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Based on interviews and document review, the facility failed to provide evidence of compliance of Emergency Medical Treatment and Labor Act (EMTALA) for the transfer of psychiatric patients to an accepting facility in five of five psychiatric transfer records reviewed (Patients #1, #2, #3, #4, and #6). Additionally, the facility failed to ensure a provider signed the certification of medical necessity for five of five medical records reviewed in which the patient was transferred to an outside facility (Patients #1, #2, #3, #4, and #6).

Findings include:

Facility policy:

The Discharge Planning for Psychosocial Emergencies Policy read, if the patient requires inpatient psychiatric treatment, the external mental health provider will arrange assessment findings. If psychiatric hospitalization is being arranged, the EMTALA forms do not need to be completed. If the patient does not meet inpatient treatment, the patient will be scheduled for an appointment with the external mental health provider, if in agreement.

1. The facility failed to ensure patients transferring to outside facilities were consented, provided the risks and benefits of the transfer, were transferring to an accepting facility and physician, and had a physician's certification pertaining to the reason for transfer.

a. Medical record review

i. Medical record review showed Patient #1 presented to the emergency department on 8/16/22 at 2:39 p.m. with extreme paranoia and hallucinations. Patient #1 had a history of schizophrenia. RN #4 documented the external mental health provider was contacted and provided the psychiatric medical screening exam for Patient #1. RN #4 documented the external mental health provider determined Patient #1 was appropriate for transfer and plans were made to transfer to an external mental health facility. Upon review, there was no evidence in the patient's medical record to indicate compliance with EMTALA including the patient's consent to transfer, the medical necessity for transfer, an accepting receiving facility and physician, and a physician's certification.

ii. Medical record review showed Patient #2 was brought from school by police to the emergency department on 9/20/22 at 12:21 p.m. with suicidal ideations with a plan to shoot herself with her grandmother's gun. Review of Patient #2's medical record showed the external mental health provider evaluated Patient #2 at her school before she was brought to the facility's emergency department. Review of the medical record showed there was no psychiatric health screening provided by the facility or the external mental health provider while she was in the facility's emergency department. RN #6 documented Patient #2 was accepted by an inpatient psychiatric facility. Upon review, there was no evidence of EMTALA paperwork or documentation in the patient's medical record to indicate compliance with EMTALA including the patient's consent to transfer and the medical necessity for transfer, an accepting receiving facility and physician, and a physician's certification.

iii. Medical record review showed Patient #3 was brought from school by police to the emergency department 1/16/23 at 7:09 p.m. for acute psychosis and had attempted to break his mother's arm. Patient #3 was placed on an M1 psychiatric hold (placed when an individual was deemed to be in imminent danger of harming him or herself or someone else or was gravely disabled). The external mental health provider completed the psychiatric medical screening exam and determined Patient #3 was appropriate for transfer to an external mental health facility. Upon review, there was no evidence of EMTALA paperwork or documentation in the patient's medical record to indicate compliance with EMTALA including the patient's consent to transfer and the medical necessity for transfer, an accepting receiving facility and physician, and a physician's certification.

iv. Similar findings of missing EMTALA paperwork or documentation in the patient's medical record to indicate compliance with EMTALA including the patient's consent to transfer and the medical necessity for transfer, an accepting receiving facility and physician, and a physician's certification were found in the medical records of Patients #4 and #6.

B. Interviews

i. An interview with the emergency department charge nurse (RN) #5 was conducted on 7/6/23 at 9:18 a.m. RN #5 stated patients who presented with psychiatric emergencies and required transfer to a psychiatric facility did not require EMTALA paperwork. RN #5 stated EMTALA paperwork was not required for patients with psychiatric emergencies because they were not transferred to a higher level of care. RN #5 stated she had been employed by the facility for 18 years and EMTALA paperwork was not required for psychiatric patients after 2010 when the external mental health provider was initially contracted. RN #5 stated transfer paperwork was completed by the external mental health provider who provided the patient transfer from the facility to a psychiatric facility.

ii. An interview with emergency department physician (Physician) #3 was conducted on 7/6/23 at 9:45 a.m. Physician #3 stated he only completed the certification of medical necessity for transfer patients with medical emergencies, not psychiatric emergencies. Physician #3 stated he was unsure of why the certification of medical necessity was not completed for psychiatric patients. Physician #3 stated he used to call the physician at the receiving facility to provide a report about a transferring psychiatric patient, however, this was not the current practice. Physician #3 stated forms were important to document risks and benefits that had been discussed with the patient and to provide evidence the transfer was appropriate.

C. Review of the Discharge Planning for Psychosocial Emergencies Policy revealed EMTALA forms did not need to be completed for patients who presented with psychiatric emergencies and required transfer.

This was in contrast to §489.24(e) related to the EMTALA requirements, which read, if an individual at a hospital has an emergency medical condition that has not been stabilized, the hospital may not transfer the individual unless; the individual (or a legally responsible person acting on the individual's behalf) requests the transfer, after being informed of the hospital's obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer; a physician has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based.

In addition, §489.24(e) read, A transfer to another medical facility will be appropriate only in those cases in which; the transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child; The receiving facility-- (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment; the transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification, and the name and address of any oncall physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital's files) must be sent as soon as practicable after transfer, and; the transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer