HospitalInspections.org

Based on policy and procedure reviews, job description review, hospital documentation review, medical record review, staff and physician interviews, the hospital leadership failed to ensure the protection of patients' rights of behavioral health patients in the inpatient psychiatric unit and failed to provide oversight and have systems in place to ensure DED physicians followed hospital policy and procedure in the care of patients presenting to the DED.

The findings include:

1. The hospital failed to an effective data-driven quality assessment and performance system
monitoring actions for the areas the hospital had identified needing improvement in the Dedicated Emergency Department (DED).
~ cross refer to 482.21QAPI, Condition Tag A0263.

2. The hospital staff failed to ensure the patient's protection by allowing an unstable psychiatric patient to leave AMA.
~ cross refer to 482.13 Patient Rights' Condition: Tag A0115

3. The Dedicated Emergency Department (DED) physician failed: A. To ensure a Medical Screening Exam was completed per the facility policy within the capabilities of the hospital that provided for the stabilization of a psychiatric patient prior to discharge from the DED. B. To complete the physician certification closely to the time of the transfer and/or document the increased risks associated with the transfer to the individual for patients having an Emergency Medical Condition (EMC) transferred to another hospital.
~ cross refer to 482.55 Emergency Services: Condition Tag A1100.

Based on policy and procedure reviews, hospital documentation review, medical record review, staff and physician extender interviews, the hospital staff failed to ensure the patient's protection by allowing an unstable psychiatric patient to leave AMA.

1. ~ cross refer to 482.13(e)(2) Care in a Safe Setting, Standard Tag A0144.

Based on policy and procedure reviews, job description review, hospital documentation review, medical record review, staff and physician interviews, the hospital staff failed to ensure the patient ' s protection by allowing an unstable psychiatric inpatient to leave AMA in 1 of 1 psychiatric patients reviewed that left the hospital AMA. (#3).

The findings include:

Review of "AMAs, Intervention with Potential and Impending " Policy Number: CPH 430.91, Effective Date: 07/07, Last Review Date: 10/10 revealed, "I. Purpose: A. Potential AMA's are assessed at admission and throughout the program. Every effort is made by the staff to prevent the impending AMA. The motivation behind the AMA intervention is the welfare of the patient ...IV. Policy Statement: A. At Admission: 1. The person responsible for admission should document any indicators of AMA potential assessed at the time of admission ...B. During Program: 1. Patients should be monitored closely for any significant behavior changes ...2. If the patient shows any signs of potential AMA, the staff will begin to intervene, using the following techniques: a. Engage the patient in dialogue about his/her concerns over leaving the program. Do not argue but rather listen and assess the problems. b. Problem solve around the specific issues if possible. c. Find areas of ambivalence and focus on positive points. d. Ask the patient peer group to work with the patient. e. Make every effort to keep the patient from escalating small problems into larger ones that may precipitate an AMA f. Inform the Program Director, Social Worker, Director of Nursing and Primary Nurse as soon as possible C. If AMA potential escalates: 1. Arrange a special counseling session with Social Worker, Director of Nursing, Program Director, Primary Nurse or Psychiatrist. 2. Enlist family support and set up an ' in-hospital ' intervention ...3. Ask patient to discuss AMA intentions in therapy group. 4. Arrange for a special meeting with the entire treatment team. 5. Call a special community meeting of patients and staff to confront AMA potential and its consequences 6. Document all intervention strategies in the patients medical record D. If AMA occurs: 1. Attempt to keep open the option of returning to treatment at another time, being clear about readmission criteria and time frames. 2. Hold a staff debriefing to review the case. 3. Complete the AMA Audit Report form and hospital required AMA forms. "

Medical record review of Patient #3 revealed a 32 year-old male presenting to Hospital's DED accompanied with his mother on 12/25/2013 at 1938 for " detox from Heroine." Review revealed the patient was assigned an Emergency Severity Index Level (ESI) of 3 at 1953. Review revealed the Medical Screening Exam (MSE) was performed at 1958 and the findings revealed, " areas of injection in both antecubital fossa (forearms)". Review revealed orders placed for a " Consult to Behavior Health Services (ED only)". Record review revealed the patient had a positive drug screen for " cannabis (marijuana), cocaine, opiate, and oxycodone." Record review revealed the patient was voluntarily admitted to the inpatient psychiatric unit on 12/25/2013 at 2250 by Physician B. Review of "MULTIDISCIPLINARY TREATMENT TEAM PLAN" dated 12/25/2013 revealed " problems identified on initial assessments were suicidal thoughts/attempts, depression, and substance abuse." Review of medical record document titled " Depressive Symptoms " revealed, " problem #2 evidenced by: non-compliance with medications, related to: History of psychiatric disorder: Depression, PHYSICIAN INTERVENTION: Monitor and educate regarding precautions, risks, benefits, and side effects of medications." Review of Physician Psychiatric Admission Note dated 12/26/2013 at 1442 revealed, " Psychiatric: Anxiety, Depression, Irritability, Sleeping problems, substance abuse, unreliable to contract for safety. Attention and concentration: poor. Fund of knowledge: poor. Mood and affect: Anxious, Depressed. Behavior: Restless. Judgment: Insight and judgment impaired. Abnormal/Psychotic thoughts: unreliable to contract for safety. Thought process: Distractible. Plan:..continue inpatient care, monitor for safety. " Review of nursing progress note dated 12/26/2013 at 0941 revealed, " stayed in room except for medications, has w/d (withdrawal) s/x (symptoms) of aches and some irritability and anxiety, compliant with some groups and medications. Review of nursing progress note dated 12/26/2013 at 2356 revealed, " w/d symptoms ongoing, c/o (complaints of) increase anxiety, irritable, restless and unable to sleep, interacts with other peers and staff, anxious and restless. Review of nursing progress nurse dated 12/27/2013 at 0942 revealed, "stayed in room through breakfast ...has w/d sx of stomach cramping, irritability, anxiety and generally not feeling good, monitor for mood changes, increase in w/d sx, and safety needs." Review of Psychiatric Physician Progress Note dated 12/27/2013 at 1549 revealed, " Mood/Affect: Depressed, Anxious. Attention: Poor. Concentration: Poor. Suicidal Ideations: Unreliable to contract for safety. Description of Patient's Judgment and Insight: Impaired. Impression and Plan: Ongoing depressive symptoms, sad, withdrawn, flat affect, ongoing withdrawal symptoms, suicidal ideations, not sleeping. Plan: Continue inpatient care, monitor for safety. Review of Progress Note dated 12/27/2013 at 2050 revealed, "Estimated date of Discharge: 7- 10 days. Review of nursing progress note dated 12/27/2013 at 2122 revealed, " did not attend evening group session, self set goal, 'to make it through the day ', appears depressed " Review of Psychiatric Physician Progress Note Dated 12/28/2013 at 0921 revealed, " Mood/Affect: Anxious. Attention: Poor. Suicidal Ideations: unreliable to contract for safety. Description of Patient ' s Judgment and Insight: Impaired. Impression and Plan: Discussed addiction with the patient, overall mood is reported as ' anxious at this time ' ...Unreliable to contract for safety. Plan: Continue inpatient care, Monitor for safety. Estimated Date of Discharge: Tuesday Dec. 31, 2013. Further review of documentation revealed documentation was signed and verified by NP #1. Review of " Psychiatric Physician Progress Note" dated 12/29/2013 at 1215 revealed, " ...He stated that he continues to have w/d symptoms and having asking more Lorazepam (Ativan). Staff was also concerned about his drug seeking behavior as he reported that he is going through w/d from opioids ...appeared anxious ...Objective: Mood/Affect: Poor, Concentration: Poor, Suicidal Ideations: unreliable to contract for safety, Description of Patient ' s Judgment and Insight: Impaired. Impression and Plan: Discussed addiction with the patient, overall mood is reported as ' anxious at this time'. Plan: Start Librium 25 mg (milligrams) po (by mouth) BID (twice a day) also getting Ativan (Lorazepam) 1 mg po q 6 hrs (every 6 hours) prn. Review of Discharge Nursing Note dated 12/29/2013 at 1354 revealed, " PT ANXIOUS AND REQUESTING DISCHARGE. PT STATES HE WAS GOING TO TEAR UP THE UNIT IF HE IS NOT DISCHARGED TODAY. NP #1 GAVE ORDER TO ALLOW PT TO SIGN AMA. PT SIGNED AMA AND WAS DISCHARGED TO FRONT DOOR." Review of Discharge Summary dated 12/30/21013 at 1300 revealed, "Hospital Course: He reported he was being held against his will and was threatening to damage the unit, the patient expressed to nursing that he was unhappy with what medications he was receiving ...Agrees to stay safe after discharge." Review of inpatient medication orders revealed, " Chlordiazepoxide (Librium) (chlordiazepoxide 25 mg Cap {capsules}) start date 12/29/13 at 10:50:00, Lorazepam (lorazepam 1 mg Tab {tablet}) start date 12/29/13 at 12:13:00, and Lorazepam (lorazepam 2mg/mL {milliliter} Inj {injection} Sol (solute) 1 mL) start date 12/29/13 at 12:13:00." Record review revealed documentation of "Intervention with Potential and Impending AMA ' s " Policy #: CPH 430.91 AMA Audit Form revealed, "When did the patient first reveal AMA intentions? 12.29.13
To whom were they revealed? Nursing staff. Is there documentation in the medical records that staff took steps to prevent the AMA? Yes By whom? NP #1. Briefly describe events that precipitated AMA: Patient became upset after physician changed his meds - demanded d/c (discharge) - threatened to destroy the unit."

Interview with NP (Nurse Practitioner) #1 on 01/09/2014 at 1425 revealed, " I expressed my concerns about Patient #3 with Physician B after I saw him on 12/28/2013. I convinced him to stay on the unit after he informed me that he had ' bad people after him for bad things '. "Interview revealed that Nurse #2 called NP #1 on 12/29/2013 related to Patient #3 requesting to sign out AMA. Interview revealed, " I could hear him yelling and cursing in the background. " Interview revealed that NP #1 was aware of Physician C's progress note dated 12/29/2013 at 1215. Interview revealed that NP #1 gave permission for Nurse #2 to allow Patient #3 to sign out of the inpatient psychiatric unit AMA at 1347.

Interview with Nurse #2 on 01/09/2014 at 1449 revealed Patient #3 became upset around 1030 on 12/29/2013 after Physician C stopped his prn (as needed medication) Ativan to Librium. The interview revealed Patient #3 stated, " If he could get his dope he would leave." The interview revealed she explained to the patient the benefits of the medication change and the patient calmed down. Interview revealed that family visited the patient between 1315-1330. Interview revealed the patient did not use the entire visitation time. Interview revealed the patient came "storming out " of the visitation area and stated " You will let me out or I'm busting the windows out." Interview revealed the patient was very agitated, angry, volatile and threatening. Interview revealed she called NP #1 and offered patient prn medications. Interview revealed the patient stated, " He could get his drugs in 20 minutes when he would get out." Interview revealed she discussed IVC (involuntary commitment) with NP #1 and the patient. Interview revealed that " NP #1 did not feel the need to IVC patient since he was not suicidal ". The patient signed out AMA of the inpatient psychiatric unit at 1347. Interview revealed that she worked the 7AM - 7PM shift on 12/29/2013. Interview revealed, " No one from the ED called me when the patent arrived. I found out the next day the patient committed suicide."

Based on staff interview, medical record reviews, physician education documentation review, the hospital failed to an effective data-driven quality assessment and performance system
monitoring actions for the areas the hospital had identified needing improvement in the Dedicated Emergency Department (DED).

The Findings include:

1. ~ cross refer to 482.21(a), (b)(1),(b)(2)(i),(b)(3)(2) Data Collection/Analysis, Standard Tag A0273.

Based on staff interview, medical record reviews, physician education documentation review, the hospital failed to monitor actions for the areas the hospital had identified needing improvement in the Dedicated Emergency Department (DED) physician documentation.

The Findings include:

Interview with administrative staff on 01/08/2014 at 1030 revealed the hospital had an event self reported to the State Agency. The interview revealed the hospital had started a root cause analysis but it was not completed yet. The interview revealed a patient voluntarily admitted on 12/25/2013 to the inpatient psychiatric bed had signed out Against Medical Advice (AMA) on 12/29/2013 at approximately 1347. The interview revealed the patient had returned to the DED on 12/29/2013 at 1728 requesting to be readmitted and voicing concerns regarding warrants for arrest. The interview revealed the patient was discharged to receive outpatient services. The interview revealed on 12/30/2013 at approximately 0930 staff at the rehabilitation hospital found the patient hanging from the railing.

Interview with administrative staff on 01/08/2014 at 1400 revealed areas needing improvement had been identified by the hospital after a State Agency complaint survey in October 2013 related to complaints of Behavioral health patients discharged from the DED and committing suicide. The interview revealed the areas identified related to DED physician documentation of the risks and benefits being specific to the patient when a patient is transferred per the EMTALA policy. The interview revealed education had started with the nursing and physician staff in the DED. The interview revealed there was documentation available for the monitoring of actions initiated for nursing staff. The interview revealed the staff was unsure of monitoring of DED physicians.

Interview with hospital administrative staff on 01/10/2014 at 1330 revealed the hospital had identified the risks and benefits were not being specifically documented. The interview revealed the hospital changed the physician certification transfer form. Interview with hospital administrative staff revealed the EMTALA transfer form had sections for the physician to complete for the medical risks and benefits. The interview revealed the staff were aware the risk and benefits were to be specifically relative to the patient's condition during transfer. The interview revealed the hospital had identified the DED physicians had not been completing the specific risks of transfer. The interview revealed the DED physician staff had education provided informing physicians the requirement for the risks to be specific to the patient. The interview revealed the transfer form indicated in writing the risks are to be specific for the patient. The interview revealed there had not been any monitoring to ensure the DED physicians were following the hospital policy and CMS regulations. The interview revealed to date 77 % of the physicians had completed the education.

Based on policy and procedure reviews, job description review, hospital documentation review, medical record review, staff and physician interviews, the Dedicated Emergency Department (DED) physician failed: A. to ensure a Medical Screening Exam was completed per the facility policy within the capabilities of the hospital that provided for the stabilization of a patient prior to discharge from the DED in 1 of 9 pschuatric patients presenting to the DED and B. to complete the physician certification closely to the time of the transfer and/or document the increased risks associated with the transfer to the individual in 2 of 7 DED patients having an Emergency Medical Condition (EMC) transferred to another hospital.

The findings include:

1. ~ cross refer to 482.55(a)(2) Integration of Emergency Services, Standard Tag A1103.

Based on policy and procedure reviews, job description review, hospital documentation review, medical record review, staff and physician interviews, the Dedicated Emergency Department (DED) physician failed: A. to ensure a Medical Screening Exam was completed per the facility policy within the capabilities of the hospital that provided for the stabilization of a patient prior to discharge from the DED in 1 of 9 psychiatric patients presenting to the DED (#3) and B. to complete the physician certification closely to the time of the transfer and/or document the increased risks associated with the transfer to the individual in 2 of 7 DED patients having an Emergency Medical Condition (EMC) transferred to another hospital (#7, #25).

The Findings include:

A. Review of hospital policy "PC 210.01 Care for the Psychiatric Patient EFFECTIVE DATE: 09/2008, LAST REVIEW DATE: 07/2011" revealed,"III. Policy Statement Patients who come to the hospital for emergency care will be provided a medical screening examination and stabilizing treatment under the EMTALA Policies... "IV. Patients Presenting with Behavioral Health Issues in the Emergency Care Center (ECC): A. This policy will facilitate consistent management of these patients to assure the safety of the patients, visitors and staff. "

Review of hospital policy "ECC450.02 Triage and Admission Care of Emergency Care Patients EFFECTIVE DATE: 01/01/11, LAST REVISION DATE: 12/17/10" revealed, "I. Purpose. To provide a standardized system whereby patients presenting to the ECC are treated in order of priority based upon the acuity utilizing the Emergency Severity Index Five-Level triage system (ESI).
B. Care of the ECC b. 1) Exception: Behavioral health patients remain an ESI Level 2 during their stay in the ECC ... "

Review of hospital protocol "ED TRIAGE PSYCHIATRIC/SUICIDE PRECAUTIONS: General Admission effective date 10/06/2010" revealed " For Patients who are being referred for behavioral health evaluation, suicidal ideation, homicidal ideation, psychosis or are under Involuntary Commitment Orders: Consults: Consult to Behavior Health Services (BHS) (ED Only)....Laboratory: Urine Drug Abuse Screen..."

Review of hospital policy "PC 210.26 "Emergency Medical Treatment and Labor Act (EMTALA) EFFECTIVE DATE: 08/01/2011, LAST REVISION DATE: 06/2011" revealed, "Definitions have been established to assure consistent interpretation of the named Hospital ' s EMTALA Policies throughout the organization. Wherever used, these capitalized terms shall have the following meanings:
7. Medical Screening Examination (MSE) - means such an examination conducted within the capability of the named Hospital's Emergency Department, including the use of appropriate ancillary services that are routinely available to the named Hospital...A MSE is not and isolated event; rather it is an ongoing process; ...The medical record must reflect continued monitoring according to the patient's needs which must continue until the patient is stabilized or appropriately transferred...
15. Stable for Discharge - A patient is stable for discharge when...the patient is given a plan for appropriate follow-up care with the discharge instructions. Psychiatric patients are stable for discharge when they are considered to be stable and no longer considered to be a threat to themselves and/or others. Such patient must be given Crisis Hotline Information at discharge."

Review of hospital policy "PC 210.59 EMTALA, Medical Screening & Stabilization, Refusal of Treatment Effective Date: 08/01/2011, Last Revision Date: 06/2011" revealed, "III. Policy Statement A. Medical Screening Examinations 1. All individuals who arrive at the Emergency Department seeking medical treatment will receive a Medical Screening Examination (MSE) to ascertain whether an Emergency Medical Condition (EMC) exists. This screening will include diagnostic or therapeutic services routinely available to Hospital A. MSE must be substantially the same for all patients with substantially similar complaints...E. Stabilization 1. If an EMC exists, medical treatment, within the capabilities of the staff and facilities routinely available (" Capacity"), will be provided to stabilize the individuals prior to consideration of discharge...3. b. Psychiatric patients are stable for discharge when they are considered to be stable and no longer considered to be a threat to themselves and/or others. Such patients must be given Crisis Hotline information at discharge. c. Substance abuse patients (who presented as dangerous to self or others) are considered to be stable for discharge when they are considered to be stable and no longer considered to be a threat to themselves and/or others."

Review of hospital policy "ECC 450.11 Discharging Patients from the Emergency Care Center EFFECTIVE DATE: 06/2010 and LAST REVISION DATE: 05/2010 " revealed, " 3.The discharging RN will see that: The patient's condition is considered stable prior to leaving the ECC and their pain has been addressed..."

Review of "Behavioral Health Specialist Job Description and Performance Criteria" EFFECTIVE DATE: 08/14/09 revealed, "...PROCESS ACCOUNTABILITIES ...Ensures patients' concerns and wishes regarding their treatment are communicated to physician and nurses for appropriate consideration...so that patient well-being is not compromised due to errors, omissions, inadequate/untimely planning or communications. "

Interview with administrative staff on 01/08/2014 at1030 revealed the hospital had an event self reported to the State Agency. The interview revealed the hospital had started a root cause analysis but it was not completed yet. The interview revealed a patient voluntarily admitted on 12/25/2013 to the inpatient psychiatric bed had signed out Against Medical Advice (AMA) on 12/29/2013 at approximately 1347. The interview revealed the patient had returned to the DED on 12/29/2013 at 1728 requesting to be readmitted and voicing concerns regarding warrants for arrest. The interview revealed the patient was discharged to receive outpatient services. The interview revealed on 12/30/2013 at approximately 0930 staff at the rehabilitation hospital found the patient hanging from the railing.

Closed medical record review of Patient #3 revealed a 32 year-old male presenting to the DED on 12/29/2013 at 1728 via police with a chief complaint of "pt (patient) return here stated that it was choice between going to jail or coming back to the hosp -pt signed himself out of inpatient psychiatric unit 4 hrs (hours) PTA (prior to admission)." Medical record review revealed patient was triaged at 1737 and assigned an ESI level of 3. Medical record review revealed nursing documentation at 1750,"current withdrawal symptoms: none, Signs and Symptoms (S/S) of dependency: none, Affect/Behavior: Calm, Cooperative." Medical record review revealed Physician A initiated the MSE (Medical Screening Exam) at 1920. Review of the MSE revealed "32 year old gentleman, history of drug abuse, he continues to smoke cigarettes presents to the emergency department requesting treatment options for drug abuse Patient was voluntarily admitted (name of psychiatric unit) for the same he left AGAINST MEDICAL ADVICE today, patient was noncompliant with the treatment/medication regime (name of psychiatric unit) had recommended He states because of warrants for his arrest he was told by police he would either go to jail or come back to the hospital to seek treatment options". Review of the medical record revealed no documentation of a physician's order for a urine drug screen. At 1930 nursing documentation revealed the patient's "pt reports was admitted to (name of psychiatric unit) x 24 hrs ago, voluntarily for drug and ETOH abuse. left abruptly against staff's wishes. pt returned Ed today for help for same. whishes to be readmitted". At 1940 the patient was given OP (outpatient) referral resources from BHS staff. Documentation revealed, " Pt. does not agree." Review of medical record revealed no documentation Patient #3 was given crisis hotline information. At 1948 documentation revealed patient complained of lumbar pain 9 out of 10 on a 10 point scale with 10 being the worst pain. Medical record review revealed no documentation of evaluation assessment or intervention of pain. At 1957 documentation reveals "the patient was agitated and cursing to self after knowing he is being d/c (discharged)". At 2002 (14 minutes after complaining of pain rated at a 9 and 5 minutes after exhibiting agitation and cursing), documentation revealed the patient left the DED. Medial record review revealed documentation on 12/30/2013 at 0946 by EMS personnel stating "EMS 8 was dispatched to a 32 year old for cardiac arrest. The patient was found hanging by his belt from a walkway railing. The patient had no pulse or respirations. The patient had an Asystole rhythm on the monitor. Rigor mortem had set in".

Review of a typed interview by Nurse #1 (primary care nurse for patient #3) dated 01/04/2014 and signed revealed, the " MD (Physician A) desired to hold off on protocol or labs." Further review revealed, Patient #3 " became visibly upset " with questioning. Review revealed, " The pt (patient) stated x 3 when asked by MD (Physician A) for reason for visit, ' My back hurts '. " Further review revealed Patient #3 stated " he knew what meds he needed and he wasn't going anywhere if they were not going to give him what works." Review revealed Physician A continued to question Patient #3 about drug seeking behaviors and if he was suicidal or homicidal. Review revealed, " clearly agitated with that line of questioning, gave a resounding no, ' I have answered that again and again '." Review revealed BHS staff entered the room and left. Review revealed, " he threw the paper back at me and said ' I won't be here in the morning ' and he walked out the door. "

Telephone interview with Physician A on 01/09/2014 at 1233 revealed, " I rarely speak to a psychiatrist. " Interview revealed Physician A sometimes collaborates with the BHS staff located in the ED to make decisions regarding psychiatric and substance abuse patients. The interview revealed Patient #3 informed Physician A that he had signed out AMA from Hospital's inpatient psychiatric unit. Further interview revealed that patient did not admit to using any drugs since he had left the inpatient unit earlier in the day. Interview revealed " I would have ordered a drug screen if he had not been requesting drug treatment options. " Interview revealed Physician A did not contact the inpatient psychiatric unit regarding the patient returning to the DED. The interview revealed the physician did she verify the reason for the patient leaving AMA earlier in the day. Interview revealed that Physician A did not order a BHS consult. Interview revealed "absolutely not", " No one informed me that patient had complained of pain 9 out of 10. " Interview revealed, " My last interaction with the patient was when I was telling him behavioral health would inform him of his outpatient options."

B. Review of policy "PC 210.60 EMTALA, Transfers-To Other Medical facilities " effective 09/2008 revealed "3. The request must be in writing and it must indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer."

1. Medical record review of patient #7 revealed a 10 year old child presenting to the DED on 12/31/2013 at 1003 with a chief complaint of hyperglycemia, Diabetes, nausea vomiting x 2 days and elevated blood sugar. Medical record review revealed at 1017 Physician A initiated the medical screening exam (MSE) at 1016. Review of the MSE revealed ""10 year-old Hispanic female history of insulin dependent diabetes presents to the emergency department fatigued, vomiting since yesterday, abdominal cramping tachycardic, pale. Accu-Chek 494. Patient's mother and sister state she has been vomiting since yesterday glucose measured as "high"...Patient's mother does not seem to understand the dosing/frequency of the patient ' s insulin". Record review revealed the patient was administered 10 units of regular insulin intravenous (IV) per physician order at 1030. Record review revealed Sodium chloride 1000 ml was started IV at 1030 at a rate of 2000 ml per hour per physician's order. Review of nursing documentation at 1040 during triage revealed "pt (patient) has been having nausea and vomiting for 2 days. mother reports BS (Blood sugar) was reading "high" all day yesterday. " Further review revealed the patient was triaged level 2 (urgent). Vital signs documented at triage Temperature 97.9 F, Pulse rate 140 (high per hospital criteria), Blood pressure 133/87 (high per hospital criteria) and respirations 22. Record review revealed lab results received at 1135. Review of the results revealed: White Blood Cell count 24.6 High ( range 4.0-10.0), Red Blood Cells 6.33 High (range 4.00-5.00), Hemoglobin 18.0 High (range 12.0-15.5), Hematocrit 52.2 High (range 35.0-46.0), Blood urea nitrogen 25 High (7-17), Creatinine 1.10 High (range 0.44-1.0), potassium 3.2 Low (range 3.5-5.5), Calcium 11.9 High (range 8.4-10.2), Magnesium 3.0 High (range 1.8-2.4), Total protein 9.4 High (range 6.0-8.5), Alkaline phosphates 417 High (range 117-390). Medical record review revealed the patient had a blood glucose level at 1135 of 499 "Critical Lab Test: Glucose less than 50 or greater than 400". Record review revealed at 1226 Physician A documented the patient ' s electrocardiogram was "rate 166, The rhythm is sinus tachycardia". Medical record review revealed the last set of vital signs documented were at 1353 heart rate 133, respirations 21, Blood pressure 108/61. Medical record review revealed written physician certification for transfer of the patient to another hospital. Review of the physician certification revealed physician A signed the certification at 1220 on 12/31/2013. Further review of the certification for transfer revealed "2nd signature validating certification transferred within 30 minutes of initial certification" signed by physician D at 1335 on 12/31/2013. Review of the certification for transfer revealed a section titled "Risk of Transfer (Must list patient specific risks.). Review of the section revealed the line provided to document the risk was blank. Review of the section revealed two check boxes for "Deterioration of condition enroute." and "Worsening of condition or death if you stay here" below the line for risks specific to the patient. Record review did not reveal any documentation of the specific risk associated with the transfer of the patient. Medical record review revealed the last documentation of reassessment of the patient by physician A was at 1321. Record review revealed physician A documented the patient's condition was "guarded" and diagnosis was Dehydration and Diabetic Ketoacidosis. Medical record review revealed documentation by nursing at 1425 "Pt (patient) provided 120 ml (milliliters) Apple juice PO (by mouth) due to BSC (Blood Sugar check) = 74, pt suddenly drowsy, difficulty arousing, BSG (Blood Sugar Glucose) checked. Dr. A notified at pt was leaving with EMS (Emergency Medical Services) event. EMS provided 360 ml apple juice for ground transport to Hospital B (receiving Hospital) if po capable". Review of documentation at 1428 by the charge nurse revealed "Primary RN (name of nurse) stated pt less responsive. BS (Blood Sugar) reading 74. Dr. A made aware and states given apple juice. (name of nurse) primary RN made aware of same." Record review revealed no further documentation of a reassessment of the patient prior to leaving the DED at 1430 ( 2 hours 10 minutes since physician written certification for transfer and 55 minutes since the "2nd signature validating certification transferred within 30 minutes of initial certification").

Interview with administrative staff on 01/09/2014 at 1100 revealed the last documentation by the physician was at 1321 on 12/31/2013. The interview revealed the patient was not reassessed after receiving apple juice and the patient's blood glucose was not rechecked prior to transfer. The interview revealed there was no further documentation for the medical record.

2. Medical record review of patient #25 revealed a 29 year old presenting to the DED on 11/17/2013 at 1716 with a chief complaint of All Terrain Vehicle (ATV) accident. Review of the nursing triage documentation revealed the patient complained of left knee and right shoulder pain. Record review revealed the patient had "swollen lips, small amount of blood in mouth". Vital signs at triage were temperature 97.7 F, pulse rate 106 (high), blood pressure 154/99 (high) and respirations rate 16. Review of the MSE by the physician at 1732 revealed "Laceration of the mucosal surface of the upper lip left side, extensive swelling of right cheek, crusted blood bilateral nares, extensive abrasions and contusions of the facial area...Right clavicle tender to palpation...Right shoulder tenderness to palpation...Left knee tender to palpation". Record review revealed documentation by the physician of reassessment at 1957. Review of the assessment revealed "appears to have nasal fractures and possible right facial fracture over the cheek area. Subsequent CT of the brain shows some abnormal minimal density along the falx cerebri and radiologist is quite sure whether this is calcification versus a small amount of blood represents minimal traumatic subarachnoid hemorrhage. We have no neurosurgeon on-call locally...We have confirmed nasal fractures and right maxillary sinus fracture on facial CT. Patient has received multiple doses of morphine for pain". Record review revealed the diagnoses documented "head injury, abrasion to face, head contusion, lower extremity contusion, knee sprain, closed fracture of the facial bones. traumatic intracranial hemorrhage and closed dislocation of the shoulder". Record review revealed written physician certification for transfer completed at 2120. Review of the certification for transfer revealed a section titled "Risk of Transfer. Review of the section revealed the line provided to document the risk documented traffic accident. Review of the section revealed two check boxes for "Deterioration of condition enroute." and "Worsening of condition or death if you stay here" below the line for risks specific to the patient. Record review did not reveal any documentation of the specific risk associated with the transfer of the patient.

Interview with hospital administrative staff on 01/10/2014 at 1330 revealed the hospital had identified the risks and benefits were not being specially documented. The interview revealed the hospital changed the physician certification transfer form. The interview revealed this record was apparently completed prior to the change in the form. The interview revealed there was no further documentation for the record. The interview revealed the DED physician did not follow the hospital policy for the documentation of the specific risks for transfer.

Interview with hospital administrative staff on 01/010/2014 at 1330 revealed the EMTALA transfer form had sections for the physician to complete for the medical risks and benefits. The interview revealed the staff was aware the risk and benefits were to be specifically relative to the patient's condition during transfer. The interview revealed the hospital had identified the DED physicians had not been completing the specific risks of transfer. The interview revealed the DED physician staff had education provided informing physicians the requirement for the risks to be specific to the patient. The interview revealed the transfer form indicated in writing the risks are to be specific for the patient. The interview revealed there had not been any monitoring to ensure the DED physicians were following the hospital policy and CMS regulations. The interview revealed to date 77 % of the physicians had completed the education.