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Based on observation, record review and interview, the hospital failed to ensure compliance with 42 CFR 489.20 in 1 of 6 required areas (A-2405: Logs); and failed to ensure compliance with 42 CFR 489.24, in 3 of 6 required areas (A-2406: Appropriate Medical Screening, A-2507: Stabilizing Treatment, and A-2409: Appropriate Transfer).

Findings include:

1) The 8/13/15 at 3 p.m. observation of ED surveillance video for Patient #1 and 8/13/15 at 3 p.m. interview with Director of Quality A reveals that when Patient #1 came to the emergency room seeking care on 7/24/15 at 10:29 p.m., the hospital failed to register Patient #1 on it's central log of patients seeking emergency medical treatment. (Reference A-2405)

2) The 8/13/15 observation of ED surveillance video for Patient #1 and 8/14/15 record review of 19 (ED) emergency department medical records reveals that 5 of the 20 ED patients (Patient #'s 1, 2, 7, 9 and 16) did not receive an appropriate MSE. The 8/14/15 at 4:45 p.m. interview with ED Manager B reveals no additional information. (Reference A- 2406)

The 8/14/15 record review of 19 of 20 patients requesting emergency department care (Patient #'s 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20), reveals a lack of an effective triage procedure that prioritized patients based on their presenting symptoms when used as part of the MSE. The 8/14/15 at 4:45 p.m. interview with ED Manager B reveals no additional information. (Reference A- 2406)

3) The 8/13/15 observation of ED surveillance video for Patient #1 and 8/14/15 record review of 19 (ED) emergency department medical records reveals that 3 of 20 ED patients (Patient #'s 1, 2 and 9) had documented information of the benefits and risks of refusing a MSE. The 8/14/15 at 4:45 p.m. interview with ED Manager B reveals no additional information(Reference A- 2407)

4) The 8/14/15 record review of 1 of 2 patients transferred to a receiving hospital (Patient #14), in a total sample of 20 patients, failed to have written documentation of benefits of transfer in the medical record. The 8/14/15 at 4:45 p.m. interview with ED Manager B reveals no additional information. (Reference A- 2409)

Based on observation and interview, the hospital failed to have a central log of every individual that came to the emergency department seeking care, in 1 of 20 ED patients (Patient #1).

Findings include:

Observations of a copy of ED surveillance video was made, in the presence of Director of Quality A on 8/13/15 at 3 p.m. Video surveillance recording (Video #4), dated 7/24/15 at 10:29 p.m. (no sound) was displayed on a laptop computer. Patient #1 was observed at 10:29 p.m. to be seated in wheelchair between the ED registration desk and the ED entrance doors. Patient #1 was observed to be accompanied by two males who appear to hold shoulders and legs in an attempt to keep Patient #1 in wheelchair. Patient #1 was observed, per video, to be extremely restless in wheelchair and hold both legs straight in front of body. Patient #1 was observed to strike right leg and grasp left calf while moving about in wheelchair. At 10:31 p.m., RN G and Unit Clerk/Coordinator I are observed to stop, observe and appear to speak to Patient #1 and the two accompanying males. At 10:32, the ED physician E is observed to come up to Patient #1, take stethoscope from around neck, insert in ears and lean over Patient #1. E is then observed to back away from Patient #1. E appears to speak while gesturing with hands and steps out of video range of Patient #1 at 10:33 p.m. As Patient #1 remains in the same location, a police officer comes through the ED entrance doors at 10:35 p.m. The two males are appear to talk with police officer for approximately 35 seconds, while Patient #1 struggles with the males and grabs for the entrance door. At 10:35 p.m., the wheelchair-bound Patient #1 and the two accompanying males are observed to exit through the ED entrance doors.

During interview with A, at the time of the showing of the video recording, A reveals that Patient #1 may have been in the hospital's ED as early as 10:14 p.m., but surveillance video captured at that time was unable to be displayed. A states that at an unknown time before 10:29 p.m., Patient #1 had an encounter with ED RN F. A stated there is no written registration record on the central ED log of Patient #1's ED visit. A stated that there was no medical record initiated for Patient #1 that documented hospital staff conversations/ instructions, Patient #1's behavior, nursing /medical care given, or Patient #1's exit from the ED.

Based on observation, record review and interview, the hospital failed to ensure that all persons coming to the ED (Emergency Department) requesting care had an appropriate MSE (Medical Screening Exam), in 5 of 20 ED patients (Patient #'s 1, 2, 7, 9, and 16); and failed to have, as part of that MSE, a triage procedure that prioritized patients based on their presenting symptoms, in 19 of 20 patients requesting emergency department care. (Patient #'s 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20).

Findings include:

The 8/17/15 at 9 a.m. record review of "Corporate Policy #1.30- Emergency Medical Treatment and Labor Act Screening, Treatment, and Transfer of Patients, effective June 1990" states under "Patient screening and treatment,
1. Appropriate medical screening. When a patient comes to the hospital seeking medical treatment, the hospital shall provide an appropriate medical screening examination to determine whether the patient has an emergency medical condition...Note: the patient is considered to have "come to the hospital" and therefore is entitled to a screening examination and treatment under this policy if the patient presents anywhere on the hospital property, including outside on the hospital's parking lot or sidewalks, as well as anywhere in the hospital, including all departments.
2. Qualified medical personnel to conduct screening. The patient must be screened by a physician or other qualified medical personnel (QMP) who has been designated as a QMP by the hospital in its bylaws or its rules and regulations. Non-physician personnel who are not designated as a QMP by the hospital by-laws or rules and regulations may not perform the screening, even if asked to do so by the ER medical director or other physician...".

The 8/17/15 at 9 a.m. record review of "Corporate Policy #1.30- Emergency Medical Treatment and Labor Act Screening, Treatment, and Transfer of Patients, effective June 1990" states under "Patient screening and treatment-Basic Screening Procedure" that "2a. The nurse will triage and prioritize patients. Based on their acuity and room availability, patients will be either directed to an examination room or directed to the ER registration desk and then placed in a room as it becomes available. Regardless of the order of patients established by triage, all patients shall be given an appropriate medical screening...".

1) On 8/12/15, the state agency received a facility self -report from hospital's Director of Quality A alleging a possible EMTALA violation surrounding the care of Patient #1 in their ED on 7/24/15.

During interview with Director of Quality A on 8/13/15 at 12:10 p.m., A stated that the hospital conducted an investigation surrounding the ED care given to Patient #1, after receiving a complaint by telephone from the mother of Patient #1 on 7/27/15. A stated that interviews with the involved staff were conducted, and that ED video surveillance had been viewed. A stated that Patient #1 came into the ED on 7/24/15 at approximately 10:30 p.m. requesting care, did not receive a MSE, and went to another area hospital, where Patient #1 was treated for Diabetic Ketoacidosis.

Observations of a copy of ED surveillance video was made, in the presence of Director of Quality A on 8/13/15 at 3 p.m. Video surveillance recording (Video #4), dated 7/24/15 at 10:29 p.m. (no sound) was displayed on a laptop computer. Patient #1 was observed at 10:29 p.m. to be seated in wheelchair between the ED registration desk and the ED entrance doors. Patient #1 was observed to be accompanied by two males who appear to hold shoulders and legs in an attempt to keep Patient #1 in wheelchair. Patient #1 was observed, per video, to be extremely restless in wheelchair and hold both legs straight in front of body. Patient #1 was observed to strike right leg and grasp left calf while moving about in wheelchair. At 10:31 p.m., RN G and Unit Clerk/Coordinator I are observed to stop, observe and appear to speak to Patient #1 and the two accompanying males. At 10:32, the ED physician E is observed to come up to Patient #1, take stethoscope from around neck, insert in ears and lean over Patient #1. E is then observed to back away from Patient #1. E appears to speak while gesturing with hands and steps out of video range of Patient #1 at 10:33 p.m. As Patient #1 remains in the same location, a police officer comes through the ED entrance doors at 10:35 p.m. The two males are appear to talk with police officer for approximately 35 seconds, while Patient #1 struggles with the males and grabs for the entrance door. At 10:35 p.m., the wheelchair-bound Patient #1 and the two accompanying males are observed to exit through the ED entrance doors.

During continued interview with A, at the time of the showing of the video recording, A reveals that Patient #1 may have been in the hospital's ED as early as 10:14 p.m., but surveillance video captured at that time was unable to be displayed. A states that at an unknown time before 10:29 p.m., Patient #1 had an encounter with ED RN F. A stated that there is no documented record of Patient #1's ED visit. A stated that there was no medical record initiated for Patient #1. A stated there is no written registration record, no documentation of hospital staff conversations/ instructions, no documentation of Patient #1's behavior and no documentation of nursing /medical care given to Patient #1, while Patient #1 was seated in hospital wheelchair located between ED entrance door and registration desk.

During interview with RN G on 8/13/15 at 5:15 p.m. RN G stated "I was passing through the ED when I saw Patient #1 sitting in a wheelchair thrashing" around. RN G told of Patient #1 being held in wheelchair by two males, one of which stated "you need to help (Patient #1)", (Patient #1's) a diabetic and has been drinking". RN G told of the doctor approaching Patient #1, listening to heart, and telling patient to calm down. RN G stated that patient was thrashing the entire time and pushed doctor away. RN G told of the doctor telling Patient #1 that they could not treat patient until patient calmed down, and if behavior continued the police would be called. RN G stated when Patient #1 heard what the doctor said, patient "thrashed around" trying to move to the door stating "I refuse treatment, I don't want to be here, take me to Tomah (hospital)", and tried to push self out door. When asked if Patient #1 appeared to be in pain during the encounter, RN G stated "yes".

Interview with ED Physician E, on 8/13/15 at 5:30 p.m. reveals that E heard Patient #1 "screaming and yelling" and cursing from inside the emergency treatment area, and came out to the registration desk to find Patient #1 complaining of cramping feet. E stated that "I was told the patient had been drinking and was a diabetic". E remembered attempting to listen to lungs, but stated that "I could not hear" because of yelling and cursing from Patient #1. E told of telling Patient #1 and accompanying males that Patient #1 would have to control self before patient could be seen. E stated "Patient #1 was being disruptive to other ED patients". E stated that Patient #1 was "uncontrollable", therefore E told staff to call the police. E stated after police arrived, "I talked to police officer and told officer that I would be willing to see Patient #1, if patient was under control". E stated "I fully expected Patient #1 to show back up" in the ED for treatment.

Interview with RN F, the ED RN, on 8/17/15 at 6:55 a.m. reveals that F talked to Patient #1 and accompanying males when Patient #1 entered the ED door. F stated "I was told about muscle cramping and patient being diabetic. I asked if patient had been injured, and offered to do a blood sugar". RN F stated that "Patient #1 lunged at me from chair". F stated that "I was concerned for my personal safety, and returned to ED treatment area to tell staff to call police". F told of talking to police officer and offering to see the patient, if the police officer was present. F told of believing that Patient #1 "refused care" before leaving this ED.

The 8/17/15 record review of "Emergency Departmental procedure" for "Subject: Disruptive Patient Management" (with no effective date or policy number) states: "...disruptive patients will be cared for in the emergency department in a safe manner for patients, staff and visitors...Specific causes of disruptive behavior will be identified and appropriately managed by the emergency department RN and physician...When necessary, activation of the hospital's security plan will be initiated by emergency department staff members...Law enforcement officers may be requested to assist in the management of disruptive patients as needed. When necessary, appropriate chemical or physical restraint will be used to assist the patient in the management of a safe environment for all present, until the underlying medical cause or condition can be identified and therapy initiated.

2) The 8/14/15 at 1:30 p.m. record review of Patient #2's "clinical data" sheet, and the "Mile Bluff EDM- ED Summary" documents that Patient #2 came in to the ED on 2/2/15 at 1:09 p.m., with complaints of Abdominal Pain. At 4:19 p.m., RN H documents that patient was discovered absent at 2:05 p.m. RN H documents "had a scheduled appointment for complaints of abdominal pain with PCP at 2 p.m. Patient was hoping to be seen earlier by coming to the ER. ER busy and patient chose to go to scheduled appointment. Chose not to wait any longer. Decided that problem was resolved. Disagreed with medical advice provided".

There was no documented evidence Patient #2's pain complaints were assessed/ triaged by nursing staff in a timely manner during the time that Patient #2 sat in the waiting area. There was no documented evidence that a QMP conducted a MSE to rule out an EMC.

During interview with ED Manager B, on 8/14/15 at 4:45 p.m., B stated "There is no additional information" about this ED visit.

3) The 8/14/15 at 2 p.m. record review of Patient #7's "clinical data" sheet, and the "Mile Bluff EDM- ED Summary" documents that Patient #7 came in to the ED on 4/23/15 at 5:20 p.m., with complaints of Suicidal Ideation. At 5:58 p.m., RN B documents "Patient met Crisis worker J at hospital in meditation room (room in hallway near the ED), received crisis worker evaluation, determined not to have a condition that is in need of emergency department assessment or intervention. Patient was not seen by ER staff. Crisis worker J did complete note. Crisis worker J dismissed patient and family before informing ER staff, resulting in no AMA form signature."

The 8/14/15 record review of the Crisis Worker J's " Intervention Outcome Notes" in the "ED summary" reveals that Patient #7 "wanted to die". Crisis worker J recommended that patient be brought to the ED for evaluation. J documents that patient denies having plan or suicidal intent, and after talking to patient's parents sent patient home. J requested that parents make "therapy appointment" in the morning.

The 8/17/15 record review of the "Medical Staff By-Laws, dated 8/26/14" reveals no information regarding County Crisis worker J as a QMP, who can provide a MSE to rule out an EMC.

There was no documented evidence that a QMP conducted a MSE to rule out an EMC.

The 8/17/15 record review of the "Emergency Departmental Procedure 72.00.25, Subject: Outpatient Psychological Crisis Evaluation and Intervention, effective date March 1981" states "Procedure: 1. Patients who come to the emergency department with actual or suspected psychological or emotional crisis will receive appropriate nursing and medical evaluations. 1.A. Nursing evaluations may include suicide assessment, depression assessment, anxiety assessment, or other nursing assessments as appropriate for the patient's condition and or stated purpose of emergency visit. 1.B. Every patient will receive an assessment to determine the actual or potential presence of an emergency medical condition.
During interview with ED Manager B, on 8/14/15 at 4:45 p.m., B stated "There is no additional information" about this ED visit.

4) The 8/14/15 at 2:20 p.m. record review of Patient #9's "clinical data" sheet, and the "Mile Bluff EDM- ED Summary" documents that Patient #9 came in to the ED on 6/10/15 at 7:20 p.m., with complaints of Chest Pain and Abdominal Cramping. At 7:30 p.m., RN K documents "Per registration, patient wanted to go sit in car for awhile. RN went to get patient to check patient in, unable to locate at this time." At 8 p.m., RN K documents "Patient did not return to ER from going outside, assumed patient left AMA."

There was no documented evidence Patient #9's pain complaints were assessed/ triaged by nursing staff in a timely manner. There was no documented evidence that a QMP conducted a MSE to rule out an EMC before Patient #9 left without being seen.

During interview with ED Manager B, on 8/14/15 at 4:45 p.m., B stated "There is no additional information" about this ED visit.

5) The 8/14/15 at 4 p.m. record review of Patient #16's "clinical data" sheet, and the "Mile Bluff EDM- ED Summary" documents that Patient #16 came in to the ED on 7/24/15 at 10:10 p.m., with complains of Urinary Tract Infection. The nursing assessment was done at 10:47 p.m. through 11:22 p.m. by RN F. Documentation by RN F reveals that patient had a urinalysis (lab test for urine) conducted at 10:27 p.m., and was given "Pyridium (urinary pain reliever) and Cipro (antibiotic) 250 mg. BID (twice daily) per Insty meds" at 20:47 p.m. before being discharged home at 11:11 p.m. There is no documented evidence that the only QMP (Physician E) on duty at the time of Patient #16's ED stay provided this patient with a medical screening exam.

Review of RN F's employee file on 8/14/15 at 12 noon, reveals a Wisconsin Registered Nurse license. There is no documented evidence that RN F is a QMP, who can provide a MSE to ED patients.

During interview with ED Manager B, on 8/14/15 at 4:45 p.m., B stated "There is no additional information" about this ED visit.

6) The 8/14/15 record review between 1:30 p.m. and 4:20 p.m. of 17 of 20 emergency department records (Patient #'s 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20) reveals that there was no documented evidence of a RN triage assessment, to define the order or ranking of how patients would be seen by the ED physicians or QMPs based of symptom severity.

During interview with ED Clinical Manager B on 8/14/15 at 9 a.m., B stated that nursing staff are attempting to put patients in ED treatment rooms as soon as they come into the ED for treatment. B stated that the ED nurses are doing their patient assessments after patients are taken into one of the 5 ED treatment rooms, from the waiting room area. B stated that based on that in-room assessment, ED patient chart's are placed on the nursing station desk in order of how medical staff should see patients. B states that there are no specific written ED policies that direct nursing staff how to triage ED patients. B stated that the non-licensed unit coordinator has a role in decision-making regarding whether patients go to emergency department or urgent care when presenting to the ED registration desk at the designated entrance having emergency /urgent care signage.

6. a.) The 8/14/15 at 1:30 p.m. record review of Patient #2's "clinical data" sheet, and the "Mile Bluff EDM- ED Summary" documents that Patient #2 came in to the ED on 2/2/15 at 1:09 p.m., with complaints of Abdominal Pain. At 4:19 p.m., RN H documents that patient was discovered absent at 2:05 p.m. RN H documents "had a scheduled appointment for complaints of abdominal pain with PCP at 2 p.m. Patient was hoping to be seen earlier by coming to the ER. ER busy and patient chose to go to scheduled appointment. Chose not to wait any longer. Decided that problem was resolved. Disagreed with medical advice provided".

There is no documented evidence that Patient #2 was triaged by a RN and given a sequence of priority for the obtainment of a MSE from a physician or other QMP.

6. b.) The 8/14/15 at 1:45 p.m. record review of Patient #5's "clinical data" sheet, and the "Mile Bluff EDM- ED Summary" documents that Patient #5 came in to the ED on 3/6/15 at 3:14 p.m., with complaints of Vomiting, Bloody Stools and Fainting. At 4:46 p.m. (1 hour and 46 minutes later) a nursing assessment and MSE were conducted. Patient #5 was given diagnosis of "Partial/ Early Bowel Obstruction".

There is no documented evidence that Patient #5 was triaged by a RN and given a sequence of priority for the obtainment of a MSE from a physician or other QMP.

7) The 8/14/15 record review between 1:30 p.m. and 4:20 p.m. reveals that in 5 of 20 ED records reviewed for Patient #'s 3, 6, 11, 13 and 17, the MSE preceded the RN assessment, making the hospital's systems of chart placement order ineffective.

7. a.) Patient #3's 2/28/15 emergency department visit reveals that MSE was done at 6:54 p.m. while nursing assessment was done at 7:02 p.m. There is no documented evidence of nursing triage or nursing assessment before 7:02 p.m.

7. b.) Review of Patient #6's 4/18/15 emergency department visit reveals that MSE was done at 11:16 p.m. while nursing assessment was done at 11:46 p.m. There is no documented evidence of nursing triage or nursing assessment before 11:46 p.m.

7. c.) Review of Patient #11's 7/24/15 emergency department visit reveals that MSE was done at 7:54 p.m. while nursing assessment was done at 7:35 p.m. There is no documented evidence of nursing triage or nursing assessment before 7:35 p.m.

8. d.) Review of Patient #13's 7/24/15 emergency department visit reveals that MSE was done at 8:41 p.m. while nursing assessment was done at 9:08 p.m. There is no documented evidence of nursing triage or nursing assessment before 9:08 p.m.

8. e.) Review of Patient #17's 7/24/15 emergency department visit reveals that MSE was done at 10:02 p.m. while nursing assessment was done at 12:01 a.m. There is no documented evidence of nursing triage or nursing assessment before 12:01 a.m.

The 8/17/15 record review of Emergency "Departmental Procedure #72.00.66, effective date January 2001, Subject: Screening for appropriate Immediate Health Care Services" reveals that it is a guide for selecting where patients will be treated when presenting to the emergency/urgent care registration desk. There is no documented evidence in this policy that it is used to rank severity or order of medical screening exam.

The 8/17/15 record review of the "Treatment Location Guide - reference table for non-professional staff" reveals that it is a decision-making system to determine where patients, presenting to the ED registration desk, are assigned to go (ED or Urgent Care) based on problem type. There is no documented evidence that this policy is used to rank severity or order of medical screening exam.

Based on observation, record review and interview, the hospital failed to ensure that patients refusing further medical treatment had explanation of benefits of further MSE (medical screening examination) and risks of not continuing examination for possible treatment, and have this information documented in their medical record, for 3 of 19 ED patients (Patient #'s 1, 2 and 9).

Findings include:

The 8/17/15 at 9 a.m. record review of "Corporate Policy #1.30- Emergency Medical Treatment and Labor Act Screening, Treatment, and Transfer of Patients, effective June 1990" states under:
"6. Voluntary withdrawal.
If an individual refuses to consent to a medical screening examination or treatment to stabilize an emergency medical condition the following procedures will be followed: a. Encourage examination and treatment. Offer the individual further medical examination and treatment within the staff and facilities available at the hospital as may be required to identify and stabilize an emergency medical condition. b. Explain risk and benefits. Give the individual or a person acting on the individual's behalf an explanation of the risk and benefits to the individual of the examination and/ or treatment. c. Note in record. Describe in the individual's medical record the examination and/or treatment that the individual refused. Obtain written refusal of examination/ treatment. Take all reasonable steps to obtain the written informed refusal of the examination and/ or treatment from the individual or the person acting on the individual's behalf."

1) The 8/13/15 at 3 p.m. observation of ED surveillance video shows Patient #1 came to the ED on 8/24/15 at approximately 10:30 p.m. complaining of Leg Cramping. Patient #1 was observed on surveillance video to be agitated, and based on staff interview (ED Physician E, ED RN F and medical -surgical RN G) to be verbally abusive towards ED staff (E and F). ED staff E and F called for a police presence to control Patient #1, and after police arrived. RN G stated that Patient #1 refused ED treatment at the hospital.

There was no documented evidence that ED staff or other hospital staff informed Patient #1/ Patient #1's representatives of benefits of having a MSE or the risks of not having a MSE.

2) The 8/14/15 at 1:30 p.m. record review of Patient #2's "clinical data" sheet, and the "Mile Bluff EDM- ED Summary" documents that Patient #2 came in to the ED on 2/2/15 at 1:09 p.m., with complaints of Abdominal Pain. At 4:19 p.m., RN H documents that patient was discovered absent at 2:05 p.m. RN H documents "had a scheduled appointment for complaints of abdominal pain with PCP at 2 p.m. Patient was hoping to be seen earlier by coming to the ER. ER busy and patient chose to go to scheduled appointment. Chose not to wait any longer. Decided that problem was resolved. Disagreed with medical advice provided".

There was no documented evidence in Patient #2's ED medical record of what "medical advice" was given to Patient #2. There was no documented evidence that RN H or other hospital staff informed Patient #2 of benefits of having a MSE or the risks of not having a MSE. There was no documented evidence that written informed refusal was provided to Patient #2 for signature.

3) The 8/14/15 at 2:10 p.m. record review of Patient #9's "clinical data" sheet, and the "Mile Bluff EDM- ED Summary" documents that Patient #9 came in to the ED on 6/10/15 at 7:20 p.m., with complaints of Chest Pain and Abdominal Cramping. At 7:30 p.m., RN K documents "Per registration, patient wanted to go sit in car for awhile. RN went to get patient to check patient in, unable to locate at this time." At 8 p.m., RN K documents "Patient did not return to ER from going outside, assumed patient left AMA."

There was no documented evidence in Patient #9's ED medical record of "medical advice" given regarding the benefits of having a MSE or the risks of not having a MSE as the documentation of RN K states.

During interview with ED Manager B, on 8/14/15 at 4:45 p.m., B stated "There is no additional information" about these 3 ED visits.

Based on record review and interview, the hospital failed to ensure that physician certification of ED patient transfer included written documentation of benefits of hospital transfer, in 1 of 2 ED patients (Patient #14) being transferred to a receiving hospital, in a total sample of 20 patients.

Findings include:

The 8/17/15 at 9 a.m. record review of "Corporate Policy #1.30- Emergency Medical Treatment and Labor Act Screening, Treatment, and Transfer of Patients, effective June 1990" states under "D. b. Physician certification - ... The certification must contain a summary of the specific risk and benefits on which it is based."

Medical record review on 8/14/15 at 3:40 p.m. reveals that Patient #14 came to the ED on 7/24/15 with complaints of Anxiety. After MSE, ED physician E documented on the "Certification of Informed Consent for Transfer" that the patient was "medically stable". E failed to document "the benefits of transferring this patient".

During interview with ED Manager B, on 8/14/15 at 4:45 p.m., B stated "There is no additional information" about these 3 ED visits.