Department that stated that Patient #12 was not allowed on the property of Hospital A and she would be charged with trespassing if the patient came onto the property. Interview revealed administrative staff were not aware of such a document prior to the incident on 01/30/2013. The investigation revealed the document was issued on 05/15/2012 when the patient was cursing and threatening staff after discharge. The patient reportedly would not leave the property and the local police were called. The police issued the written notice as a result of the incident and gave a copy of the written notice to hospital security who shared the information with emergency department staff. Interview revealed the patient was a "frequent flyer" and was well known to the DED staff and physicians. Administrative staff members stated the DED Charge Nurse stated he told EMS staff upon arrival that the patient was "banned" from the premises and could not be treated unless it was a life or death situation.

Interview on 03/07/2013 at 1215 with the DED nursing manager (RN #3) revealed she was notified about the event from a written letter from the involved nurse (RN #7). The letter stated Patient #12 was brought by EMS for treatment and the staff member recognized her. Review of the letter revealed the nurse told EMS staff that the patient was "banned from the hospital unless she was having life threatening illness I.E. chest or something like that because of her abusive nature to staff. (Patient #12) then stated to EMS 'I told you to take me to (Hospital B)' then she cursed a couple of times and they left. I advised (DED physician) after they left. We never registered her in, and she was always in the company of EMS." Further review of the letter revealed (Hospital B) staff called back to the DED nurse to notify the staff of a possible EMTALA violation. Interview with the nursing manager revealed several administrative staff meetings were held related to this incident and it had been determined that the patient should have been offered a medical screening examination and was not. The staff member stated the paperwork documenting that the patient was banned from the facility issued by the police had been discussed during these meetings.

Telephone interview on 03/07/2013 at 1425 with the Charge Nurse (RN #7) working on 01/30/2013 when Patient #12 was brought into the DED revealed Patient #12 walked into the DED entrance behind EMS staff. The staff member stated "I recognized her voice. I said to EMT 'She is only to be here if life threatening emergency like chest pain or something like that.' She said 'I want to go to (Hospital B) now.' We never established care. They turned around and walked out. I was aware of a restraining order. She had been there a few days before and had threatened staff. (Physician name) told me there was a restraining order. They said she was having suicide thoughts. I didn't take that as a life threatening emergency. I never assumed care of the patient."

Telephone interview on 03/07/2013 at 1505 with hospital security (staff #8) revealed he was working on 01/30/2013 when Patient #12 was brought into the DED. The staff member stated the charge nurse told EMS staff that she was "banned" from the DED because of abusive language to doctors and nurses. The patient said she didn't want to come here. She wanted to go to Hospital B. The staff member stated EMS took her to Hospital B.

Interview on 03/07/2013 at 1400 with hospital security staff (staff #5) revealed he knew Patient #12 because she came into the DED frequently. Interview revealed he was present on 01/30/2013 when the patient was brought into the DED. Interview revealed the staff member heard the patient say "I didn't want to come here" and EMS left and took the patient to Hospital B. Interview revealed the staff member was aware of the police department paperwork that stated that the patient was not to be on the hospital property. Interview revealed the staff member had been told that the hospital couldn't refuse to see the patient, but that she had to leave when she was discharged.

Telephone interview on 03/07/2013 at 1410 with the local Police Chief (police #6) revealed the document issued by the police department is not a restraining order. Interview revealed the document was a first step in notifying the identified person that trespassing charges will be pursued if they are found on the property creating a disturbance. Interview revealed the document for Patient #12 had been issued on 05/15/2012 at the request of hospital security after the patient caused a disturbance at the hospital after being discharged. Interview further revealed that these written notices are primarily issued for businesses like apartment complexes and it was understood that it would exclude any person seeking medical treatment.

Interview on 03/07/2013 at 1545 with an EMS staff member (EMS #10) that brought Patient #12 to the DED on 01/30/2013 revealed the patient was picked up at home and was having suicidal thoughts. The staff member stated upon arrival in the DED, the charge nurse told him that the patient was "banned and we would need to take her to (Hospital B). The patient wasn't agitated until that was said, then she got agitated. She had agreed to come to (Hospital A). She walked in for treatment." Interview revealed the nurse refused treatment so they EMS crew took the patient to Hospital B.

Interview on 03/07/2013 at 1520 with local County EMS Director (EMS #9) revealed he was aware of the incident involving Patient #12 on 01/30/2013. Interview revealed he had received a telephone call from Hospital B and had investigated this incident. Interview revealed it was the policy of EMS to transport locally whenever possible to maximize the availability of EMS transport trucks and to support the local hospital. The Director stated his investigation revealed the patient initially requested to go to Hospital B and then agreed to go to Hospital A. Upon arrival at Hospital A, the EMS crew were told that the patient was "banned" and the patient was refused treatment. EMS then transported the patient to Hospital B. Further interview revealed the Director had talked with hospital administration after the incident regarding improving communication and diversion issues.

Telephone interview on 03/07/2013 at 1600 with the DED physician (Physician #11) that was on duty on 01/30/2013 when Patient #12 arrived revealed he had no idea the patient was there. Interview revealed the physician was notified after the patient left and was told that she was taken to Hospital B. Interview revealed the physician was not aware that the patient had been "banned" and stated "I didn't know you could do that."

Review of Patient #12's DED record from Hospital B revealed the patient, a 49 year-old female arrived via EMS on 01/30/2013 at 0520 with a chief complaint of "I need psychiatric help." Record review revealed the patient was having suicidal thoughts and wanted help for withdrawal symptoms. Review revealed a medical screening examination was completed that included laboratory tests. Further review revealed the patient was placed on suicide precautions with a sitter at bedside and medications were administered. Record review revealed a psychiatric screening consult was conducted with recommendations for inpatient treatment. Record review revealed the patient was not an involuntary commitment and was transferred via EMS to another facility for inpatient treatment on 01/30/2013 at 1245.

Consequently, Patient #12 presented via EMS to the Hospital A's DED on 01/30/2013 for suicidal thoughts. DED nursing staff told EMS that the patient was banned and would not be seen and treated. EMS staff took the patient to Hospital B's DED where the patient was treated and subsequently transferred to another facility. The hospital's dedicated emergency department (DED) failed to ensure an appropriate transfer by failing to ensure physician certification that the medical benefits expected at the time of transfer outweighed the risks of transfer, failing to ensure the receiving facility had accepted the transfer and failing to send related medical records to the receiving facility.