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Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure an appropriate medical screening exam (MSE) for a patient with a emergency medical condition (EMC), was provided for one (1) of twenty (20) sampled patients, Patient #1. Patient #1 was transported from the Personal Care Home (PCH) where he/she resided for evaluation of abnormal laboratory values that included an Ammonia level of 161 umol/L (micromole/Liter). The normal reference range is 18-75 umol/L. Upon arrival to Facility #1's Emergency Department (ED), the facility refused to allow Emergency Medical Services (EMS) staff to bring Patient #1 into the ED.

Cross Refer: A2406 The facility failed to provide a medical screening exam to Patient #1.

Cross Refer: A2407 The facility failed to provide stabilizing medical treatment for a patient with an emergency medical condition, Patient #1.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure an appropriate medical screening exam (MSE) for a patient with an emergency medical condition (EMC), was provided for one (1) of twenty (20) sampled patients, Patient #1. Patient #1 was transported on 11/22/16, from the Personal Care Home (PCH) where he/she resided for evaluation of abnormal laboratory values including an Ammonia level of 161 umol/L (micromole/Liter) (normal reference range of 18-75 umol/L). However, upon arrival to Facility #1's Emergency Department (ED), Facility #1 failed to complete the MSE in order to determine whether or not an EMC existed, as Facility #1 instructed Emergency Medical Services (EMS) to divert the patient to Facility #2.

The findings include:

Review of Facility #1's policy titled, "Medical Screening Examination, Stabilization and Transfer of Patients", Policy number ACORP-M-02, last reviewed June 03, 2015, revealed it's purpose was to provide a MSE to determine if an EMC exists and to provide stabilizing medical treatment, prior to an appropriate transfer, if applicable, to any individual presenting to the ED, within the meaning of EMTALA (Emergency Medical Treatment and Labor Act).

Review of the EMS run sheet, dated 11/22/16 at 10:15 AM, revealed EMS was dispatched to the PCH where Patient #1 resided, for transport to the ED for evaluation of abnormal laboratory values which included an increased ammonia level of 161 umol/L (normal reference range of 18-75 umol/L).

Review of Facility #2's ED documentation, dated 11/22/16, revealed an uneventful course while Resident #1 was admitted there. Continued review revealed he/she was discharged from the ED on 11/22/16 and admitted to Medical Intensive Care (MICU) on 11/22/16 for monitoring of the abnormal Ammonia level.

Review of Resident #1's Community Plan, dated 01/22/15, as agreed on by local law enforcment and Emergency Medical Services (EMS), Security for the regional hospital system, ED Managers, Behavioral Health Manager and Logistics revealed the following:

1. Law enforcement and/or EMS, after arrival to the scene will determine if Patient #1 will need transportation to a medical facility for medical assessment.

2. Once determined, if Patient #1 requires medical assessment by a physician, he/she will be transported to Facility #2, as Patient #1 is familiar with the staff in the Behavioral Health Unit (BHU) and staff are familiar with him/her.

3. A Crisis Intervention Team-trained Police Officer will assist the EMS by riding in the ambulance to Facility #2.

4. A call will be placed by the Paramedic to Facility #2, communicating that Patient #1 is en route to the ED by ambulance.

5. The Charge Nurse will notify the BHU and Logistics that he/she will need to be assigned a BHU bed.

6. The Charge Nurse will notify Security that Patient #1 is en route.

7. Security for Facility #2 responds to the ED and contacts local Police for possible assistance.

8. A BHU Nurse will respond to the ED to communicate with Patient #1, upon arrival, as a good rapport by the BHU staff has previously been established.

9. If Patient #1 requires an inpatient bed, this will be assigned immediately.

In the event Patient #1 is in another city and transported to another ED, the following will occur:

1. Security responds to the ED

2. Clerical in the ED contacts Logistics for admission to Facility #2's BHU.

3. EMS is contacted to transport Patient #1 to Facility #2 with extra crew.

4. Once the ambulance leaves the ED, Clerical staff contact Security at Facility #2 that Patient #1 is en route by EMS and may need assistance.

Review of the sampled nineteen (19) medical records from Facility #1, did not reveal any concerns with EMTALA components, such as, not receiving a MSE or stabilizing treatment prior to discharge or transfer.

Review of Facility #1's ED log, dated 11/22/16, revealed no documented evidence of Patient #1's name, date/time of arrival/discharge or disposition.

Request for clinical documentation regarding Patient #1's arrival at Facility #1, revealed through interview with the Vice President, Chief Nursing Officer, on 01/10/17 at 9:17 AM, that there was no clinical documentation concerning Patient #1's arrival at Facility #1.

Interview with Unit Secretary of Facility #1 ED, on 01/09/17 at 2:27 PM, revealed the ED had radios and phones to monitor conversations between local area EMS dispatches and EMS departments. She went on to state that EMS squads were different in that some would call them every single time when coming to the ER but stated most usually just called the emergent dispatches, to give the ED a heads up.

Interview with Paramedic #1, 01/10/17 at 9:02 AM, and again on 01/11/17 at 11:32 AM with a Director of Quality present, revealed he was working Triage the date of the incident. He stated he had a phone call from the BHU at Facility #2 transferred to him by the Unit Secretary of the ED at Facility #1. Per interview, the phone call was to inform EMS staff, upon arrival, that Patient #1 needed to be transported to Facility #2, but there was no reason given. Further interview revealed that at no time was he given Patient #1's name during the encounter and he did not see a need to document the encounter. Additional interview revealed he was aware of the components of EMTALA. He further stated a Community Plan was a plan to provide the safest environment for certain patients to be treated, in response to their aggressive/destructive nature or mental health behaviors.

Interview with the Registered Nurse (RN) in Facility #1's ED, on 01/10/17 at 11:17 AM, revealed she had been instructed by the ED Physician to go out to the EMS bay and let them know their patient (Patient #1) needed to go to the Facility #2 ED. She further stated the Paramedic had questions she didn't have answers for and she advised Paramedic to wait while she sought the answers. However, she stated when she came back with answers, the ambulance was gone. She further stated she did not have any physical contact with Patient #1, but did visualize him/her in the back of the ambulance as being calm and in no apparent distress. Continued interview revealed she was aware of the components of EMTALA, and would never turn a patient away without a MSE and/or stabilizing treatment. She further stated, at no time did she remember being given Patient #1's name until after the fact.

Interview with the EMS Coordinator for Facility #1 and all sister facilities, who served as a liaison between the fire stations and the ED's, on 01/10/17 at 10:37 AM, revealed was making rounds at Facility #2 when the EMS arrived with Patient #1. Per interview, he stated Paramedic #2 asked to speak to him. Continued interview revealed the Paramedic told him when they picked Patient #1 up at the PCH, they were instructed that the Power of Attorney (POA), who was Patient #1's mother, wanted the patient taken to Facility #1. The Paramedic further stated when they arrived at Facility #1, before they could off-load the patient, ED staff told EMS the best place for the patient was Facility #2, without giving an explanation. Further interview revealed the EMS Coordinator spoke to Patient #1's mother/POA while Patient #1 was being evaluated in the ED and she was under the impression EMS only went to one (1) facility and he explained to her, EMS would go to the closest, appropriate facility for a patient's situation. The EMS Coordinator further stated when he was notified on 11/22/16 that Patient #1 had a Community Plan, he immediately set about notifying the transferring EMS station and 911 Dispatch Center (not a participant in the initial Community Plan service area) about the Community Plan for Patient #1 and in the future, if they were the transferring EMS squad, when Patient #1's name was entered into their system, it would "flag" and let them know he/she had a Community Plan. Continued interview revealed the PCH where Patient #1 resided was also informed of Patient #1's community Plan. He stated the education was completed 11/22/16 for both entities.

Interview with Paramedic #2, on 01/10/17 at 1:11 PM, revealed he had been frustrated that EMS was being used as a transport service for Patient #1's abnormal lab results and he felt Patient #1 was above the level of care for the PCH where he/she resided because of his/her stature (7'1'' tall and a weight of 400-450#) and there was usually just females working there. He went on to state they were met at the Facility #1 ED bay by a nurse (unable to remember name) who stated the patient needed to go to Facility #2 per their request (Facility #2). Per interview, Paramedic #2 did not remember being asked to wait while the confusion was straightened out. He stated he was educated on the Community Plan for Patient #1 later that day, on 11/22/16. Continued interview revealed he had spoken to the EMS Coordinator, who he had previously worked with, about his frustration concerning the run.

Interview on 01/11/17 at 10:32 AM, with Facility #1's ED Physician who was involved in the encounter, revealed he recollected the incident and stated the ED was receiving a phone call from EMS, and at the same time Logistics (responsible for assigning beds within the entire hospital system) was on the phone with information that Patient #1 had a Community Plan and EMS needed to be be advised to bring him/her to Facility #2 per the Plan. Per interview the call to Dispatch did not occur in time to divert Patient #1 to Facility #2, as EMS was already pulling into the bay. He stated he did not remember telling a nurse to let EMS know the Patient needed to go to Facility #2 because of the Community Plan. The ED Physician stated he did remember going out to the bay to tell EMS to wait, and he stated there was some confusion as to the best place for Patient #1. He further stated when the nurse went back out to let them know the patient needed to go to Facility #2, EMS was gone. Per interview, the ED Physician stated in retrospect, yes, he should have performed a MSE, even if it was in the back of the ambulance. "I would never turn anyone away with a medical emergency, EMTALA components require that a MSE be completed and stabilizing treatment provided prior to an appropriate transfer, if applicable."

Interview with the Director of Logistics, on 01/11/17 at 1:12 PM, revealed her department made all bed assignments for the hospital system which included Facility #1, Facility #2, and others, once it was determined a bed was needed. Continued interview revealed her staff (a nurse and clerk) received a call from the BHU Nurse Manager at Facility #2, stating a patient with a Community Plan was being transported to Facility #1 and needed to go to Facility #2 instead. She stated clerical staff called Facility #1's ED Unit Secretary to let them know about the patient.

Interview with the RN Nurse Manager at Facility #2's BHU, on 01/11/17 at 1:50 PM, revealed Patient #1's mother/POA called her on 11/22/16 to let them know the patient was being transferred to Facility #1 and was concerned because she was aware of the Community Plan which indicated he/she was supposed to be transferred to Facility #2. She further stated the resident's mother/POA indicated it had been a struggle to get Patient #1 to agree to get in the ambulance at the PCH anyway, and she was afraid if he/she got out at Facility #1, staff would never get him/her back in for the trip to Facility #2. Continued interview revealed she was the one that called Facility #1's ED and notified the Paramedic working Triage on 11/22/16, a patient was being transported from an outlying area, had a Community Plan and would need to be diverted to Facility #2.

Continued interview with the ED Unit Secretary at Facility #1, on 01/11/17 at 2:21 PM, revealed only a Physician, RN or Paramedic could respond to a call on the EMS phone. She stated staff could only hear the communication between Dispatch and EMS squad on the radio. Per interview, she was unable to remember if the transferring EMS squad called on the phone and the ED was unable to hear that County's dispatch because it was in a different service area. Further interview revealed when she received the call from the Logistic staff, all she was told was the patient was seven (7) foot tall and weighed about four hundred fifty (450) pounds and needed to go to Facility #2 because of having a Community Plan. She stated she then handed the call off to the Triage Paramedic and that was the end of her involvement. Continued interview revealed in order for the Community Plan to "flag" in the system, a patient name needed to be entered and to her knowledge, the ED never received a patient name.

Interview with the Director of Patient Safety, Infection Control and Accreditation, on 01/10/17 at 8:17 AM, revealed Facility #1 and Facility #2 were considered as one (1) campus and Patient #1 was sent to the facility that could best handle his/her needs in a safe manner for him/her, other patients and staff, should his/her behavior become violent and aggressive. She further stated, given Patient #1's stature and diagnoses which included Schizo-Affective Disorder with Behavioral Disturbances, a Community Plan had been devised for him/her to assist in ensuring his/her needs were met safely. Per interview, the Community Plan interventions included transporting Patient #1 to Facility #2 for healthcare needs in case a BHU bed was needed. She revealed the patient and BHU staff had established a rapport over the years he/she had been treated at Facility #2.

Interview with the Vice-President/Chief Nursing Officer, on 01/10/17 at 9:17 AM, revealed if the ED at Facility #1 had been given the patient's name and entered it into the system, the Community Plan would have flagged and the transferring EMS squad could have been contacted sooner and Patient #1 transported to Facility #2, per the Community Plan interventions. Per interview, the Community Plans were developed for Patient #1 and the four (4) or five (5) other aggressive/violent individuals in the community from meetings with local police and ambulance services. She stated, over the years Patient #1 had been treated by the BHU staff at Facility #2, a rapport had developed, and he/she was comfortable with the staff. She further stated the staff could usually keep him/her from escalating behaviors, thus keeping him/her, other patients, and staff safe. Per interview, it would be irresponsible to knowingly put Patient #1 in an unfamiliar environment, because this could lead to a negative outcome. Further interview, revealed the ED staff at Facility #1 were not refusing to examine Patient #1, but were just trying to sort out why they had received the phone call requesting the patient be sent to Facility #2.

Interview with the Director of Risk Management, on 01/10/17 at 2:15 PM, revealed 2014 was the first time Patient #1 was admitted to Facility #2 and the patient hurt Security staff and had to be tazed twice to bring him/her under control. He stated it was during review of that incident, it was recognized there was a need for a plan to involve community resources that would include local EMS, Police, hospital campus Security, BHU staff and Nursing. He further stated the purpose of the Community Plan was to streamline the Intake Process for typically aggressive, violent patients in order to place them at the facility they responded to in a positive manner, thereby reducing the risk of serious harm to themselves, other individuals, and staff caring for them.

Continued interview with the Director of Risk Management revealed the Community Plan concept was presented to the Crisis Intervention Training (CIT) team in June 2015. Per interview the Community Plan involved input from regional law enforcement officers who were trained in Mental Health issues, judges who oversee mental health courts, and a regional Psychiatric Hospital. He stated with the Community Plan, the situation could then become about de-escalation instead of arrest or a more negative outcome at the scene. He stated the whole purpose of a Community Plan was to provide care to individuals with behavioral health issues in an efficient and safe manner for all involved.

Continued interview revealed January 2015 through September 2016, the Workplace Violence Committee (WVC) met to facilitate integrating the Community Plan into the electronic medical record (EMR) and clarifying the process by which an individual had a Community Plan instituted for them. He stated, in normal circumstances, Patient #1 should have received a MSE prior to the transfer; however, the situation was unique because he/she had known aggressive, violent behaviors, to the point of injuring EMS, Security and Nursing staff that had cared for him/her. He stated it was known through previous encounters Patient #1 responded in a more positive manner to the BHU staff at Facility #2. He further stated Patient #1 was calm on arrival at Facility #1; however, it was reported Patient #1 was becoming agitated and uncooperative on the approximately five (5) mile trip to Facility #2.

Furthermore, the Director of Risk Management stated training would be held in January 2017 to clarify to all staff, especially ED and Obstetrical staff, any individual presenting to any hospital within the system would be afforded a MSE and stabilizing treatment prior to any applicable disposition as set forth in the EMTALA regulations.

Based on interview, record review, and review of facility's policies, it was determined the facility failed to provide stabilizing medical treatment for a patient with a emergency medical condition (EMC), for one (1) of twenty (20) sampled patients, Patient #1. Patient #1 was transported from the Personal Care Home (PCH) where he/she resided for evaluation of abnormal laboratory values that included an elevated ammonia level of 161 umol/L (micromole/Liter), with normal being 18-75 umol/L. Upon arrival to the Emergency Department, Facility #1 instructed the Emergency Medical Service (EMS) to take Patient #1 on to Facility #2, without providing stabilizing medical treatment.

The findings include:

Review of Facility #1's policy titled, "Medical Screening Examination, Stabilization and Transfer of Patients", Policy number ACORP-M-02, last reviewed June 03, 2015, revealed it's purpose was to provide a MSE to determine if an EMC exists and to provide stabilizing medical treatment, prior to an appropriate transfer, if applicable, to any individual presenting to the ED, within the meaning of EMTALA (Emergency Medical Treatment and Labor Act).

Review of the EMS run sheet dated, 11/22/16 at 10:15 AM, revealed EMS was dispatched to the PCH where Patient #1 resided for transport to the ED for evaluation of abnormal laboratory values which included an elevated ammonia level of 161 umol/L, with normal being 18-75 umol/L.

Review of Facility #2's ED documentation, dated 11/22/16, revealed an uneventful course while Resident #1 was admitted there. Continued review revealed he/she was discharged from the ED on 11/22/16 and admitted to Medical Intensive Care (MICU) on 11/22/16 for monitoring of the abnormal Ammonia level.

Review of Resident #1's Community Plan dated 01/22/15, as agreed on by local law enforcement, ambulance services, hospital campus security personnel, ED Managers, BHU Manager and Logistics revealed the following:

1. Local law enforcement or EMS, after arrival to the scene will determine if Patient #1 will need transportation to a medical facility for medical assessment.

2. Once determined, if Patient #1 requires medical assessment by a physician, he/she will be transported to Facility #2, as Patient #1 is familiar with the staff in the Behavioral Health Unit (BHU) and staff are familiar with the patient.

3. A Crisis Intervention Team-trained police officer will assist the EMS by riding in the ambulance to Facility #2.

4. A call will be placed by the Paramedic to the ED Charge Nurse at Facility #2, communicating that Patient #1 is en route to the ED by ambulance.

5. The Charge Nurse will notify the BHU and Logistics that the patient will need to be assigned a BHU bed.

6. The Charge Nurse will notify Security that Patient #1 is en route.

7. Security responds to the ED and contacts local police for possible assistance.

8. A BHU Nurse will respond to the ED to communicate with Patient #1, upon arrival, as a good rapport by the BHU staff has previously been established.

9. If Patient #1 requires an inpatient bed, this will be assigned immediately.

In the event Patient #1 is in a city other than Covington and transported to an ED other than Covington or Edgewood:

1. Security responds to the ED

2. Clerical in the ED contacts Logistics for admission to Facility #2's BHU.

3. The EMS is contacted to transport Patient #1 to Facility #2 with extra crew.

4. Once EMS leaves the ED, clerical staff contacts Security that Patient #1 is en route by EMS and may need assistance.

Review of the sampled nineteen (19) medical records from Facility #1, did not reveal any concerns with EMTALA components, such as, not receiving a MSE or stabilizing treatment prior to discharge or transfer.

Review of Facility #1's ED log, dated 11/22/16, revealed no documented evidence of Patient #1's name, date/time of arrival/discharge or disposition.

Request for clinical documentation regarding Patient #1's arrival at Facility #1, revealed through interview with the Vice President/Chief Nursing Officer, on 01/10/17 at 9:17 AM, revealed there was no clinical documentation concerning Patient #1's arrival at Facility #1.

Interview with Unit Secretary of Facility #1 ED, on 01/09/17 at 2:27 PM, revealed the ED had radios and phones to monitor conversations between local area EMS dispatches and EMS departments. She went on to state that EMS squads were different in that some would call them every single time when coming to the ER but stated most usually just called the emergent dispatches, to give the ED a heads up.

Interview with Paramedic #1, 01/10/17 at 9:02 AM, and again on 01/11/17 at 11:32 AM, with a Director of Quality present revealed he was working Triage the date of the incident. He stated he had a phone call transferred to him from the Unit Secretary of the ED, from the Charge Nurse (unable to remember her name) at Facility #2's (sister facility) Behavioral Health Unit (BHU). Per interview the phone call was to inform EMS staff, upon arrival, that Patient # 1 needed to be transported to Facility #2, but there was no reason given. Further interview revealed that at no time was he given Patient #1's name during the encounter and he did not see a need to document the encounter. Additional interview revealed he was aware of the components of EMTALA. He further stated a Community Plan was a plan to provide the safest environment for certain patients to be treated, in response to their aggressive/destructive nature or mental health behaviors.

Interview with the Registered Nurse (RN) in Facility #1's ED, on 01/10/17, at 11:17 AM, revealed she had been instructed by the ED Physician to go out to the EMS bay and let them know their patient (Patient #1) needed to go to SEE ED. She further stated the Paramedic had questions she didn't have answers for and she advised Paramedic to wait while she sought the answers. However, she stated when she came back with answers, the ambulance was gone. She further stated she did not have any physical contact with Patient #1, but did visualize him/her in the back of the ambulance as being calm and in no apparent distress. Continued interview revealed she was aware of the components of EMTALA, and would never turn a patient away without a MSE and/or stabilizing treatment. She further stated, at no time did she remember being given Patient #1's name until after the fact.

Interview with the EMS Coordinator for the regional hospital system which included Facility #1 and Facility #2, on 01/10/17 at 10:37 AM, revealed he served as a liaison between the fire stations and the various ED's within the system. He stated he had been making rounds at Facility #2 when the EMS run with Patient #1 came in. Per interview, he stated Paramedic #2 asked to speak to him.

Continued interview revealed the Paramedic told him when they picked Patient #1 up at the PCH, they were instructed that the Power of Attorney (POA), who was Patient #1's mother, wanted him/her taken to Facility #1. The Paramedic stated when they arrived, before they could off-load the patient, ED staff told EMS the best place for the patient was Facility #2, without giving an explanation.

Further interview revealed the EMS Coordinator spoke to Patient #1's mother/POA while Patient #1 was being evaluated in the ED and she was under the impression EMS only went to one (1) facility and he explained to her, EMS would go to the closest, appropriate facility for a patient's situation. The EMS Coordinator further stated when he was notified on 11/22/16 that Patient #1 had a Community Plan, he immediately set about notifying the transferring EMS station and 911 Dispatch Center (not a participant in the initial Community Plan service area) about the Community Plan for Patient #1 and in the future, if they were the transferring EMS squad, when Patient #1's name was entered into their system, it would "flag" and let them know he/she had a Community Plan. Continued interview revealed the PCH where Patient #1 resided was also informed of Patient #1's Community Plan. He stated the education was completed 11/22/16 for both entities.

Interview with Paramedic #2, on 01/10/17 at 1:11 PM, revealed he had been frustrated that EMS was being used as a transport service for Patient #1's abnormal lab results and he felt Patient #1 was above the level of care for the PCH where he/she resided because of his/her stature (seven foot one inches tall and four hundred to four hundred fifty pounds (7'1'' and 400-450#') and there was usually just females working there. He went on to state they were met at the Facility #1 ED bay by a nurse (unable to remember name) who stated the patient needed to go to Facility #2 per their request (Facility #2). Per interview, Paramedic #2 did not remember being asked to wait while the confusion was straightened out. He stated he was educated on the Community Plan for Patient #1 later that day, on 11/22/16. Continued interview revealed he had spoken to the EMS Coordinator, who he had previously worked with, about his frustration concerning the run.

Interview on 01/11/17 at 10:32 AM, with Facility #1's ED Physician who was involved in the encounter, revealed he recollected the incident and stated the ED was receiving a phone call from EMS, and at the same time Logistics (responsible for assigning beds within the hospital system) was on the phone with information that Patient #1 had a Community Plan and EMS needed to be be advised to bring him/her to Facility #2 per the Plan. Per interview the call to Dispatch to divert Patient #1 was unsuccessful, as EMS was already pulling into the bay. He stated he did not remember telling a nurse to let EMS know the Patient needed to go to Facility #2 because of the Community Plan. The ED Physician stated he did remember going out to the bay to tell EMS to wait, and he stated there was some confusion as to the best place for Patient #1. He further stated when the nurse went back out to let them know the patient needed to go to Facility #2, EMS was gone. Per interview, the ED Physician stated in retrospect, yes, he should have performed a MSE, even if it was in the back of the ambulance. "I would never turn anyone away with a medical emergency, EMTALA components require that a MSE be completed and stabilizing treatment provided prior to an appropriate transfer, if applicable."

Interview with the Director of Logistics for the entire hospital system, on 01/11/17, at 1:12 PM revealed her department made all bed assignments for each hospital within the system entities once it was determined a bed was needed. Continued interview revealed her staff (a nurse and clerk) received a call from the BHU Nurse Manager, stating a patient with a Community Plan was being transported to Facility #1 and needed to go to Facility #2. She stated clerical staff called Facility #1's ED Unit Secretary to let them know about the patient.

Interview with the RN Nurse Manager at Facility #2's BHU, on 01/11/17 at 1:50 PM, revealed Patient #1's mother/POA called her on 11/22/16 to let them know the patient was being transferred to Facility #1 and was concerned because she was aware of the Community Plan which indicated he/she was supposed to be transferred to Facility #2. She further stated the resident's mother/POA indicated it had been a struggle to get Patient #1 to agree to get in the ambulance at the PCH anyway, and she was afraid if he/she got out at Facility #1, staff would never get him/her back in for the trip to Facility #2. Continued interview revealed she was the one that called Facility #1's ED and notified the Paramedic working Triage on 11/22/16, a patient was being transported from an outlying area, had a Community Plan and would need to be diverted to Facility #2.

Continued interview with the ED Unit Secretary at Facility #1, on 01/11/17 at 2:21 PM, revealed only a Physician, RN or Paramedic could respond to a call on the EMS phone. She stated staff could only hear the communication between Dispatch and EMS squad on the radio. Per interview, she was unable to remember if the transferring EMS squad called on the phone and the ED was unable to hear that County's dispatch because it was in a different service area. Further interview revealed when she received the call from the Logistic staff, all she was told was the patient was seven (7) foot tall and weighed about four hundred fifty (450) pounds and needed to go to Facility #2 because of having a Community Plan. She stated she then handed the call off to the Triage Paramedic and that was the end of her involvement. Continued interview revealed in order for the Community Plan to "flag" in the system, a patient name needed to be entered and to her knowledge, the ED never received a patient name.

Interview with the Director of Patient Safety, Infection Control and Accreditation, on 01/10/17 at 8:17 AM, revealed Facility #1 and Facility #2 were considered as one (1) campus and Patient #1 was sent to the facility that could best handle his/her needs in a safe manner for him/her, other patients and staff, should his/her behavior become violent and aggressive. She further stated, given Patient #1's stature and diagnoses which included Schizo-Affective Disorder with Behavioral Disturbances, a Community Plan had been devised for him/her to assist in ensuring his/her needs were met safely. Per interview, the Community Plan interventions included transporting Patient #1 to Facility #2 for healthcare needs in case a BHU bed was needed. She revealed the patient and BHU staff had established a rapport over the years he/she had been treated at Facility #2.

Interview with the Vice-President/Chief Nursing Officer on 01/10/17, at 9:17 AM, revealed if the ED had been given the patient's name and entered it into the system, the Community Plan would have flagged and the transferring EMS squad could have been contacted sooner and Patient #1 transported to Facility #2, per the Community Plan interventions. Per interview, the Community Plans were developed for Patient #1 and the four (4) or five (5) other aggressive/violent individuals in the community from meetings with the local police department and ambulance services which served the area. She stated over the years Patient #1 had been treated by the BHU staff at Facility #2, a rapport had developed, and he/she was comfortable with the staff. She further stated the staff could usually keep him/her from escalating behaviors, thus keeping him/her, other patients, and staff safe. Per interview, it would be irresponsible to knowingly put Patient #1 in an unfamiliar environment, because this could lead to a negative outcome. Further interview, revealed the ED staff were not refusing to examine Patient #1, but were just trying to sort out why they had received the phone call requesting the patient be sent to Facility #2.

Interview with the Director of Risk Management, on 01/10/17, at 2:15 PM, revealed 2014 was the first time Patient #1 was admitted to Facility #2 and the patient hurt Security staff and had to be tazed twice to bring him/her under control. He stated it was during review of that incident (see Incident Report), it was recognized there was a need for a plan to involve community resources that would include local EMS, Police, hospital campus Security, BHU staff and Nursing. He further stated the purpose of the Community Plan was to streamline the Intake Process for typically aggressive and violent patients, and to place them at the facility they respond to in a positive manner, thereby reducing the risk of serious harm to themselves, or other individuals and staff caring for them.

Further interview revealed the Community Plan concept was presented to the Crisis Intervention Training (CIT) team in June 2015. Per interview the Community Plan involved input from regional law enforcement officers which were trained in Mental Health, judges that oversee the Mental Health courts, and a regional Psychiatric Hospital. He stated with the Community Plan, the situation can then become about de-escalation instead of arrest or a more negative outcome at the scene. He stated the whole purpose of a Community Plan was to provide individuals with behavioral health issues, care in an efficient and safe manner for all involved.

Continued interview revealed January 2015 through September 2016, the Workplace Violence Committee (WVC) met to facilitate integrating the Community Plan into the electronic medical record (EMR) and clarifying the process by which an individual had a Community Plan instituted for them. He stated, in normal circumstances, Patient #1 should have received a MSE prior to the transfer; however, the situation was unique because he/she had known aggressive, violent behaviors, to the point of injuring EMS, Security and Nursing staff that had cared for him/her. He stated it was known through previous encounters, Patient #1 responded in a more positive manner to the BHU staff at Facility #2. He further stated Patient #1 was calm on arrival at Facility #1; however, it was reported Patient #1 was becoming agitated and uncooperative on the approximately five (5) mile trip to Facility #2.

Additional interview, revealed training would be held in January 2017 to clarify to all staff, especially ED and Obstetrical staff, any individual presenting to any hospital medical entity, will be afforded a MSE and stabilizing treatment prior to any applicable disposition as set forth in the EMTALA regulations.