HospitalInspections.org

Based on observation, interview, review of documentation in the medical record of a patient who had a psychiatric EMC that had not been removed or resolved (Patient 1), review of documentation in 1 of 4 medical records of patients who were transferred from the hospital to other facilities for specialty services not available at the hospital (Patient 18), and review of hospital policies and procedures and other documentation it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure compliance in the following areas:
* Stabilizing treatment of patients.
* Appropriate transfers of patients.
* Whistleblower protection.

Findings included:

1. Regarding stabilizing treatment refer to the findings identified under Tag A2407, CFR 489.24(d).

2. Regarding appropriate transfers refer to the findings identified under Tag A2409, CFR 489.24(e)(1-2).

3. The policy and procedure titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance - SAHS dated as approved 05/18/2018, was reviewed and contained no language related to the required EMTALA whistleblower protection.

4. During an interview with the RDES on 10/26/2018 at 1605 regarding a policy and procedure related to the required EMTALA whistleblower protection, he/she stated "I don't think we have anything specific to that."

Based on observation, interview, review of documentation in the medical record of a patient who had a psychiatric EMC that had not been removed or resolved (Patient 1), and review of hospital policies and procedures and other documentation, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure that within the capabilities and capacity of the hospital, it provided stabilizing treatment necessary for the patient's psychiatric condition.
* Patient 1 was not observed and monitored in the ED to protect him/her from injury and self harm. After repeated elopements from the ED, the patient eloped from the hospital premises.

Findings include:

1.a. The policy and procedure titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance - SAHS" dated as approved 05/18/2018, was reviewed. It stipulated:
* "Any individual who comes to Saint Alphonsus (the 'Hospital') seeking an examination and treatment of a potential emergency medical condition will receive a screening examination to determine the existence of any emergency medical condition, necessary stabilizing treatment for any emergency medical condition, and if necessary, an appropriate transfer to another medical facility..."
* The "Definitions" section reflected "Emergency Medical Condition ('EMC')...A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in...serious impairment to bodily functions; or...serious dysfunction of any bodily organ or part."
* "...MSE. The Hospital will provide a MSE, within the capability of the Hospital, for purposes of determining whether an EMC exists, to the following individuals...any individual presenting at a DED seeking examination and treatment of a medical condition, or on whose behalf a request is made..."
* "...Treatment Of Individuals With An EMC. If it is determined that an EMC exists, the Hospital shall: provide further examination and treatment, within the capability of the Hospital, until the individual's condition is stabilized; or provide for an appropriate transfer of an un-stabilized individual to another medical facility..."
* "...Patient Refusal To Accept MSE, Treatment, or Physician Certified Transfer...If an individual refuses a MSE or treatment, refuses a physician certified transfer, or requests to be transferred against medical advice, explain the risks and benefits of the proposed services and make reasonable efforts to have the individual sign the Informed Consent to Refuse Offered Services form. If the individual refuses to sign the form, document the risks and benefits explained to the individual, the efforts taken to have the individual sign the form, and the individual's refusal to do so..."

b. The policy and procedure titled "Treatment of Mental Health Patients in the ED" dated as approved 06/12/2017, was reviewed. It stipulated:
* "...Upon patient arrival to hospital emergency department...St Alphonsus will provide appropriate medical evaluation and treatment to 'stabilize the emergency medical condition' as required by the federal laws under the Emergency Medical Treatment and Active Labor Act (EMTALA)..."
* "...Prioritization of safety for patient, staff, and others...Place patient in an observable location...Call code Gray, hospital security, or police officers for help in securing the safety of patients who are at risk of imminent danger of harming themselves or others...Security can be contacted by radio...If restraints are required, follow SAMC-O policy for use of restraints...Medical providers will prioritize care of the at risk patient who poses a risk of safety to themselves or others...If the mental health patient being evaluated for their illness against their will decides to leave, and cannot be safely constrained to stay without putting the staff or others at risk, hospital staff should allow the patient to leave..."
* "...Documentation requirements for hospital staff...Describe actions, plans, prior history, statements, and indications of imminent danger to self or others...Is the person refusing treatment, aggressive or agitated and does he/she require seclusion/restraint or compelling of medications for safety..."

c. The policy and procedure titled "Sitters: Use in Patient Care Areas," dated as approved 07/26/2018, was reviewed. It stipulated:
* "In an attempt to keep our patients most at risk of harm to self, a Sitter may be assigned to support provision of a safe environment. Saint Alphonsus Medical Center - Ontario will provide sitters for patients when the care needs of the patient demand very close observation and monitoring for safety purposes. All other methods to assure safety of the patient will be first prior to making arrangements for a sitter. The decision for the sitter will be the responsibility of the RN who will collaborate with team members...and notify the physician of plan of care and any changes in the plan of care. The use of sitters should not be considered an alternative to judicious use of restraints...The sitter will not physically detain a patient demonstrating a desire to leave Saint Alphonsus Medical Center - Ontario premises...The patient will be re-evaluated and re-assessed every four hours and the plan of care adjusted as needed to meet the needs of the patient..."
* "The supervision of the sitter is the responsibility of the RN assigned to the patient...The nurse assigned to the patient retains responsibility for the patients nursing care...Report all concerns to the charge nurse for resolution then the manager or their designee."

d. The policy and procedure titled "Emergency Care Provision," dated 09/16/2013, was reviewed and reflected "All patients entering the Emergency Department will be treated according to ED Guidelines, Policy and current practice."

2.a. A 2-page document titled "Mental Health Patient Risk Reduction Checklist ON-206" dated "Rev 6/17" was provided by the RDES. It reflected:
* It was applicable to "All involuntary mental hold, suicidal/homicidal, and/or patients deemed to be a danger to themselves or others..." The checklist was used to document interventions for patients at risk of harm to self or others as follows:
* "Explain Safety precautions to patient (Removing clothing/belongings from patient and room, removing potentially dangerous items from the room...they will not be allowed to leave department to smoke or for other reasons..."
* "Explain plan of care/usual process and expected time frames to patient."
* "Reduce wait times whenever possible."
* "Patient will be placed preferably into Bay 6 Note: If Bay 6 is unavailable, secondary line-of-sight rooms: Bay 4 or 5 will be selected."
* "Inventory of all belongings by security and/or clinical staff."
* "Belongings placed in designated location by clinical and/or security staff."
* "Patient medications remain with patient belongings."
* "No patient medications present."
* "List of all Patient belongings."
* "Provide safer environment for patient by removing all identified items that pose risk including (but not limited to)...Roller door closed on linen cabinet...Phone...Monitor cords...Gloves (boxes and holder)...Gurney...Blankets, sheets...Otoscopes, covers, etc...Cup dispenser..."
* "Document steps taken to ensure safer environment a minimum of once every shift and with any Handoff within the ED progress note."
* "Provides constant one-on-one observation for Mental Health Patients..."
* "Ensure direct line of sight al ALL time."
* "Handoffs...Clinical Staff will provide...Verbal report to security...Pertinent behaviors...Handoff will be documented in the progress notes including...Patient mental status and behavior...Safety interventions in place...Plan of care."

b. During an interview on 10/25/2018 at 1800 with the RDES related to the "Mental Health Patient Risk Reduction Checklist ON-206," he/she stated the hospital had no policy and procedure that addressed the checklist, including a process for when it was required to be completed, who was responsible to carry out the tasks and interventions reflected on it, and who was to complete it. The RDES stated "We acknowledge there's a gap there."

3. The undated document titled "Saint Alphonsus Medical Center-Ontario" provided by the MRQ on 10/24/2018 at 1550 to reflect the hospital's scope of services and capabilities was reviewed. It reflected the hospital did not provide inpatient psychiatric services.

4. During an interview with the ED Manager on 10/25/2018 at 1050 he/she confirmed the hospital had no inpatient psychiatric services and no psychiatric providers on its medical staff.

5. The ED record of Patient 1 reflected he/she presented to the ED on 09/04/2018 at 2047 with a chief complaint of 'I'm coming off of fluoxetine..."I've had manic and psychosis (sic)."
* The "ED Physician Notes" reflected the "Time Seen" was 09/04/2018 at 2100. The notes were signed by the physician and dated 09/05/2018 at 0644 and reflected a MSE was conducted and "...history somewhat limited by the patient's mental state...obtained from [him/her] as well as [parent]...history of depression...anxiety...schizophrenia, bipolar, multiple personality disorder, and chronic abdominal pain...presents for the evaluation of increased anxiety and agitation that worsened two days ago...punched a hole in the wall today after arguing with [his/her] [significant other]..."
* On 09/04/2018 at 2102 the RN notes reflected "...Patient appears manic and impulsive. Speaking with pressured speech and intermittently laughing and screaming loudly at inappropriate moments in the conversation...Pt stated 'I've been up and down and manic' since stopping Prozac 1.5 months ago which [he/she] was taking for 'anxiety, depression, split personality, those sort of things'. Pt reported [he/she] quit taking the Prozac because 'I felt like I was in a fog and it made me do things like cut myself.' Patient ambulated back to Bay 7 with friend at bedside. Pt...gave a loud shrill laugh heard throughout the department."
* On 09/04/2018 at 2127 the RN notes reflected "Patient experiencing alternating emotions and going from crying to laughing..."
* On 09/04/2018 at 2238 the RN notes reflected "Patient's [parent] voiced concerns about patient's safety at home regarding [his/her] ability to keep the patient from hurting [him/herself] since [he/she] punched a hole in the wall earlier today..."
* On 09/04/2018 at 2305 the RN notes reflected "[QMHP] at bedside talking to patient and [family]."
* On 09/04/2018 at 2341 the RN notes reflected "Patient sitting on bed. [Wallet/purse] in garbage can. I picked [wallet/purse] out of can asked if [he/she] would like me to keep it safe for [him/her] and [he/she] grabbed it and threw it back in the carbage (sic) can."
* The [QMHP] "Crisis Assessment & Stabilization Plan" dated "9/4/2018 11:05 PM to 9/5/2018 12:28 AM" reflected "...Patient states [he/she] tried to decrease [his/her] Prozac and [his/her] symptoms have increased...reports that [his/her] most recent manic episode has lasted for the last 3 days...presents with bizarre behaviors...states that [he/she] has experienced 'auditory hallucinations' and is able to hear things that are often described as quiet...reports [he/she] has a historical addiction to 'Benzos'...reports that [he/she] is willing to explore a higher level of care in order to obtain and maintain mental health stability...Referred To: Acute or Sub-Acute Psychiatric Facility."
* On 09/05/2018 at 0014 the RN notes reflected "Patient sitting on floor 'getting grounded.' Myself and other staff began to removed (sic) potentially dangerous objects from the room and patient screamed and hit the wall...Mattress placed on floor with sheets and pillow. Gurney removed from room...Sitter present...for continuous observation due to emotional outburst and potential for self harm."
* On 09/05/2018 at 0017 the RN notes reflected "Personal belongings ([wallet/purse], cell phone, and glasses) put into psych box until patient is transported to Intermountain."
* On 09/05/2018 at 0117 the RN notes reflected "Patent doing meditation and yoga in room, was kindly asked by sitter to stop yoga pose due to safety concern and patient yelled at sitter to get out..."
* On 09/05/2018 at 0246 the RN notes reflected "Patient provided water cup and opened tea bag and pouring tea mixed liquid in with liquid sopped up from the floor and then drank the combined liquid..."
* On 09/05/2018 at 0331 the RN notes reflected "...Patient beginning to become more agitated and verbally aggressive with yelling at staff saying [he/she] needs Cannibas, walking around the department and out to the waiting room, back to [his/her] room, after repeated requests to stay in [his/her] room. Patient remains compliant to be admitted to [Intermountain] and is requesting to be transported immediately. As I told the patient three times before, we are waiting for [him/her] to be accepted to Intermountain."
* On 09/05/2018 at 0338 the RN notes reflected "Patient's aggression and agitation continues to increase. Patient aggreed (sic) that [he/she] needs something to calm [his/her] 'crazy' thoughts, requested Cannibas...Patient offered Zyprexa ODT and refused. Patient medicated with 10mg IM Zyprexa."
* On 09/05/2018 at 0634 the RN notes reflected "Sitter remains at bedside."
* On 09/05/2018 at 0807 the SW notes reflected "SW received consult for this pt for MH. Pt was evaluated by [QMHP] From crisis team and is still awaiting acceptance from Intermountain. SW called Intermountain and they reported that '[he/she] is on the board but has not been reviewed as of yet.' SW spoke to...RN in ER, and [he/she] reports that [QMHP] is on [his/her] way to ER to start looking for other alternatives for Inpt. SW to f/u as needed."
* On 09/05/2018 at 0856 the RN notes reflected "pt states 'I'd like to go home'..."
* On 09/05/2018 at 0904 the RN notes reflected "...pt does not know why [he/she] is being 'held' here...'I'm feeling claustrophobic...I want to talk to someone'..."
* On 09/05/2018 at 0905 the RN notes reflected "[QMHP] here to talk with pt."
* On 09/05/2018 at 0910 the RN notes reflected "...Pt seen ambulating out of the department..."
* On 09/05/2018 at 0912 the RN notes reflected "...[QMHP]...out to lobby to talk with pt."
* On 09/05/2018 at 0916 the RN notes reflected "...pt and [QMHP] back to room."
The next RN note on 09/05/2018 at 1000, 44 minutes later, and it reflected "...pt left department...[QMHP] aware of this." This was the last RN note.
* The physician "ER Dispo Form" dated "Entered on" 09/05/2018 at 1019 reflected "The patient became increasingly agitated while in the emergency department. [He/she] punched the wall here in the room...[He/she] continued to have episodes of agitation. Initially offered Zyprexa but the patient declined. Later [he/she] became increasingly agitated and walked from the room on several different occasions towards the exit. The last time [he/she] walked to the ambulance bay exit and attempted to leave. I was concerned about [his/her] safety with [his/her] increasing agitation. Zyprexa Zydis was again offered, but the patient declined. I ordered Zyprexa 10 mg IM, after which the patient's agitation drastically improved." The "Disposition" section reflected the "Time of Departure From ER" was 09/05/2018 at 1018." The "Discharge/Transfer From ER" section reflected "Elopement...Comment: pt walked out of department saying something about [his/her] rights."
* A [QMHP] "Crisis Assessment & Stabilization Plan" dated "9/5/2018 10:28 AM to 10:35 AM" reflected "Date/Services/Activity: 9:00am [QRMP] consulted with client about the need for inpatient services. Client does not want inpatient...Clinician contacted clients (sic) [parent] and [he/she] reports that [he/she] does not think it is safe for [patient] to come home...Clinician contacted clients [other parent] and [he/she] reports it is not an option for client to come to [his/her] house. Clinician followed up with client and recommended inpatient treatment. Client became agitated and walked out of the Emergency Department. Dispatch was called..."
* The record included an undated, untimed and unauthenticated "Mental Health Patient Risk Reduction Checklist ON-206." The following items on the list were not checked and there was no documentation reflecting they had been completed:
- "Explain Safety precautions to patient (Removing clothing/belongings from patient and room, removing potentially dangerous items from the room...they will not be allowed to leave department to smoke or for other reasons..."
- "Explain plan of care/usual process and expected time frames to patient."
- "Reduce wait times whenever possible."
- "Patient medications remain with patient belongings."
The list also reflected "Provide safer environment for patient by removing all identified items that pose risk including (but not limited to):" The following items on the list were not checked and there was no documentation reflecting they had been removed from the room:
- "Gloves (boxes and holder)"
- "Blankets, sheets..."
- "Otoscopes, covers, etc..."
- "Cup dispenser..."
The spaces for recording signatures, date and time of "Primary RN," "Secondary RN (if applicable)," and "Security Staff Member" were blank.

6. During a tour of the ED with the ED Manager on 10/25/2018 at 1720 the following observations were made:
* ED room 7 (Bay 7) entry was across the hall and diagonal to the central area of the nurse's station. However, a large pillar was observed between the room entry and the nurse's station so that the room entry was not fully visible from all areas of the nurse's station. This was confirmed with the ED Manager at the time of the observation.

7. During an interview on 10/26/2018 at 0955 with RN L he/she provided the following information:
* RN L was Patient 1's assigned nurse from 09/04/2018 at 1900 until 09/05/2018 at 0730. He/she remembered the patient "really well."
* The patient came in to the ED because he/she was "coming off a med."
* At around 0500, the patient "started to escalate more" and was needing more frequent redirection to remain in his/her room. He/she was impulsive and wandering in the unit. He/she went over by the ambulance entrance "like [he/she] was going to go out...The patient was at high risk for leaving. I felt [he/she] was at risk where [he/she] might harm [him/herself]...We weren't sure what [his/her] intentions were."
* On another occasion the "the sitter allowed the patient to go into the break room without letting anyone know. That put the patient at higher risk of leaving."
* At around 0730, the patient wandered out of the ED to the waiting room.
* RN L "I think there's a disconnect...I expect the sitter to let me know when the patient leaves their room especially when they're high risk like [Patient 1], and [he/she] did not do that...That's something we're working on."
* RN L acknowledged he/she initiated the "Mental Health Patient Risk Reduction Checklist ON-206." He/she did not know what time he/she initiated it. He/she confirmed the checklist was incomplete and the patient was not placed in Bay 4, 5 or 6 for "line-of-site" monitoring as it directed.

8. During an interview with RN M on 10/26/2018 at 1115, he/she provided the following information:
* The RN confirmed he/she was assigned to care for Patient 1 beginning at or around 0700 on 09/05/2018 and until the patient left the hospital.
* The RN stated that the expectation for monitoring the patient with consideration of his/her psychiatric condition and behaviors was to "look in to see how they're doing maybe every half hour, maybe every hour, maybe every hour and a half." He/she reviewed the medical record and confirmed it lacked documentation reflecting he/she monitored the patient at least every hour.
* The RN didn't remember anyone telling him/her about the patient's behaviors leading up to and when the patient left the hospital.
* The RN confirmed there was no documentation in the medical record reflecting he/she notified the physician of the patient's increasing behaviors leading up to and when the patient left the hospital.

9. During an interview on 10/26/2018 at 1145 Sitter P provided the following information:
* Sitter P was assigned to Patient 1 on 09/05/2018 beginning at or around 0745.
* He/she stated at the beginning of the shift "The patient was asleep. I was outside the door."
* The patient woke up at around 0900 "and started talking and was very talkative. [His/her] thoughts were ping-ponging, switching from one subject to another. [He/she] started talking about leaving."
* The patient was "walking out the door of his/her room and down the halls as if [he/she] was leaving."
* At around 1000, the patient was getting more agitated. One time he/she went to the triage area near the ED exit, another time he/she went out to the waiting area outside the ED, and then after that he/she left the hospital.
* The patient's agitation progressed over a period of about an hour from the time he/she woke up until the time he/she left the hospital.
* He/she did not remember reporting the patient's agitation to the nurse or physician. He/she stated "I'm sure I told someone [he/she] was leaving but I don't know who."
* He/she did not remember any nurse or physician offering or providing interventions to assist with the patient's behaviors.

10. During an interview with the QMHP on 10/26/2018 at 1035, he/she provided the following information:
* QMHP remembered Patient 1. The patient was having a manic episode, racing thoughts, punching the wall, and needing sleep. The plan was for the patient to be monitored 1:1 with a sitter and go to "Intermountain" for inpatient psychiatric placement.
* The patient left the ED "two times I think." The first time the patient left the ED, the patient went out to the parking lot. The sitter was with the patient. The sitter left the patient outside and came in to tell QMHP the patient had left.
* QMHP stated he/she called the patient's parents.
* QMHP went out and redirected the patient back into the waiting area.
* The patient did not go back into the ED and approximately 3 minutes later, the patient got agitated and "[he/she] walked out again and left the hospital...I saw [him/her] leave the hospital grounds."
* He/she did not indicate what, if anything, he/she did to intervene to prevent the patient from leaving the hospital.
* QMHP stated he/she stated he/she did not inform the nurse or the physician when the patient went out to the parking lot or when the patient left the hospital.
* QMHP stated he/she called the patient's [family] after the patient went out to the parking lot.
* QMHP stated the family "found the patient and picked [him/her] up and brought [him/her] back to the ED."
* QMHP stated the family brought the patient back to the ED approximately 2 hours later and the patient was reevalated in the ED.

11. The ED record lacked documentation of the provision of stabilizing treatment within the capability and capacity of the hospital to ensure the patient was protected and prevented from injuring or harming him/herself. For example:
* There was no documentation the patient was placed in ED room 4, 5 or 6 for line-of-sight monitoring in accordance with the "Mental Health Patient Risk Reduction Checklist ON-206."
* The RN documented on 09/05/2018 at 0014, "Sitter present...due to emotional outburst and potential for self harm." At 0634 the RN documented the sitter was at the patient's bedside. There was no further no documentation reflecting the sitter was present after 0634. There was no documentation by the sitter in the record.
* The physician notes reflected he/she "ordered Zyprexa 10 mg IM, after which the patient's agitation drastically improved." However, the RN documented the patient received the Zyprexa IM on 09/05/2018 at 0338, and at 0856 the RN documented "pt states 'I'd like to go home," at 0904 "pt does not know why [he/she] is being 'held' here...feeling claustrophobic," at 0910 "Pt seen ambulating out of the department," and at 1000 "pt left department."
* There was no RN documentation reflecting the RN notified the physician of the patients increasing behaviors or implemented interventions to prevent the patient from leaving, including reevaluating the patient's condition and adjusting the care plan to address the patient's behaviors in accordance with hospital policy.
* There was no documentation reflecting an evaluation of if the patient required seclusion/restraint or further medication interventions in accordance with hospital policy.
* There was no documentation reflecting efforts to "safely constrain" the patient who was seen leaving the hospital in accordance with hospital policy.
* There was no documentation reflecting a Code Gray was called or security provided assistance when the patient was seen leaving the hospital in accordance with hospital policy.
* There was no documentation reflecting the patient who was seen leaving the hospital was provided an explanation of the risks and benefits of refusing treatment or efforts to have the patient sign the "Informed Consent to Refuse Offered Services" form as required by hospital policy, or an assessment of whether it was appropriate for the psychiatric patient to sign such a consent form.
* Documentation in the ED record was not consistent with the patient's wandering and elopement behaviors and risk, and the lack of monitoring, observations and interventions described during the interviews with the RNs, sitter and QMHP.

12. Lifeways event documentation dated 09/05/2018 related to Patient 1 was reviewed. The documentation reflected it was completed by the sitter who was assigned to Patient 1 on 09/05/2018:
* "Type of...Event...Other: Client walked away."
* "Date...9/5/2018"
* "Location...St Alphonsus ER - Ontario, OR"
* "Provide Details...Psych sit. Client asked to read the HIPPA paperwork, said [his/her] rights were being violated and wanted to leave. [He/she] walked out of the ER and came back after a few minutes. [QMHP] recommended that the client become inpatient. Client become (sic) very agitated and walked out of the hospital once more."
* The "Follow-up" section dated 10/26/2018 reflected "...No further action has been taken or is anticipated because...report was completed due to dispatch call after the client left the emergency room against professional advice. Client was picked up by [his/her] [family]..."

13. During an interview with the ED Manager on 10/25/2018 at 1600, he/she reviewed the ED record and confirmed the following:
* The "Mental Health Patient Risk Reduction Checklist ON-206" was undated, untimed, unauthenticated and incomplete.
* The ED Manager confirmed the plan for the patient was for him/her to be transferred to an inpatient psychiatric facility but instead the patient eloped.
* There was no documentation reflecting the sitter notified the RN of the patient's increased behaviors leading up to when he/she eloped from the hospital.
* There was no documentation reflecting the RN, QMHP or sitter notified the physician of the patient's increased behaviors leading up to when he/she eloped from the hospital.
* There was no documentation reflecting the sitter was monitoring the patient when the patient eloped from the hospital.
* The ED Manager confirmed the record lacked documentation reflecting the patient was provided stabilizing treatment, including appropriate monitoring and interventions to address the patient's increased behaviors leading up to and when the patient eloped.
* Further, the ED Manager stated that after the patient eloped an incident report should have been completed by the hospital. He/she stated there was no incident report completed by the hospital.

Based on interview, review of documentation in 1 of 4 medical records of patients who were transferred from SAMC to other facilities for specialty services not available at SAMC (Patient 18), and review of hospital policies and procedures, it was determined that the hospital failed to develop and enforce its EMTALA policies and procedures to ensure that it affected appropriate transfers for patients for whom an EMC had not been ruled out, removed or resolved:
* Appropriate mode of transfer was not effected and documented for 18.

Findings include:

1. The policy and procedure titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance - SAHS dated as approved 05/18/2018, was reviewed. It stipulated:
* Transfer...Circumstances Permitting Transfer. An individual in an unstable EMC may only be transferred to another medical facility in either of the following circumstances...Physician Certification. A physician or QMP makes a determination, based on information available at the time of transfer, that the medical benefits to the patient reasonably expected from treatment at another medical facility outweigh the risks of transfer...The physician or QMP must complete and sign the Physician Certification on Saint Alphonsus' Patient Consent To/Request for Transfer form (the physician must counter-sign the form in the event a QMP signs the Certification), which must contain a summary of the risks and benefits upon which the Certification is based. If the individual consents to the physician-certified transfer, reasonable efforts should be made to have the individual sign the Patient Consent To/Request For Transfer form indicating the individual's consent to the physician-certified transfer. If the individual consents but refuses to sign the form, document the risks and benefits explained to the individual, the efforts taken to have the individual sign the form, and the individual's refusal to do so."
* "...Appropriate Transfer Of Individuals with Un-stabilized EMC. Any transfer of an individual in an unstable EMC...must be conducted in the following manner...Prior to transferring the individual, the Hospital must confirm that the receiving medical facility has available space and qualified personnel for treatment of the individual and the receiving medical facility must agree to accept the individual. The Hospital must document in writing the receiving medical facility's acceptance of the transfer, including the name of any accepting physician..."
* "...The transfer must be effected through qualified personnel and proper transport equipment, including the use of any necessary and medically appropriate life support measures during the transfer..."

2. The ED record of Patient 18 was reviewed and reflected:
* The patient presented to the ED on 08/23/2018 at 1520 with a chief complaint of "Suicidal."
* The "ED Physician Notes" electronically signed by the physician and dated 08/25/2018 at 1438 reflected a MSE was conducted on 08/23/2018 at 1527. The "Medical Decision Making" reflected "Patient presents today with concern about ongoing SI and depression that have become more severe lately. [He/she] returned to ED after being discharged; [he/she] now would like to be admitted to a psychiatric unit for examination..." The "Assessment/Plan" reflected "...Disposition: Awaiting psychiatric facility placement."
* The QMHP "Crisis Assessment & Stabilization Plan" dated 08/23/2018 at 2109 reflected "...Patient states that [he/she] had been experiencing auditory hallucinations recently that have been telling [him/her] to hurt [him/herself] or others...has a history of suicidal ideation and suicidal attempts. Patient presents with a plan that includes the use of personal medications or use of gun...states that [he/she] has access to guns at home and access to a plethora of psychotropic medications...Referred To: Acute...Psychiatric Facility."
* RN notes on 08/24/2018 at 0305 reflected "...Sitter present at door."
* RN notes on 08/24/2018 at 1110 reflected "[QMHP]...is working on placement."
* RN notes on 08/25/2018 at 0300 reflected "PT in direct line of sight from Rn's station for safety."
* The "Emergency Room Progress Note" electronically signed by the physician and dated 08/25/2018 at 0827 reflected "...I had a discussion with the emergency physician...a social worker, and a psychiatrist all in Bend, OR. They've accepted the patient for transfer, but to the emergency department. They are aware that the patient had already had an emergency evaluation but would like the patient to go the emergency department to see if any further workup needs to be done prior to placement."
* A 3-page form titled "Patient Consent to/Request for Transfer SAHS-0416" was reviewed and reflected the patient was transferred to "St Charles Bend OR" for psychiatric services. Page 3 of the form reflected the "Mode of Transport" was "Transporting Agency:" This was followed by "Lifeways Staff" and first names of two individuals. There was no other information, such as title or position of the two individuals.
* The RN "ER Dispo Form" on 08/25/2018 at 0930 reflected the patient departed from the ED on 08/25/2018 at 0916. The "Discharge/Transfer From ER" reflected "Psychiatric facility 65 (transfer)."
* The RN "ER Follow-up Progress Note" on 08/25/2018 at 1438, after the patient was transferred reflected "...St Charles Medical Center in Bend, OR called because of concern about the Transport Team 'dropping a psychiatric pt off in Main Admitting and leaving'.

* The record lacked documentation reflecting that the transfer was effected through qualified personnel and proper transportation equipment, including the use of any necessary and medically appropriate measures during the transfer as required by this CFR. For example, the "Patient Consent to/Request for Transfer" form reflected the "Transporting Agency" was "Lifeways Staff" followed by the first names of two individuals. However, there was no further information about the transportation arrangements, including the type of transportation vehicle, qualifications of the two individuals who accompanied the patient, transportation equipment, and any necessary and medically appropriate measures. Further, there was no documentation in the record reflecting the outcome of the Transport Team "dropping a psychiatric pt off in Main Admitting and leaving."

3 The ED record of Patient 18 was reviewed with the ED Manager on 10/25/2018 at approximately 1630. He/she confirmed finding 2.

4. MapQuest online driving directions reflected SCMC is located in Bend, OR and is 258 miles and 4 hours and 28 minutes driving time from SAMC.