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Based on medical record review, staff interview and review of facility policy and procedures it was determined the facility failed to comply with the requirement to accept an appropriate transfer of a patient requiring specialized services that are provided by the facility for one (#20) of twenty patients sampled (see A2411).

Based on medical record review, staff interview, review of facility policy and procedures, and review of facility central log and documents, it was determined the facility failed to maintain a central log on each individual who came to the facility, as defined in ?489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for one (#20) of twenty patients sampled.

Findings include:

Patient #20 was seen and evaluated at facility #1 (transferring facility) emergency department on 4/2/2013. Review of facility #1 ED (Emergency Department) physician documentation revealed a medical screening exam was performed at 12:00 pm. Documentation revealed the patient had an intentional fall out of a slow moving vehicle and had a psychiatric history. The patient was Baker Acted on the scene by police and brought to the ED for evaluation. Following a medical screening exam and psychiatric evaluation it was determined the patient required in-patient psychiatric treatment for stabilization of acute schizophrenia with paranoid ideation. The patient was referred to facility #2 (receiving facility) and accepted by an admitting physician on 4/2/2013 at 8:45 pm.

Review of facility #2 central log for the past 6 months revealed no evidence of patient
#20 being recorded on the log. Review of the policy, " EMTALA " , #ADM 10-41, last revised 5/2012, states (3) the Emergency Medical Care Log is maintained of all individuals who come to the facility. An interview on 7/22/2013 at 11:50 am with the Director of Assessment & Referral was conducted. He was questioned regarding the exclusion of patient #20 from the log dated 4/2/2013. He stated he was not aware the patient was not on the log until it was brought to his attention on 7/18/2013. He stated it was an oversight by staff and the patient 's name should have been documented on the log. He stated there had been no formal education provided to staff regarding the exclusion of a patient on the log.

Based on medical record review, staff interview, review of facility policy and procedures and EMS run sheets, it was determined the facility failed to comply with the requirement to accept an appropriate transfer of a patient requiring specialized services that are provided by the accepting facility as evidenced by initially accepting the patient for transfer, then refused the patient upon arrival facility for one (#20) of twenty patients sampled.

Findings include:

Patient #20 was seen and evaluated at facility #1 (transferring facility) emergency department on 4/2/2013. Review of facility #1 ED (Emergency Department) physician documentation revealed a medical screening exam was performed at 12:00 p.m. Documentation revealed the patient had an intentional fall out of a slow moving vehicle and had a psychiatric history. The patient was Baker Acted on the scene by police and brought to the ED for evaluation.

Review of the documentation from facility #1 revealed the patient's treatment included wound care, x-rays, and 2 sutures. Physician documentation revealed the patient had multiple abrasions to bilateral arms and legs and a laceration to the right 5th toe that required 2 sutures. Documentation stated the patient was ambulatory but used a wheelchair when outside of the house. A psychiatric consultation was completed on 4/2/2013 at 4:00 p.m. confirming the diagnosis of acute schizophrenia with paranoid ideations. The patient was medically cleared on 4/2/2013 at 5:07 p.m. by the ED physician.

Review of the nursing documentation revealed the patient's wounds were cleaned and antibiotic ointment was applied at 12:28 p.m. At 12:44 p.m. IV (Intravenous) antibiotic was administered and at 2:36 p.m. the patient was medicated with PO (by mouth) pain medication. Nursing documentation revealed the patient was assisted to the bathroom at 6:35 p.m. Review of the form titled Physician Certification Statement for Ambulance Transportation revealed documentation that the patient had been accepted by an admitting physician at facility #2 (Windmoor Healthcare of Clearwater) on 4/2/2013 at 8:45 p.m. Documentation revealed the ambulance transport arrived at 10:04 p.m. to transport the patient.

Review of the EMS (Emergency Medical Services) run sheet, under the section titled Scene Information, revealed the patient was found in a semi-fowlers position and was assisted to the stretcher. Documentation revealed the patient was able to get up without assistance and could ambulate.

Review of the nursing documentation for patient #20 provided by facility #2 (receiving facility) revealed the RN (Registered Nurse) documented the patient was accepted for treatment by accepting psychiatrist at Windmoor on 4/2/2013 at 7:50 p.m. Review of the nursing documentation, dated 4/2/2013 at 10:45 p.m., stated the ambulance arrived to facility #2 and the ambulance crew asked the staff to evaluate the patient before they brought the patient into the facility. Nursing documented the patient was evaluated in the ambulance and was noted to have large areas of abrasions on her right thigh and both feet were bandaged. Nursing documented, "per the ambulance crew she also had large abraded areas on her buttocks and back". Nursing documentation revealed the AOC (Administrator on Call) at facility #2 was notified of the patient's "medical complications" and informed the nurse to send the patient back to facility #1. Review of the nursing documentation revealed the nurse notified facility #1 that facility #2 could not accept the patient due to the extent of her injuries.

Review of the EMS run sheet dated 4/2/13, under the section titled History, documentation stated the patient was denied admission at facility #2 and was being transported back to facility #1. Documentation revealed the patient was transported back and arrived at facility #1 at 11:31 p.m.

Review of the policy, " EMTALA " , #ADM 10-41, last revised 5/2012, states (21) Patient Transfers, the hospital will accept transfers from other facilities to provide the specialized services when the requesting facility does not have the capability to provide such specialized service and the hospital has the "capability and capacity" to provide the needed emergency care. The facility failed to follow the policy after initially accepting the transfer of patient #20 on 4/2/2013, refused patient #20 upon arrival and sent patient back to the transferring hospital; as patient required in-patient psychiatric emergency care that was within the capability and capacity of the hospital.

Review of the policy, " Nursing Admission Procedure " , #CLI 02-01, last revised 3/2012, states (4) upon any patient ' s arrival to the Admission & Referral Department, whether from a transferring ER or as a walk-in, the RN or QMP will complete the triage to determine the patient ' s acuity level and the QMP Medical (Psychiatric) screening exam. Review of the nursing documentation for patient #20 revealed a note stating the patient had multiple abrasions and dressings on both feet. Review of the documentation revealed no evidence the patient ' s acuity level or Medical (Psychiatric) screening exam was completed.

An interview was conducted on 7/22/2013 at 4:00 p.m. with the RN (Registered Nurse) that assessed the patient in the ambulance on 4/2/2013. The RN confirmed her documentation was accurate. She stated the patient was not removed from the ambulance on 4/2/2013. The RN stated she assessed the patient to have a visible, open to air, wound on her right thigh area, both feet were bandaged and the patient appeared to be in pain. The nurse stated she did not have a verbal exchange with the patient as the patient appeared to be in pain. There was no documentation of the patient's pain assessment or level of pain at the time of the nursing assessment. The nurse stated her assessment was a visual assessment and she did not remove any bandages or move the patient to assess her back or buttocks. She confirmed after speaking with administrative personnel it was determined the patient was too medically complicated and was denied admission.