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Based on interview and record review, Facility A failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA) as evidenced by:

1. Facility A failed to provide necessary stabilizing treatment to an individual with an Emergency Medical Condition (EMC). For one of 20 sampled patients (Patient 7). This failure resulted in Patient 7 to not receive stabilizing treatment for an emergency medical condition, and had the potential for Patient 7 to commit suicide.

2. Facility A failed to have a procedure in place to ensure standardized care, stabilizing treatment, or transfer criteria to outside facility for burn patients. For one of 20 sampled patients (Patient 1). This failure resulted in Patient 1 to not receive standardized care, and transfer to a higher level of care, with the potential for worsening of his burns.

3. Facility A failed to ensure one of 20 sampled patients (Patient 12) or responsible party (RP) for Patient 12, signed a consent acknowledging the risks and benefits of transferring to another facility after a medical emergency was identified and stabilized (state where, within reasonable clinical confidence, the emergency condition resolved, or no deterioration is expected). This failure had the potential for Patient 12's Responsible party (RP) to be unaware of the benefits and risks of transfer to another facility.

Findings:
1. During a review of Patient 7's Emergency Patient Record, Record indicated, Patient 7 arrived to Facility A's Emergency Department on 12/16/24 at 2253 (10:53pm). Record indicated, Patient 7's complaint was "Suicidal", with a "Priority 2" (acuity levels are numbered one through five, with levels one and two indicating the greatest urgency.) Record indicated, Patient 7 stated complaint of "I've had massive amounts of voices telling me to kill myself for years. I want to put myself in front of a car".

During a review of Patient 7's "Suicide Assessment" (Columbia Scale: assessment tool to determine suicide risk) dated 12/16/24 at 2320 (11:20pm) indicated a score of "High risk" signed by Registered Nurse A (RN A).

During a review of Patient 7's Emergency Patient Record, record indicated "Medical Health History. . .Bipolar [A disorder associated with episodes of mood swings ranging from depressive lows to manic highs], Schizophrenia [A disorder that affects a person's ability to think, feel, and behave clearly], Dual Personality Disorder [A disorder characterized by the presence of two or more distinct personality states]".

During a review of Patient 7's Emergency Patient Record dated 12/17/24, at 0030 (12:30am) indicated, "Per PT [patient 7] he hears voices that tell him to self harm himself. . . Per pt [patient 7] he is off his meds" Signed by RN B.

During a review of Patient 7's Emergency Patient Record dated 12/17/24 indicated, no AMA (against medical advice) form was signed.

During a review of Patient 7's Physician Progress Note, dated 12/17/24 0010 (1210am) "Patient was a 36-year old man comes in complaining of suicidal thoughts. Patient states he has been feeling this way all day. Patient states he was not been on [sic] any medications for a long time. . .Communications/Consultations: Tele psych: Patient evaluated by Psychiatrist. He meets criteria for 5150 hold [an involuntary legal hold for patients at risk to harm themselves or others for up to 72 hours]. Patient was unable to contract for safety. . .Primary Impression Suicidal Ideations". Signed by Medical Doctor C (MD C).

During a review of Patient 7's Emergency Patient Record dated 12/17/24, at 0150 (1:50am) indicated, Patient 7 "reports hearing voices to harm self. Pt [patient 7] appears anxious, getting out of bed pacing back and forth". Signed by RN B.

During a review of Patient 7's Emergency Patient Record dated 12/17/24, at 0305 (305am) indicated, Patient 7 "walked out of ER with all belongings".

During an interview on 12/31/24 at 802 a.m., with RN A, RN A stated, she was the triage nurse the night patient 7 came into the Emergency Department. RN A stated, "If they [patients] score a high on the suicide risk assessment, I can't let them leave my sight, while they are in the chair. I call the charge nurse and let them know they [patient] needs a sitter [staff member responsible for observing patients who are at risk for harm] and a room". RN A stated, she is aware all patients who score high for suicide risk (Columbia scale), need to have a one to one sitter immediately. RN A stated, the staff member who receives the patient to their room will complete the environmental safety check (removing any wires, curtains, or sharp objects a patient could harm themselves with) and documents that the sitter (one to one observation) is in place to monitor the patient. RN A stated, "the MD puts an order in for the sitter".

During a review of Patient 7's Orders dated 12/16-12/17/24 indicated, no order for sitter(one to one observation). No orders for medications were charted. A psychiatric consultation was ordered at 2318 (1118pm).

During an interview on 1/2/25, at 9:57 a.m., with MD C. MD C stated, he completed the medical screening exam for Patient 7 on 12/16/24. MDS C stated, Patient 7 had expressed SI (suicidal ideations) which is an emergency medical condition. MD C stated, all patients who are suicidal should have a sitter with them. MD C stated, he was informed by staff, Patient 7 eloped from the Emergency Department prior to the psychiatric consultation.

During a review of Patient 7's Emergency Patient Record dated 12/16-12/17, indicated, no documentation patient's environmental safety checklist was completed, no documentation was found to indicated Patient 7 had continuous monitoring. No documentation was found to indicated Patient 7 received any stabilizing treatment for his Suicidal Ideation prior to eloping on 12/17/24 at 0305 (3:05 pm).

During a review of Facility A's P&P titled, "Suicide Risk Assessment and Management for Non-behavioral Health Settings the P&P indicated, "Ensure. . .all patients twelve (12) years and older are assessed for risk of suicide with appropriate suicide precautions implemented as indicated. . . Columbia Suicide Severity Rating Scale (C-SSRS): Initial screening tool utilized by the nurse. It will provide an auto calculated level of no risk, low, moderate, or high risk. . .One to one observation [aka sitter] (continuous observation): May be implemented as virtual/ line of sight or physical in-person. . .this is initiate by nursing based on the C-SSRS score. . .E. The at risk patient's (low, moderate, or high) environment will be made safe by implementing the checklist and observation precautions. . .A, Continuous Observation (1:1) is required if the patient is screened high suicide risk on the C-SSRS. . .Emergency Detention A. California (5150): If a patient is determined to be low, moderate, or high risk for suicide and refuses to remain in the hospital for a psychiatric evaluation, an Emergency Detention may be requested and executed".

2. During a review of Patient 1's Physician Note dated 12/17/24, note indicated, "[Patient 1] here today [facility A] for burn to the lower extremities bilaterally x 1 hour. He has multiple burns to his feet, ankles, shins, and inner thighs. He states that he was using matches and it dropped on his blanket which started a fire. . .Multiple 2nd degree burns [partial thickness burns
Second-degree burns involve both layers of the skin]. 2nd degree covering entire left dorsal [front] thigh. 3cm x 3 cm diameter 2nd degree on the right ankle. 10cm by 7cm degree burn on the dorsal feet bilaterally. . . I discussed diagnosis with patient and the patient agrees with discharge home with burn unit follow up in 3-5 days. . .Disposition Decision Discharged to Home Yes Time 1345 [145pm] Signed by Physician Assistant E (PA E), and approved by Supervising Physician MD D.

During an interview on 12/3/24 at 4:29 p.m., with Quality Staff F (QS F), QS F stated, "we do not have a specific policy for treatment for burn patients".

During a review of Patient 1's ED Provider Note at Facility B dated 12/19/24, (3 days after visit at Facility A), note indicated, Patient 1 was seen at Facility B's Emergency department at 1:26p.m. Note indicated, "Extremities: no deformities, + third degree burns to b/l [bilateral] feet/ worse at heels, with whitish tissue insensate [lacking sensation] multiple b/l [bilateral] . . .wounds to thighgs [sic] with broken blisters and erythematous [redness] base, yellow discharge noted in L [left] heel. . . Medical Decision Making . . . #Burns: third and second degree burns to thighs/shins/feet. Wounds were not debrided [remove damaged tissue or foreign objects from a wound] at outside hospital [Facility A]. . . Admitted for third degree burns management, pain control. . .Diagnosis 1. Full thickness burn [Third-degree burns destroy the epidermis and dermis. Third-degree burns may also damage the underlying bones, muscles, and tendons.] of foot".

During a review of Patient 1's "Plastic & Burn Surgery Consult" at Facility B, dated 12/19/24, consult indicated, "Burns: bilateral lower extremities and fingers of both hands-deep full thickness burns". Consult indicated, Patient 1 required multiple Skin Graft Applications [process of using donor skin to provide blood flow and close open wounds or burns].

During an interview on 1/6/25, at 2:35 p.m., with MD D, MD D stated, she was the supervising physician on 12/17/24 at Facility A, when Patient 1 came to the Emergency Department. MD D stated, she is not aware the facility has a specific policy for burn patients. MD D stated, she does not know of a specific policy or guidelines from Facility A on when to transfer a burn patient since Facility A does not have a burn unit, she follows one of the professional medical association guidelines in caring for burn patients, but cannot recall the organization name. MD D stated, she generally will transfer a burn patient if they have over 10% total body surface area burned to Facility B. MD D stated, for Patient 1, the Physician Assistant (PA E) who charted did not specify the total body surface area for his burns.


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3. During a review of the ED Note-Physician, 'Emergency provider report,' (signed 11/5/2024), this document indicated Patient 12, who was 4 years old, entered the emergency department with her mother for an evaluation of Patient 12 's burn to his right thigh. Patient 12's mother stated that he caught water off the counter onto himself landing mostly on the right thigh. During a physical examination, Patient 12 exhibited with large burn to right thigh and smaller burn to right chest, equaling about one -two % of body without involvement of sensitive structures such as hands, feet, genitalia, or face. This report indicated that the Attending Physician arranged to transfer Patient 12 by private vehicle to another facility at Burn Center who accepts Patient 12 for transfer by private car.

During a review of the 'Patient Transfer 'form all the following were verified before transferring Patient 12: name of facility sent to; medical record number, Patient 12 ' s condition upon transfer was stable. There was no record of consent to transfer by a responsible party.

During a concurrent interview and record review on 12/30/2024 at 2:16 p.m., with the Accreditation and Regulatory Manager (ARM), She reviewed Patient 12's Emergency Medical Treatment and Labor Act (EMTALA) Memorandum of transfer dated 11/5/24 indicated that the transfer documents for Patient12, that the consent for transfer to another hospital had not been signed by the patient or a responsible party. ARM stated that all patients who qualify for a transfer to another facility, must sign the facility's consent form for further care, to be informed of the benefits and risk of transfer as stated in the facility ' s policy. ARM further stated that the reason for Patient 12 being transferred to another facility was that this facility does not have burn unit.

During a concurrent interview and record review on 12/30/24 at 2:38p.m., with the Emergency Department Manager (EDM), she reviewed and acknowledged that the EMTALA Memorandum of transfer dated 11/5/24 for Patient12, that the consent had not been signed by the responsible party for transfer to another hospital. She further stated that the transfer form should have been completed and signed by RP.

During a review of the facility's policy and procedure (P&P) revised 7/2024, titled, "EMTALA - Transfer Policy," revision dated 7/2024, the P&P indicated, "Any transfer of an individual with an EMC must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual's behalf or by a physician order with the appropriate physician certification as required under EMTALA."

Based on interview and record review, Facility A failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA) when, Facility A failed to provide necessary stabilizing treatment to an individual with an Emergency Medical Condition (EMC). For one of 20 sampled patients (Patient 7). This failure resulted in Patient 7 to not receive stabilizing treatment for an emergency medical condition, and had the potential for Patient 7 to commit suicide.

Findings:

1. During a review of Patient 7's Emergency Patient Record, Record indicated, Patient 7 arrived to Facility A's Emergency Department on 12/16/24 at 2253 (10:53pm). Record indicated, Patient 7's complaint was "Suicidal", with a "Priority 2" (acuity levels are numbered one through five, with levels one and two indicating the greatest urgency.) Record indicated, Patient 7 stated complaint of "I've had massive amounts of voices telling me to kill myself for years. I want to put myself in front of a car".

During a review of Patient 7's "Suicide Assessment" (Columbia Scale: assessment tool to determine suicide risk) dated 12/16/24 at 2320 (11:20pm) indicated a score of "High risk" signed by Registered Nurse A (RN A).

During a review of Patient 7's Emergency Patient Record, record indicated "Medical Health History. . .Bipolar [A disorder associated with episodes of mood swings ranging from depressive lows to manic highs], Schizophrenia [A disorder that affects a person's ability to think, feel, and behave clearly], Dual Personality Disorder [A disorder characterized by the presence of two or more distinct personality states]".

During a review of Patient 7's Emergency Patient Record dated 12/17/24, at 0030 (12:30am) indicated, "Per PT [patient 7] he hears voices that tell him to self harm himself. . .Per pt [patient 7] he is off his meds" Signed by RN B.

During a review of Patient 7's Emergency Patient Record dated 12/17/24 indicated, no AMA (against medical advice) form was signed.

During a review of Patient 7's Physician Progress Note, dated 12/17/24 0010 (1210am) "Patient was a 36-year old man comes in complaining of suicidal thoughts. Patient states he has been feeling this way all day. Patient states he was not been on [sic] any medications for a long time. . .Communications/Consultations: Tele psych: Patient evaluated by Psychiatrist. He meets criteria for 5150 hold [an involuntary legal hold for patients at risk to harm themselves or others for up to 72 hours]. Patient was unable to contract for safety. . .Primary Impression Suicidal Ideations". Signed by Medical Doctor C (MD C).

During a review of Patient 7's Emergency Patient Record dated 12/17/24, at 0150 (1:50am) indicated, Patient 7 "reports hearing voices to harm self. Pt [patient 7] appears anxious, getting out of bed pacing back and forth". Signed by RN B.

During a review of Patient 7's Emergency Patient Record dated 12/17/24, at 0305 (305am) indicated, Patient 7 "walked out of ER with all belongings".

During an interview on 12/31/24 at 802 a.m., with RN A, RN A stated, she was the triage nurse the night patient 7 came into the Emergency Department. RN A stated, "If they [patients] score a high on the suicide risk assessment, I can't let them leave my sight, while they are in the chair. I call the charge nurse and let them know they [patient] needs a sitter [staff member responsible for observing patients who are at risk for harm] and a room". RN A stated, she is aware all patients who score high for suicide risk (Columbia scale), need to have a one to one sitter immediately. RN A stated, the staff member who receives the patient to their room will complete the environmental safety check (removing any wires, curtains, or sharp objects a patient could harm themselves with) and documents that the sitter (one to one observation) is in place to monitor the patient. RN A stated, "the MD puts an order in for the sitter".

During a review of Patient 7's Orders dated 12/16-12/17/24 indicated, no order for sitter(one to one observation). No orders for medications were charted. A psychiatric consultation was ordered at 2318 (1118pm).

During an interview on 1/2/25, at 9:57 a.m., with MD C. MD C stated, he completed the medical screening exam for Patient 7 on 12/16/24. MDS C stated, Patient 7 had expressed SI (suicidal ideations) which is an emergency medical condition. MD C stated, all patients who are suicidal should have a sitter with them. MD C stated, he was informed by staff, Patient 7 eloped from the Emergency Department prior to the psychiatric consultation.

During a review of Patient 7's Emergency Patient Record dated 12/16-12/17, indicated, no documentation patient's environmental safety checklist was completed, no documentation was found to indicated Patient 7 had continuous monitoring. No documentation was found to indicated Patient 7 received any stabilizing treatment for his Suicidal Ideation prior to eloping on 12/17/24 at 0305 (3:05 pm).

During a review of Facility A's P&P titled, "Suicide Risk Assessment and Management for Non-behavioral Health Settings the P&P indicated, "Ensure. . .all patients twelve (12) years and older are assessed for risk of suicide with appropriate suicide precautions implemented as indicated. . . Columbia Suicide Severity Rating Scale (C-SSRS): Initial screening tool utilized by the nurse. It will provide an auto calculated level of no risk, low, moderate, or high risk. . .One to one observation [aka sitter] (continuous observation): May be implemented as virtual/ line of sight or physical in-person. . .this is initiate by nursing based on the C-SSRS score. . .E. The at risk patient's (low, moderate, or high) environment will be made safe by implementing the checklist and observation precautions. . .A, Continuous Observation (1:1) is required if the patient is screened high suicide risk on the C-SSRS. . .Emergency Detention A. California (5150): If a patient is determined to be low, moderate, or high risk for suicide and refuses to remain in the hospital for a psychiatric evaluation, an Emergency Detention may be requested and executed".