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Based on policy review, medical record review, and staff interview, the critical access hospital (CAH) failed to ensure 2 of 31 sampled patients, presenting to the CAH's Emergency Room (ER) for care due to an emergency medical condition and needing a higher level of care were maintained and monitored in the ER until an appropriate transfer could be arranged (Patients #2 and 31). The sampled patients were selected from the CAH's ER Log between the dates of 5/1/13 and 10/21/13. The CAH's administrative staff reported 281 emergency room visits.

Failure to provide appropriate transfers resulted in the CAH discharging Patients #2 and 31 back to the Residential Care Facility (RCF) where they lived after the patients presented to the ER with psychiatric emergency conditions, including agitation, suicidal ideation, and threatening/assaultive behaviors. The CAH failed to ensure the patients were transferred to a hospital with a psychiatric unit or a psychiatric hospital for further evaluation and treatment rather than discharging the patients to their residence at the RCF. The return of these patients to their residence at the RCF put other RCF residents, staff, and themselves at risk for harm.

Findings include:

1. Review of Patient #2's ER record revealed a 25-year-old male with a history of schizophrenia was escorted to the ER by 2 local police officers on 10/16/13 at 10:35 AM. The patient resided at the local RCF. The patient was non-compliant with his evening medications on 10/15/13 and became agitated the morning of the 10/16/13. The staff at the RCF became fearful when the patient started making threatening gestures. The RCF's Registered Nurse (RN) was unable to reach the patient's primary care provider and contacted Practitioner A, a physician assistant at the CAH, to establish medical clearance to enable bed placement at a psychiatric unit of a hospital or a psychiatric hospital. Practitioner A medically cleared the patient to return to the RCF after the patient's ER visit.

a. Practitioner A's plan at discharge, dated 10/16/13 at 11:46 AM, read as follows: "I do think the patient is cleared medically. He needs to be sent to a psychiatric hospital where his medications can be adjusted as he certainly would be a danger at a residential facility that he is in right now. Hard to know whether he was cheeking his meds and not taking them or whether just the lowering of his dose of the Depakote set off this agitation." The patient's medical record showed labs (including blood tests) were drawn but the Depakote (medication) level results were not back during the patient's stay in the ER.

b. Review of the progress note by Staff A, an RN in the ER, dated 10/16/13 at 11:24 AM, showed the Patient continued to display aggressive and accusatory tendencies. The patient refused to sign ER forms or participate in any portion of the exam. The patient was discharged to the custody of the police to be transferred back to the RCF.

c. During an interview on 10/22/13 at 9:45 AM, Practitioner A reported Patient #2 had an examination in the ER on 10/16/13 at 10:35 AM. The patient was previously at the CAH for a lab draw to check Depakote/ammonia levels due to recent medication changes and agitation; the patient refused to allow the staff to draw his blood and became agitated. The patient returned to the RCF. Practitioner A reported the RCF RN phoned him later that morning and stated they were trying to get him committed due to his agitation and his threatening gestures, but the patient needed a medical clearance. Practitioner A agreed to see him in the ER to draw labs and provide the medical clearance and suggested if he was that agitated that he should be transported by the police. Practitioner A saw the patient and gave medical clearance. The patient was paranoid and agitated. I felt threatened or in danger due to the patient's size (approximately. 6 ' 2 " , 220#).

Practitioner A sent the patient back to the RCF to await bed placement at the psychiatric hospital. Practitioner A reported he did not talk to a psychiatrist or place any calls to surrounding psychiatric hospitals for bed placement at that time because the RCF staff were already finding placement for the patient. I had no other choice but to send him back to the RCF. Our facility is not equipped to handle this type of patient. When asked twice if it was appropriate to send the patient back to the RCF, Practitioner A did not answer the question, but talked about the CAH not being equipped to handle this type of patient.

d. During an interview on 10/22/13 at 11:00 AM, Staff A, RN, revealed Patient #2 was brought to the ER by two police officers. The patient would only tell her his first name during her examination. Staff A reported Patient #2 was accusatory, questioned everything, and refused to tell her why he was there. Staff A reported trying numerous times to take his vital signs and complete a nursing assessment. After the patient's labs were drawn, he accused staff of putting air into his veins. Staff A reported feeling uncomfortable with the patient because he was aggressive and jumpy. He displayed no physical tendencies toward staff, but there was a potential for the patient to harm himself or others. He was of medium build, approximately. 6 ft. tall. I discharged the patient with instructions back to the RCF he went willingly with the police. The patient did not harm anyone here at the hospital.

e. During an interview on 10/22/13 at 11:30 AM, Staff B, RN, reported Patient #2 would not let the staff take vitals or do a nursing assessment during their examination. Practitioner A, was talking to the patient explaining why we needed to do lab work and answering various other questions for the patient. The patient did not share a lot of information about himself. I instructed the lab staff not to stand too close to the patient until he gave approval. The patient let the lab staff draw his blood and the patient asked many questions during the process. The patient seemed edgy to me, like he might strike out and hurt someone. I was on guard due to the type of patient (psych patient) he was. He did not appear to be agitated and I did not observe him hurting anyone. Staff B reported the staff have been instructed by Practitioners A and B, a Physician, that we were not going to keep these people until a bed was available. The Practitioners say the RFC needs to get enough staff on board to take care of these people. This has been a big issue.

f. During an interview on 10/22/13 at 11:45 AM, Practitioner B, a physician, revealed Practitioner A has been my PA for about 3 years. Practitioner A, has been instructed to call me to report on all patients he sees, even the small things. To the physician's knowledge this has been done. Practitioner B did not see Patient #2 in the ER, but spoke with the Practitioner A after the patient was sent back to the RCF. The patient was sent to the ER from the RCF for medical clearance for committal to a psychiatric hospital. When Practitioner A and Practitioner B spoke, Practitioner A did not mention the patient was a threat to himself or others. If the patient was a danger to himself and others, he should not have been sent back to the RCF. Our purpose is to medically clear patients for admittance to psychiatric hospitals. Practitioner A did not make any calls to an outside facility for psychiatric bed placement. He only medically cleared the patient for an admission to a psychiatric bed.

g. During a second interview with Practitioner A, on 10/22/13 at 12:20 PM, Practitioner A stated I would like to clarify my use of the word "danger " used in Patient #2's PLAN dated 10/16/13. This probably wasn't the best choice of words. I would like to ask for forgiveness. The patient needed to be admitted to a psychiatric hospital for medication adjustment. He was nervous and anxious, but did not threaten the staff at the hospital or at the RCF. He never voiced a threat to himself or others. I did not think he would harm himself or others when he was sent back to the RFC.

h. During an interview on 10/22/13 at 3:20 PM, the RN working at the RCF verified sending Patient #2 to the CAH ER for lab work and a medical clearance to allow the patient's admission to a psychiatric hospital. The patient was extremely psychotic, paranoid, asking questions, easily agitated, raising his voice, and pacing. This was not usual behavior for him. The patient did not threaten others or harm himself. I placed a call to his provider and there was no answer. Then I called Practitioner A, because he has helped us before. I asked for lab orders that would enable us to establish medical clearance for admission to a psychiatric hospital.

2. Review of the medical record for Patient #31 revealed the patient presented to the ER on 5/2/13 at 7:14 PM. The Final Report documented a Chief Complaint of suicidal ideation, threatening to kill herself. The patient's ER care was provided by Practitioner C, a physician.

a. According to the patient's history in the medical record, the patient was a 30 year old resident of the local RCF, brought in to the ER by the RCF's administrator. The patient's diagnoses included schizoaffective disorder, bipolar disorder, major depression, and a history of recurrent psychosis.

The RCF administrator stated the patient was having suicidal ideation and threatening to kill herself. According to the RCF staff, the patient went out to the highway and told the staff she wanted to kill herself. She also states she will slit her wrists, but she had not attempted anything. In the past, she has had suicidal ideation also. The patient also stated she was depressed and she was crying. She is afraid she might not see her family again. She states nobody cares for her.

b. The documentation of the patient's Physical Examination showed the patient was quite distraught initially and crying, but later she calmed down and relaxed. The patient answers questions appropriately. She is alert and oriented x 3, vital signs are stable, and the neurological exam is intact.

The Plan in the patient's medical record was as follows: Due to her suicidal ideation, even though she has not attempted anything, we attempted to find placement for the patient. We are hoping we can get a psych (psychiatric) evaluation tonight. Calls were made to other hospitals to arrange for a transfer to two different acute care hospitals with psychiatric units and a psychiatric hospital but the CAH ER staff was not successful in locating an available psychiatric bed. Information in the patient's medical record show the psychiatric hospital did not have a bed available that night but may have one in the morning.

c. Practitioner C explained to the patient and administrator from the RCF about the situation. We do not have any psych beds available and we are not a psychiatric hospital. We are unable to keep her here either. We will discharge her back to the RCF with the agreement the staff will watch her tonight and call the psychiatrist in the morning to decide what will be done. The patient has done this several times in the past with suicidal ideation, but has never attempted. She probably needs a psych evaluation and medication adjustment. They will take care of this in the morning. The patient was discharged back to the RCF with the RCF administrator about two hours after arriving at the CAH ER.

d. During an interview on 10/23/13 at 11:00 AM, Practitioner C, MD stated the reason the patient presented to the ER was because of suicidal ideation and threatening to kill herself according to the administrator at the RCF. When I evaluated the patient, she had a history of depression and suicidal ideation in the past. I evaluated the patient's mentation for 3 criteria; suicidal ideation, a plan and if she acted on it. If the patient meets all 3 criteria, they need to be evaluated by a psychiatrist. My evaluation showed no threat to self, RCF staff, or other residents. I did attempt to find placement for the patient in a psychiatric facility because the administrator at the RCF wanted a psychiatric evaluation. I could not find placement for the patient and discharged her back to the RCF because my evaluation showed she was calm and not a threat for suicide at that time. If the patient was suicidal and going to kill herself, I would have kept her at the hospital until placement was found.


3. Review of policy titled, EMTALA Compliance, last reviewed/revision date 9/13, states in part: ...I. POLICY: Baum-Harmon Mercy Hospital will be in compliance with COBRA/EMTALA rules and regulations.

PROCEDURE: 3. Medical Screening examinations will determine the presence of an Emergency Medical Condition as defined by COBRA/EMTALA. a. An emergency medical condition is a condition that 1. Places the health of the individual in serious jeopardy.

VI. DEFINITIONS AS APPLIED TO PATIENT COVERED BY EMTALA:

1. Emergency Medical Condition - A medical condition manifesting itself by acute symptoms of sufficient severity including pain, psychiatric disturbances, and/or substance abuse such that the absence of immediate medical attention could result in: b. Serious impairment to bodily function, c. Serious dysfunction of any body organ or part.

7. To stabilize - to provide medical treatment of a condition necessary to assure with reasonable medical probability no material deterioration of the condition is likely to result from or occur during transfer to another facility.

9. Necessary stabilization - if an individual, whether eligible for Medicare or not, comes to the hospital an is determined to have an emergency medical condition, the hospital must provide...

a. Medical examination and treatment required to stabilize the patient with further care at BHMH (Baum Harmon Mercy Hospital) or the patient discharge home as appropriate.

b. Medical examination and treatment required to stabilize the patient for transfer to another acute facility for definitive care.

c. Medical examination and treatment to the capacity and capability of BHMH and staff with appropriate transfer of the patient in unstable condition to another facility for continued care.

4. Patients' #2 and 31 presented to the ER and identified as having emergency medical conditions. The CAH staff failed to follow its policy for EMTALA by failing to provide stabilizing treatment and/or monitoring the patients until an appropriate transfer could be arranged. Instead Patients #2 and 31 were discharged back to the local RCF where they resided while their condition remained unstable.

Based on policy review, medical record review, peer review and staff interview, the critical access hospital (CAH) failed to ensure 2 of 31 sampled patients, presenting to the CAH's Emergency Room (ER) for care due to an emergency medical condition and needing a higher level of care were maintained and monitored in the ER until an appropriate transfer could be arranged (Patients #2 and 31). The sampled patients were selected from the CAH's ER Log between the dates of 5/1/13 and 10/21/13. The CAH's administrative staff reported 281 emergency room visits.

Failure to provide appropriate transfers resulted in the CAH discharging Patients #2 and 31 back to the Residential Care Facility (RCF) where they lived after the patients presented to the ER with psychiatric emergency conditions, including agitation, suicidal ideation, and threatening/assaultive behaviors. The CAH failed to ensure the patients were transferred to a hospital with a psychiatric unit or a psychiatric hospital for further evaluation and treatment rather than discharging the patients to their residence at the RCF. The return of these patients to their residence at the RCF put other RCF residents, staff, and themselves at risk for harm.

Findings include:

1. Review of Patient #2's ER record revealed a 25-year-old male with a history of schizophrenia was escorted to the ER by 2 local police officers on 10/16/13 at 10:35 AM. The patient resided at the local RCF. The patient was non-compliant with his evening medications on 10/15/13 and became agitated the morning of the 10/16/13. The staff at the RCF became fearful when the patient started making threatening gestures. The RCF's Registered Nurse (RN) was unable to reach the patient's primary care provider and contacted Practitioner A, a physician assistant at the CAH, to establish medical clearance to enable bed placement at a psychiatric unit of a hospital or a psychiatric hospital. Practitioner A medically cleared the patient to return to the RCF after the patient's ER visit.

a. Practitioner A's plan at discharge, dated 10/16/13 at 11:46 AM, read as follows: "I do think the patient is cleared medically. He needs to be sent to a psychiatric hospital where his medications can be adjusted as he certainly would be a danger at a residential facility that he is in right now. Hard to know whether he was cheeking his meds (medication) and not taking them or whether just the lowering of his dose of the Depakote set off this agitation." The patient's medical record showed labs (including blood tests) were drawn but the Depakote (medication) level results were not back during the patient's stay in the ER.

b. Review of the progress note by Staff A, an RN in the ER, dated 10/16/13 at 11:24 AM, showed the Patient continued to display aggressive and accusatory tendencies. The patient refused to sign ER forms or participate in any portion of the exam. The patient was discharged to the custody of the police to be transferred back to the RCF.

c. During an interview on 10/22/13 at 9:45 AM, Practitioner A reported Patient #2 had an examination in the ER on 10/16/13 at 10:35 AM. The patient was previously at the CAH for a lab draw to check Depakote/ammonia levels due to recent medication changes and agitation; the patient refused to allow the staff to draw his blood and became agitated. The patient returned to the RCF. Practitioner A reported the RCF RN phoned him later that morning and stated they were trying to get him committed due to his agitation and his threatening gestures, but the patient needed a medical clearance. Practitioner A agreed to see him in the ER to draw labs and provide the medical clearance and suggested if he was that agitated that he should be transported by the police. Practitioner A saw the patient and gave medical clearance. The patient was paranoid and agitated. I felt threatened or in danger due to the patient's size (approximately. 6 ' 2 " , 220#).

Practitioner A sent the patient back to the RCF to await bed placement at the psychiatric hospital. Practitioner A reported he did not talk to a psychiatrist or place any calls to surrounding psychiatric hospitals for bed placement at that time because the RCF staff were already finding placement for the patient. I had no other choice but to send him back to the RCF. Our facility is not equipped to handle this type of patient. When asked twice if it was appropriate to send the patient back to the RCF, Practitioner A did not answer the question, but talked about the CAH not being equipped to handle this type of patient.

d. During an interview on 10/22/13 at 11:00 AM, Staff A, RN, revealed Patient #2 was brought to the ER by two police officers. The patient would only tell her his first name during her examination. Staff A reported Patient #2 was accusatory, questioned everything, and refused to tell her why he was there. Staff A reported trying numerous times to take his vital signs and complete a nursing assessment. After the patient's labs were drawn, he accused staff of putting air into his veins. Staff A reported feeling uncomfortable with the patient because he was aggressive and jumpy. He displayed no physical tendencies toward staff, but there was a potential for the patient to harm himself or others. He was of medium build, approximately. 6 ft. tall. I discharged the patient with instructions back to the RCF he went willingly with the police. The patient did not harm anyone here at the hospital.

e. During an interview on 10/22/13 at 11:30 AM, Staff B, RN, reported Patient #2 would not let the staff take vitals or do a nursing assessment during their examination. Practitioner A, was talking to the patient explaining why we needed to do lab work and answering various other questions for the patient. The patient did not share a lot of information about himself. I instructed the lab staff not to stand too close to the patient until he gave approval. The patient let the lab staff draw his blood and the patient asked many questions during the process. The patient seemed edgy to me, like he might strike out and hurt someone. I was on guard due to the type of patient (psych patient) he was. He did not appear to be agitated and I did not observe him hurting anyone. Staff B reported the staff have been instructed by Practitioners A and B, a Physician, that we were not going to keep these people until a bed was available. The Practitioners say the RFC needs to get enough staff on board to take care of these people. This has been a big issue.

f. During an interview on 10/22/13 at 11:45 AM, Practitioner B, a physician, revealed Practitioner A has been my PA for about 3 years. Practitioner A, has been instructed to call me to report on all patients he sees, even the small things. To the physician's knowledge this has been done. Practitioner B did not see Patient #2 in the ER, but spoke with the Practitioner A after the patient was sent back to the RCF. The patient was sent to the ER from the RCF for medical clearance for committal to a psychiatric hospital. When Practitioner A and Practitioner B spoke, Practitioner A did not mention the patient was a threat to himself or others. If the patient was a danger to himself and others, he should not have been sent back to the RCF. Our purpose is to medically clear patients for admittance to psychiatric hospitals. Practitioner A did not make any calls to an outside facility for psychiatric bed placement. He only medically cleared the patient for an admission to a psychiatric bed.

g. During a second interview with Practitioner A, on 10/22/13 at 12:20 PM, Practitioner A stated I would like to clarify my use of the word "danger " used in Patient #2's PLAN dated 10/16/13. This probably wasn't the best choice of words. I would like to ask for forgiveness. The patient needed to be admitted to a psychiatric hospital for medication adjustment. He was nervous and anxious, but did not threaten the staff at the hospital or at the RCF. He never voiced a threat to himself or others. I did not think he would harm himself or others when he was sent back to the RFC.

h. During an interview on 10/22/13 at 3:20 PM, the RN working at the RCF verified sending Patient #2 to the CAH ER for lab work and a medical clearance to allow the patient's admission to a psychiatric hospital. The patient was extremely psychotic, paranoid, asking questions, easily agitated, raising his voice, and pacing. This was not usual behavior for him. The patient did not threaten others or harm himself. I placed a call to his provider and there was no answer. Then I called Practitioner A, because he has helped us before. I asked for lab orders that would enable us to establish medical clearance for admission to a psychiatric hospital.

2. Review of the medical record for Patient #31 revealed the patient presented to the ER on 5/2/13 at 7:14 PM. The Final Report documented a Chief Complaint of suicidal ideation, threatening to kill herself. The patient's ER care was provided by Practitioner C, a physician.

a. According to the patient's history in the medical record, the patient was a 30 year old resident of the local RCF, brought in to the ER by the RCF's administrator. The patient's diagnoses included schizoaffective disorder, bipolar disorder, major depression, and a history of recurrent psychosis.

The RCF administrator stated the patient was having suicidal ideation and threatening to kill herself. According to the RCF staff, the patient went out to the highway and told the staff she wanted to kill herself. She also states she will slit her wrists, but she had not attempted anything. In the past, she has had suicidal ideation also. The patient also stated she was depressed and she was crying. She is afraid she might not see her family again. She states nobody cares for her.

b. The documentation of the patient's Physical Examination showed the patient was quite distraught initially and crying, but later she calmed down and relaxed. The patient answers questions appropriately. She is alert and oriented x 3, vital signs are stable, and the neurological exam is intact.

The Plan in the patient's medical record was as follows: Due to her suicidal ideation, even though she has not attempted anything, we attempted to find placement for the patient. We are hoping we can get a psych (psychiatric) evaluation tonight. Calls were made to other hospitals to arrange for a transfer to two different acute care hospitals with psychiatric units and a psychiatric hospital but the CAH ER staff was not successful in locating an available psychiatric bed. Information in the patient's medical record show the psychiatric hospital did not have a bed available that night but may have one in the morning.

c. Practitioner C explained to the patient and administrator from the RCF about the situation. We do not have any psych beds available and we are not a psychiatric hospital. We are unable to keep her here either. We will discharge her back to the RCF with the agreement the staff will watch her tonight and call the psychiatrist in the morning to decide what will be done. The patient has done this several times in the past with suicidal ideation, but has never attempted. She probably needs a psych evaluation and medication adjustment. They will take care of this in the morning. The patient was discharged back to the RCF with the RCF administrator about two hours after arriving at the CAH ER.

d. During an interview on 10/23/13 at 11:00 AM, Practitioner C, MD stated the reason the patient presented to the ER was because of suicidal ideation and threatening to kill herself according to the administrator at the RCF. When I evaluated the patient, she had a history of depression and suicidal ideation in the past. I evaluated the patient's mentation for 3 criteria; suicidal ideation, a plan and if she acted on it. If the patient meets all 3 criteria, they need to be evaluated by a psychiatrist. My evaluation showed no threat to self, RCF staff, or other residents. I did attempt to find placement for the patient in a psychiatric facility because the administrator at the RCF wanted a psychiatric evaluation. I could not find placement for the patient and discharged her back to the RCF because my evaluation showed she was calm and not a threat for suicide at that time. If the patient was suicidal and going to kill herself, I would have kept her at the hospital until placement was found.


3. Review of the peer review for Patient #2, dated 11/2/13, revealed Patient #2 was determined to have a psychiatric emergency medical condition that placed others at risk. Patient #2 needed acute psychiatric care but was discharged back to the residential facility that was not able to provide medical or psychiatric treatment. This delay in treatment placed Patient #2 and others in danger.

4. Review of the peer review for Patient #31, dated 11/2/13, revealed Patient #31 presented to the ER with active suicidal thoughts documented by both the physician and nursing staff with plans to "slit her wrists with razor blades". Patient #31 was medically screened and determined to have an active psychiatric emergency medical condition. The hospital attempted unsuccessfully to find placement in a psychiatric facility. Patient #31 was discharged without stabilization of the emergency medical condition. Further, the ER had the ability to safely monitor Patient #31 until a psychiatric bed could be found.