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Based on observation, interview and record review, the facility failed to comply with CFR 489.24, by failing to ensure:

1. An on-call schedule for Gastroenterology (GI - branch of medicine focuses on the digestive system and its disorders) was maintained in order to provide further evaluation and/or stabilizing treatment to an individual with an emergency medical condition. (Refer to A2404);

2. Medical screening examinations (MSE) were performed for two sampled patients (Patient 9 and 28);

a. Patient 9, a three year old child, who presented to the facility Emergency Department (ED), with a temperature of 103.1° Fahrenheit (F) and a heart rate of 148 beats per minute, had a timely medical screening examination (MSE) performed, cooling measures implemented, and a reassessment completed per facility policy and procedure. (Refer to A2406);

b. Patient 28, a suicidal "5150" patient was kept safe and was stabilized following presentation to the facility's Emergency Department (ED). (Refer to A2406);

3. A Labor & Delivery nurse performing Medical Screening Examinations (MSE) for the Obstetrical (OB) patient met the qualifications of the facility's standardized procedure for "Medical Screen Exam for Labor." This resulted in Registered Nurse (RN) 3 performing MSEs on OB patients without the required fetal monitoring certification. (Refer to A2406);

4. Suicidal "5150" patients were kept safe and were stabilized following presentation to the facility's Emergency Department (ED) for two sampled patients (Patients 1 and 12). (Refer to A2407);

5. The necessary stabilizing treatment was provided for one sampled patient (Patient 23) who required the services of a Gastroenterologist (GI physician). This resulted in Patient 23 being unnecessarily transferred to another facility, and had the potential to result in a delay in care and treatment for Patient 23's emergency medical condition. (Refer to A2407);

6. A timely triage assessment and Medical Screening Exam (MSE) was provided for one sampled patient (Patient 11). This failure resulted in a delay in determination whether an emergency medical condition existed for the patient, and had the potential to result in the delay of stabilizing medical treatment. (Refer to A2408); and

7. Transfer documents were completed for two sampled patients (Patients 12 and 21). This failure had the potential to negatively impact the ongoing provision of care for both patients and maintain continuity of care for the patients.. (Refer to A2409).

Based on observation, interview and record review, the facility failed to maintain an on-call schedule for Gastroenterology (GI - branch of medicine focuses on the digestive system and its disorders) in order to provide further evaluation and/or stabilizing treatment to an individual with an emergency medical condition. This resulted in no on-call schedule of providers for GI which was a service the facility provided.

Findings:

During a tour of the facility's Emergency Department (ED), on August 24, 2015, at 9:15 a.m., an observation of the speciality physician's posted on call schedule was conducted. There was no evidence of a Gastroenterologist's on call schedule.

A review of the facility's ED On Call Schedules, dated June, July and August 2015, indicated the following services provided on-call schedules:

- Internal Medicine;
- Surgery;
- Orthopedics;
- Hand/plastic Surgery;
- Urology;
- Pediatrics;
- Obstetrics and Gynecology;
- Ear, Nose, and Throat (ENT);
- Cardiology;
- Neurology; and
- Anesthesia.

The facility did not have a calendar listing of GI on-call physicians for June, July and August 2015.

An interview was conducted with the Chief Executive Officer (CEO), on August 26, 2015, at 11:15 a.m., and he stated the facility did provide GI services but did not maintain a GI physician on-call schedule. The CEO stated the facility had three GI physicians currently on staff and the GI physicians' availability should have been reflected on an on-call schedule.

A review of the facility Medical Staff Bylaws dated and signed by the Governing Body on February 25, 2015, indicated "... Make(ing) appropriate arrangements for coverage of that member's patients as determined by the Medical Staff. ... this patient coverage includes the evaluation and treatment of any of this practitioner's patient's, including both inpatients and those arriving in the Emergency department ..."

Based on interview and record review, the facility failed to ensure:

1. Medical screening examinations (MSE) were performed for two sampled patients (Patient 9 and 28);

a. When Patient 9, a three year old child, presented to the facility Emergency Department (ED), with a temperature of 103.1° Fahrenheit (F) and a heart rate of 148 beats per minute, had a timely medical screening examination (MSE) performed, cooling measures implemented, and a reassessment completed per facility policy and procedure. This resulted in a delay in care and treatment for Patient 9.

b. Patient 28, a suicidal "5150" patient, was kept safe and was stabilized following presentation to the facility's Emergency Department (ED). This had the potential to result in Patient 28 sustaining further harm or death.

2. A Labor & Delivery nurse performing Medical Screening Examinations (MSE) for the Obstetrical (OB) patients, met the qualifications of the facility's standardized procedure for "Medical Screen Exam for Labor." This resulted in Registered Nurse (RN) 3 performing MSEs on OB patients without the required fetal monitoring certification.

Findings:

1a. On August 24, 2015, the record for Patient 9 was reviewed. Patient 9, a three year old child, arrived to the facility ED on August 16, 2015, at 6:03 p.m., with the chief complaint of fever.

The "triage" vital signs, dated August 16, 2015, at 6:05 p.m., indicated Patient 9 had a temperature of 103.1°F (normal 98.6°F with a fever being anything greater than 100.4°F) and a heart rate of 148 (a danger zone vital sign) beats per minute (normal 60 - 110 beats per minute), and was assigned an Emergency Severity Index (ESI) of 3 (on a 1 to 5 scale with 5 being the least urgent to be seen).

A "Nursing Note," dated August 16, 2015, at 6:14 p.m., indicated Patient 9's grandmother stated the child was still febrile in spite of cooling measures done at home.

There was no indication Patient 9 was evaluated by a provider.

A "Nursing Note," dated August 16, 2015, at 9:47 p.m., indicated, "No answer at 2115 (9:15 p.m.) when called to re assess vitals (3 hours and 10 minutes after the initial assessment/vital signs)."

There was no indication a reassessment, to include vital signs, was completed following the initial assessment/vital signs.

There was no indication Patient 9's fever was treated in the ED.

Patient 9's last documented temperature was 103.1°F and heart rate was 148 beats per minute.

During an interview with Emergency Department Charge Nurse (EDCN) 1, on August 26, 2015, at 11:40 a.m., she reviewed the record and was unable to find documentation of Patient 9 being treated for the fever, being seen by a provider, and having a reassessment at least every two hours. EDCN 1 stated based on Patient 9's vital signs, cooling measures should have been implemented, the patient should have been evaluated by a provider, and an attempt at a reassessment should have been done at least every two hours.

The facility policy and procedure titled, "Triage," reviewed/revised April 2015, revealed "Danger Zone Vitals" included a heart rate of greater than 140 beats per minute for a 3 to 8 year old, and included instructions for nursing to "consider an ESI of 2."

The facility policy and procedure titled, "Patient Assessment and Reassessment," revised June 2015, revealed, "Assessment and Re-assessment - Every 2 hrs. (hours) prior to MSE (medical screening examination) (in waiting room). ... Prior to MSE (in bed): Level 1 - Every 15 minutes; Level 2 - Every 20 minutes; Level 3 - Every hour; Level 4 and 5 - Every 2 hours. ..."

b. "5150" - a section of the California Welfare and Institutions Code which allows a qualified person to involuntarily confine a person suspected to have a mental disorder that makes them a danger to self, a danger to others, and/or gravely disabled.

On August 26, 2015, the record for Patient 28 was reviewed. Patient 28 presented to the facility ED on August 7, 2015, at 6:14 p.m., accompanied by a police officer who had placed the patient on a "5150" in the field.

The "Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 Form)" completed by the police officer indicated Patient 28 had a history of self harm which included cutting (using a sharp object to injure self).

The "Triage," dated August 7, 2015, at 6:14 p.m., indicated Patient 28 was assigned an Emergency Severity Index (ESI) of "2." (ESI level 2 patients are ill and at high risk for deterioration, and placement in an ED bed should be initiated rapidly. Patients who are suicidal, homicidal, or psychotic are classified as level two patients)."

There was no indication an immediate assessment of Patient 28's suicidal status was completed by the Registered Nurse (RN) and/or the provider.

A "Nursing Note" dated August 7, 2015, at 7:25 p.m.(greater than one hour after Patient 28's presentation to the facility ED), indicated the police officer left with Patient 28 stating he was going to take the patient to another facility since there was no bed available for Patient 28 in the ED.

An interview was conducted with the ED Charge Nurse (EDCN) 1, on August 26, 2015, at 12:10 p.m., and she stated the ED staff was to "bring back" a 5150 patient to the Rapid Medical Exam (RME) area and the patient should be "bedded immediately." EDCN 1 stated Patient 28 should have been brought back and examined/screened by a provider.

An interview was conducted with ED Charge Nurse (EDCN) 2, who was on duty during Patient 28's visit to the ED on August 26, 2015, at 1:30 p.m. EDCN 2 stated, when a police officer brings a psychiatric patient to the ED, the patient should be triaged and placed in a bed. EDCN 2 stated 5150/psychiatric patients should be kept within view of the nursing staff and assessed immediately. EDCN 2 stated the police officer brought the patient to the ED for medical care and treatment, and that once a patient came to the ED, the patient was the facility's responsibility. EDCN 2 stated she did not know if a physician was notified of the need for an MSE and treatment for Patient 28.

The facility policy and procedure titled, "Management of Psychiatry Involuntary Holds (5150), Suicidal Patients and Risk Assessment," reviewed March 2014, revealed "... Patients who are at moderate risk should be placed in bedside #7 whenever possible and provided 1:1 observation. ... The Psychosocial section of the nursing note provides trigger items that will require the Suicide Risk Assessment tool (SAD Person) to be completed. ... Checklist for Suicidal and 5150 Patients:

- Place patient at bedside adjacent to nursing station as appropriate and whenever possible.
- Prepare the bedside as to reduce risk, to include:
- Remove all cables (electrical, cardiac, etc.),
- Remove crash cart,
- Remove any potentially harmful items.
- Patient is placed in a gown and clothing and shoes are placed in a patient belonging's bag.
- Purses and personal items are checked for potentially harmful items; i.e. medications, sharp objects, cigarette lighters, and bagged with the clothing and kept at the nursing station.
- Remove lighters, matches and cigarettes. ...
- Notify security that there is a patient at risk for suicide or 5150 patient in the ED and request assistance when possible to assist with observing the patient.
- Contact Staffing Office to obtain a sitter, who is responsible to provide direct 1:1 staffing for continuous observation."

2. On August 25, 2015, at 3 p.m., the employee file for RN 3 was reviewed with the Senior Human Resources Generalist (SHRG).

RN 3's date of hire was June 22, 2015. Rn 3's Emergency Medical Treatment and Active Labor Act (EMTALA)/Medical Screening Examination (MSE) competency was validated and signed off on July 2, 2015.

There was no documention in RN 3's employee file which indicated she completed basic, intermediate, and/or advanced fetal monitoring (part of the MSE competency and a requirement in order to perform an MSE).

During an interview with the Director Perinatal Services (DPS), on August 26, 2015, at 8:20 a.m., she stated RN 3 was a new nurse at the facility. The DPS stated RN 3 took basic fetal monitoring, intermediate fetal monitoring, and advanced fetal monitoring, but the advanced fetal monitoring certificate expired on May 17, 2014. The DPS stated, once an individual completed advanced fetal monitoring, the certification had to be renewed every two years in order to maintain certification. The DPS stated RN 3 should have a current advanced fetal monitoring certification to perform the MSE for OB patients.

The facility standardized procedure titled, "Medical Screen Exam for Labor," reviewed November 2014, revealed, "... Requirements for Registered Nurse: Training: Intermediate Fetal Monitoring Competency. ... Ongoing Skill Evaluation Validation will occur regularly. ..."

Based on interview and record review, the facility failed to ensure:

1. Suicidal "5150" patients were kept safe and were stabilized following presentation to the facility's Emergency Department (ED) for two sampled patients (Patients 1 and 12). This had the potential to result in Patients 1 and 12 sustaining further harm or death.

2. The necessary stabilizing treatment was provided to one sampled patient (Patient 23) who required the services of a Gastroenterologist (GI physician). This resulted in Patient 23 being unnecessarily transferred to another facility, and had the potential to result in a delay in care and treatment for Patient 23's emergency medical condition.

Findings:

"5150" - a section of the California Welfare and Institutions Code which allows a qualified person to involuntarily confine a person suspected to have a mental disorder that makes them a danger to self, a danger to others, and/or gravely disabled.

The "Sad Persons Scale" is an acronym utilized as a mnemonic device used to assist in the prediction for suicidal risk. A point is given for each yes answer to the following questions:

- Sex- Male;
- Age- less than 19 and greater than 65 years of age;
- Depression;
- Prior History (Previous suicide attempt or psychiatric care);
- Ethanol and/or drug abuse;
- Rational thinking loss;
- Support system loss;
- Organized plan;
- No Significant other (separated, divorced, single or widowed); and
- Sickness (terminal illness, cancer).

The score is mapped onto a risk assessment scale as follows:

- 0 to 2 points- no real problem, keep watch;
- 3 to 4 points- Low;
- 5 to 6 points- Moderate; and
- 7 to 10 points- High.

["Evaluation of suicidal patients: the SAD PERSONS scale," Psychosomatics, 1983.]

1a. During an interview with Emergency Department Charge Nurse (EDCN) 1, on August 26, 2015, at 11:15 a.m., she stated it was the facility's practice/policy to have all "5150" patients: Change into a hospital gown; check patient belongings for illegal or harmful items; place the patient's belongings/clothing in a secure spot in the nurses station, prepare the patient's environment to minimize the potential for the patient harming themselves, place the patient in a bed that was visible from the nurses station, such as bed seven, and provide a 1:1 observer either by a security guard or a sitter. EDCN 1 stated this practice/policy was for the safety of the patient.

On June 15, 2015, and August 24, 2015, the record for Patient 1 was reviewed. Patient 1 presented to the facility Emergency Department (ED), on May 27, 2015, at 3:27 a.m., with the chief complaint of a drug overdose with sleeping pills, Excedrin, and alcohol. Patient 1 was placed in ED bed number 5.

The "Emergency Nursing Record," dated May 27, 2015, at 3:30 a.m., indicated Patient 1 was anxious, depressed, harming self, and had suicidal ideations. In addition, Patient 1 had a history of previous attempts to harm herself and a drug overdose as a teenager.

Patient 1 had an IV (intravenous - method used to administer fluids directly into a vein) started in the right arm at 4:10 a.m.

The "ED Physician Record," dated May 27, 2015, at 5:15 a.m., indicated Patient 1 was seen and evaluated by Physician 1 and a 5150 written by Physician 1 was completed.

The "Triage Note" dated May 27, 2015, at 5:20 a.m., indicated Patient 1 had a "SAD Person Scale (clinical assessment tool used to determine suicide risk)" score of 4 (ethanol use, rational thinking loss, organized plan and no spouse or significant other).

There was no indication Patient 1 was given a point for "depression" or "prior history" of suicide attempt which would have given Patient 1 a "SAD Person Scale" score of 6 (moderate risk).

The "ED Physician Record," dated May 27, 2015, at 7 a.m., indicated Patient 1 was seen and evaluated by Physician 2, and was "medically cleared," awaiting placement at an inpatient psychiatric facility at 10:10 a.m.

The "Nursing Note" dated May 27, 2015, at 1:40 p.m., indicated "Pt (patient) not in room."

The facility was unable to locate Patient 1.

On May 27, 2015, at 2 p.m., the local law enforcement agency was notified of Patient 1 leaving the facility while on a "5150" and a welfare check was requested.

There was no indication Patient 1's environment at the facility was prepared to reduce the risk of the patient harming themselves.

There was no indication Patient 1 was placed in a gown, and clothing and personal items were removed to the nurses' station in order to protect the patient from harm.

There was no indication Patient 1 was placed on 1:1 observation, and security was notified a patient placed on a "5150" was in the ED in order to enhance the patient's safety.

During a subsequent interview with EDCN 1, on August 26, 2015, at 11:45 a.m., she reviewed the record and was unable to find documentation of Patient 1's environment being prepared to reduce the risk of the patient harming themselves; the patient being placed in a gown, and clothing and personal items being removed from the room; and Patient 1 being placed on 1:1 observation. EDCN 1 stated Patient 1 could be seen on a facility camera leaving the ED at 1:06 p.m., fully clothed with her cellular telephone in her hand. EDCN 1 stated Patient 1 was at "high risk" for elopement from the facility. EDCN 1 stated Patient 1 should have been placed in a hospital gown, with her clothing and personal items removed from the room, and placed in a secured spot in the nurses station. EDCN 1 stated Patient 1 should have been placed on 1:1 observation either by a security guard or a sitter (constant observer). In addition, EDCN 1 stated the "Individual Observation Form" should have been implemented for Patient 1.



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b. The record for Patient 12 was reviewed on August 26, 2015. Patient 12 presented to the Emergency Department (ED) by ambulance, on May 26, 2015, at 12:25 p.m. Ambulance documentation indicated Patient 12 was placed on a 5150 (psychiatric hold) by the police department after the determination the patient was a danger to herself and/or others.

The police 5150 document titled, "Evaluation and Crisis Intervention...Placement For Evaluation And Treatment," dated May 26, 2015, at 12 p.m., indicated "Upon contact...(Patient 12) told me she has nothing to live for and wants to die. Said she could jump off a balcony to kill herself if she could..."

The ED nursing triage note for May 26, 2015, at 1:09 p.m., revealed the ED Registered Nurse (RN) did not complete a suicide assessment which in turn would have initiated a SAD scale assessment for Patient 12.

The ED physician documentation indicated Patient 12 would be transferred to a psychiatric facility for the diagnosis of suicidal ideation (having thoughts of killing oneself).

The record further indicated Patient 12 was transferred to a psychiatric facility, on May 27, 2015, at 12:36 a.m., or 24 hours after presenting to the ED.

An interview and concurrent record review was conducted with the Emergency Department Charge Nurse (EDCN) 1, on August 26 , 2015, at 11:40 a.m. EDCN 1 stated suicide risk assessments were completed on all patients presenting with suicidal ideation. EDCN 1 stated the assessment included questions regarding a patient's risk for suicide, and would give a numeric value to the questions answered. EDCN 1 stated the numeric value would alert the RN as to which interventions were to be initiated for the patient to include hourly monitoring, and one to one observation with a sitter.

EDCN 1 reviewed the record for Patient 12, and was unable to find documentation to include a suicide risk assessment completed for Patient 12. EDCN 1 was unable to find documentation that indicated interventions to prevent Patient 12 from harming herself were implemented.

EDCN 1 further stated based on the patient's presenting complaint and history, the RN should have completed a suicide assessment for the patient, and initiated interventions as indicated.

The facility policy and procedure titled, "Management of Psychiatry Involuntary Holds (5150), Suicidal Patients and Risk Assessment" reviewed March 2014, revealed, "... Patients who are at moderate risk should be placed in bedside #7 whenever possible and provided 1:1 observation. ... The Psychosocial section of the nursing note provides trigger items that will require the Suicide Risk Assessment tool (SAD Person) to be completed. ... Checklist for Suicidal and 5150 Patients:

- Place patient at bedside adjacent to nursing station as appropriate and whenever possible.
- Prepare the bedside as to reduce risk, to include:
- Remove all cables (electrical, cardiac, etc.),
- Remove crash cart,
- Remove any potentially harmful items.
- Patient is placed in a gown and clothing and shoes are placed in a patient belonging's bag.
- Purses and personal items are checked for potentially harmful items; i.e. medications, sharp objects, cigarette lighters, and bagged with the clothing and kept at the nursing station.
- Remove lighters, matches and cigarettes. ...
- Notify security that there is a patient at risk for suicide or 5150 patient in the ED and request assistance when possible to assist with observing the patient.
- Contact Staffing Office to obtain a sitter, who is responsible to provide direct 1:1 staffing for continuous observation."



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2. A record review of Patient 23's record was conducted on August 26, 2015. Patient 23, an uninsured 53 year old male, presented to the facility Emergency Department (ED), on August 3, 2015, at 6:15 p.m., with the chief complaint of hematemesis (vomiting blood) two times.

Record review indicated Patient 23 was triaged at 6:19 p.m., and at 6:49 p.m. a complete blood count (laboratory work) was drawn that resulted in a hemoglobin (protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues) of 3.8 (facility laboratory values normal as 13.2 to 17.3).

Patient 23 was given one unit of packed red blood as per the ED physician's order on August 3, 2015, at 8:18 p.m.

The ED physician progress note dated August 3, 2015, at 8:18 p.m., indicated, "Spoken to Hospitalist on call, (Hospitalist) could not accept patient because GI is not available to see patient tonight. Spoke to (GI specialist), states he is not able to see patient. (Another facility) consulted and will accept patient..."

Patient 23 was transferred to another acute care facility on August 4, 2015, at 2:14 a.m.

An interview was conducted with the ED Charge Nurse (EDCN) 1 on August 26, 2015, at 11:00 a.m. The EDCN 1 stated the Hospitalist did not take the call further in determining who was the GI back up physician to call if the initial GI physician could not/would not come in.. The EDCN 1 stated the Hospitalist should have called the other two GI physicians on call when the initial GI physician would not come in.

An interview was conducted with the Chief Executive Officer (CEO), on August 26, 2015, at 11:15 a.m. The CEO stated the facility did provide GI services and currently there were three GI physicians on staff. The CEO stated if the physician was seen attending other ED GI patients that day, the GI physician should have come in to see Patient 23. The CEO stated the GI physician had been at the facility evaluating two other GI patients earlier that same day, and had just left the facility. In addition, the CEO stated the facility had a contractual agreement with the GI physicians to see uninsured patients and the physician should have come in to see the patient.

Based on interview and record review, the facility failed to provide a timely triage assessment and Medical Screening Exam (MSE) for one sampled patient (Patients 11). This failure resulted in am increased delay of the determination if an emergency medical condition existed for the patient, and had the potential to result in the delay of stabilizing medical treatment.

Findings:

The record for Patient 11 was reviewed on August 25, 2015. Patient 11 presented to the Emergency Department (ED) by fire department personnel, on August 7, 2015, at 12:48 a.m. The fire department's documentation indicated Patient 11 had an altered level of consciousness.

The nursing triage note for August 7, 2015, at 1:27 a.m., indicated Patient 11 presenting complaint was triaged an Emergency Severity Index (ESI) 2 indicating Patient 11 had an emergent medical condition which had the potential to deteriorate, and required immediate provider intervention. The triage note further indicated Patient 11 "did not speak, stared at her right side, and was vomiting."

Documented vital signs at the time of triage revealed Patient 11's heart rate was at 110 beats per minute (bpm - normal range is 60-100 bpm per the AHA- American Heart Association), and blood pressure was 170/93 mmHg (millimeters of mercury - per the AHA normal blood range is less than 120/80 mmHg).

The record indicated Patient 11 was provided a MSE by the ED physician at 3:22 a.m. This was three hours and 10 minutes after Patient 11 presented to the ED.

The nursing note for 3:31 a.m., indicated Patient 11 was brought the ED bed 1, and was unable to communicate or follow directions.

The record further indicated Patient 11 was admitted to the Progressive Care Unit (PCU- a unit of a facility designated to provide care to patients who required specialized monitoring) with the diagnosis of accidental drug overdose.

During an interview and concurrent record review conducted with the Emergency Department Charge Nurse (EDCN) 1, on August 26, 2015, at 11:40 a.m., EDCN 1 stated it was the expectation patients brought to the facility by ambulance would be triaged with within 10 minutes of arrival. EDCN 1 stated following the nurse triage assessment, the physician would be notified in order to complete a timely MSE.

EDCN 1 stated Patient 11 was not provided a timely triage and MSE based on the patient's medical condition on arrival to the ED.

Based on interview and record review, the facility failed to ensure transfer documents were completed for two sampled patients (Patients 12 and 21). This failure had the potential to negatively impact the ongoing provision of care for both patients.

Findings:

The facility policy and procedure titled, "Emergency Department: Transfer to Another Facility," revised March 2009, was reviewed on August 26, 2015. The policy indicated, "It is the policy of this hospital to comply with all requirements of the Consolidated Omnibus Budget Act (COBRA), Emergency Medical Transport Active Labor Act (EMTALA)...to provide for the safe transfer of all ED patients..."

The policy further indicated, "...The transferring physician is responsible for the individual patient and determines whether the individual is medically fit to transfer...The individual or the individual's acknowledgement of such notification should be reflected in appropriate signing of the Patient Transfer Acknowledgement Form...Transfer of patient records: All relevant medical information accompanies the patient, including but not limited to...Patient's authorization release information is documented and signed on the "Patient Transfer Acknowledgement" form...The "Patient Transfer Acknowledgement" form and "Physician Certification" form are signed by the physician and contain relevant information pertaining to the individual's condition and treatment..."

a. The record for Patient 12 was reviewed on August 26, 2015. Patient 12 presented to the facility by ambulance on May 26, 2015, at 12:25 a.m. Ambulance documentation indicated Patient 12 was placed on a 72 hour psychiatric hold by the police department following the determination the patient was a danger to herself and/or others.

The Emergency Department (ED) physician's documentation for May 26, 2015, at 5:19 p.m., indicated Patient 12 would be transferred to a psychiatric facility when a bed was available.

A review of the "Physician Authorization For Transfer " form for Patient 12 was reviewed. The section of the form to indicate if the patient's medical condition was stabilized was blank. The section of the form to indicate the name of the accepting facility, if the facility had the space, and qualified personnel to provide appropriate medical treatment was blank. The section of the form to indicate the update status of the patient's condition was blank.

There was no physician documentation to indicate Patient 12 was medically fit for transfer.

An interview and concurrent review of Patient 12's record, was conducted with Emergency Department Charge Nurse (EDCN) 1, on August 26, 2015, at 11:40 a.m. EDCN 1 stated transfer forms, to include a patient transfer acknowledgement form, must be completed prior to the patient's transfer. EDCN 1 stated transfer forms were completed and sent with the patient to the receiving facility. EDCN 1 further stated transfer forms were used to communicate vital patient medical condition information to the receiving facility.

EDCN 1 was unable to find a "Patient Transfer Acknowledgement" for Patient 12. EDCN 1 reviewed the form titled "Patient Authorization For Transfer" form for Patient 12, and stated the form was incomplete, and should have been completed prior to the patient's transfer from the facility.



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b. On August 26, 2015, the record for Patient 21 was reviewed. Patient 21 presented to the facility Emergency Department (ED) on August 2, 2015, at 9:25 a.m., with the chief complaint of, "drift to all four extremities, altered level of consciousness, nonverbal..."

Patient 21 was triaged at 9:25 a.m., and seen by the ED physician at 9:31 a.m., who determined Patient 21 had a stroke (cerebrovascular accident, spontaneous brain injury).

The ED physician made the decision to transfer Patient 21 to another acute care facility for a higher level of care, on August 2, 2015, at 10:19 a.m.

Patient 21 was transferred from the facility via ambulance, on August 2, 2015, at 1:05 p.m.

There was no indication the "Patient Transfer Acknowledgement" form was completed to include the patient's signature or the signature of the patient's responsible party.

There was no indication the "Physician Certification" form was completed to indicate the risks and benefits of the transfer were explained to the patient/patient's responsible party and the physician's signature.

There was no indication the "Physician Authorization for Transfer" form was completed to indicate the patient was accepted by the receiving facility. There was no indication of the patient's condition/stability at the time of transfer.

An interview and concurrent record review was conducted with Emergency Department Charge Nurse (EDCN) 1, on August 26 , 2015, at 11 a.m. The EDCN 1 stated transfer forms included a "Patient Transfer Acknowledgement" completed prior to the patient's transfer. The forms communicate the need for transfer and the condition of the patient along with the risk and benefits of transferring to another facility. EDCN 1 further stated transfer forms were used to communicate vital patient medical information to the receiving facility.

EDCN 1 was unable to find the following forms for Patient 21: "Patient Transfer Acknowledgement," "Patient Authorization For Transfer," and "Physician Certification." The EDCN stated the forms should have been completed prior to the patient's transfer from the facility.