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Based on a review of the EMTALA Log, medical records, Medical Staff Rules and Regulations, facility policy and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) within the facility's capability and capacity , including ancillary services routinely available to the dedicated emergency department, in order to determine whether or not an emergency medical condition (EMC) exists for six (P#1,P#4, P#7, P#9, P#11, and P#17) of 20 sampled patients. Specifically:

1. Medical screening exams (MSE) were not conducted by qualified medical personnel (QMP) as defined in the facility's Medical Staff Rules and Regulations and policies for six (P#1, P#4, P#7, P#9, P#11, and P#17) of 20 sampled patients, who entered the facility seeking medical assistance for psychiatric complaints.

Refer to findings in Tag A- 2406

2. Based on review of facility policy and procedures, EMTALA Log, Hospital-Wide On-call Calendar, patient census report and interviews with staff, it was determined that the facility failed to provide further medical examination and treatment as required for one (P#7) of 20 sampled patients. P#7 was denied inpatient admission for chemical dependency due to their lack of financial resources. Specifically, P#7 arrived at the facility on 12/3/24 with a complaint of alcohol withdrawal. P#7 reported symptoms of nausea, vomiting, and 'shakes'. It was recommended that P#7 be admitted for inpatient detoxification treatment; however, after speaking to the facility's financial counselor, P#7 expressed an inability to afford the hospitalization. P#7 was then discharged with an outpatient referral without further medical assessment.

Refer to findings in Tag A- 2408.

3. Based on review of the EMTALA Log, medical records, policies and procedures, and staff interviews it was determined that the facility failed to provide an appropriate transfer for four (P#1, P#11, P#13 and P#15) of 20 sampled patients reviewed. Specifically:

a. The facility failed to complete a memo of transfer that included documentation of risks and benefits, confirmation of an accepting physician, nurse to nurse report, mode of transport and confirmation of medical records accompanied the patient for P#1 and P#11.
b. The facility failed to effect an appropriate transfer utilizing qualified personnel and transportation equipment for P#13 when the patient was instructed to go to an acute care ED for evaluation of his elevated blood pressure and for P#15 when he was instructed to go to an acute care ED after a suicide attempt by overdose.

Refer to findings in Tag A-2409.

Based on review of the EMTALA Log, and staff interviews, it was determined that the facility failed to maintain/initiate medical and other records for nine (P#2, P#3, P#5, P#8, P#12, P#16, P#18, P#19, and P#20) of 20 sampled patients that presented to the facility's intake department seeking medical assistance for psychiatric complaints.

Findings Included:

During a review of the facility's EMTALA Log for 7/1/24 through 3/25/25, the facility failed to produce medical records for nine (P#2, P#3, P#5, P#8, P#12, P#16, P#18, P#19, and P#20) of 20 sampled medical records requested.

During an interview on 3/26/25 at 9:45 a.m. with the Vice President of Clinical Services (VPCS) EE in a conference room, VPCS EE acknowledged that the facility was unable to produce several of the requested medical records. He said he was not aware that medical records were not being created on all patients.

During an interview on 3/27/25, at 9:54 a.m. with the Medical Director (MD) II in an office, he explained that he expects staff to create a medical record for every patient being treated and he expects staff to follow documentation requirements. The facility failed to implement an effective system as it relates on maintaining medical records for individuals who present to the intake department seeking medical assistance for P#2, P#3, P#5, P#8, P#12, P#16, P#18, P#19, and P#20.

Based on a review of the EMTALA Log, medical records, Medical Staff Rules and Regulations, facility policy and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the facility's dedicated emergency department, including ancillary services routinely available to the dedicated emergency department, to determine
whether or not an emergency medical condition (EMC) exists for six (P#1,P#4, P#7, P#9, P#11, and P#17) of 20 sampled patients. Specifically: Medical screening exams (MSE) were not conducted by qualified medical personnel (QMP) as defined in the facility's Medical Staff Rules and Regulations and policies for six (P#1, P#4, P#7, P#9, P#11, and P#17) of 20 sampled patients who presented to the facility seeking medical assistance for psychiatric complaints.

Findings Included:

A review of Medical Staff Rules and Regulations reviewed 10/2024 revealed in Chapter VI g). Medical Screening Exam (MSE)
1) The process required to determine within reasonable clinical confidence where an
Emergency Medical Condition (EMC) does or does not exist. The MSE is an ongoing process and must be done within the facilities capability.
The Qualified Medical Personal (QMP) designated to provide an MSE is a physician,
advanced practice registered nurse or registered nurse, whose scope of responsibilities are approved by the hospital's governing board through the medical staff rules and regulations.

A review of the facility's policy number 21, titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" last revised on 1/2025 reveled the following:
POLICY: Ridgeview Institute will assure that (1) all patients who come to the hospital requesting emergency services receive an appropriate Medical Screening Examination.
DEFINITIONS:
"Qualified Medical Personnel" means a licensed registered nurse, advanced practice nurse (APN) or licensed physician whose scope of responsibilities are approved by the hospital's governing board and the Medical Staff Rules & Regulations.
PROCEDURE:
Medical Screening Exam (MSE): The Medical Screening Examination is to be
provided by Qualified Medical Personnel (QMP).
Procedure for Completion of the MEDICAL SCREENING EXAMINATION
1: Receptionist will notify the Assessment & Referral Department that a person has been presented seeking medical/psychiatric services.
2: Upon completion of the initial screening by the Assessment & Referral staff, assignment of care will be based on the identified acuity. A qualified medical professional will evaluate all patients by performing a medical screening examination.
Psychiatric Emergency
The law requires that a person must be, because of a mental disorder, a danger to self, a danger to others, or gravely disabled. The physician and/or on call physician is responsible for supervision, evaluation, and stabilization of the patient. In the
absence of the physician, a designated Qualified Medical Professional (QMP) who has
demonstrated competency may be conducted in a medical screening examination.

A review of the EMTALA Log revealed that P#1 arrived at the facility via walk-in on 3/16/25 at 10:15 a.m. A review of the medical record revealed that a master's Level Clinician (MLC) initiated the EMTALA Medical Screening at 8:09 p.m. P#1's chief complaints were depression and alcohol dependence. P#1 reported suicidal ideation with a plan to overdose on medication. Patient #1 had an emergency medical condition
of suicidal ideation and at risk for self-harm. Review of the medical record revealed the medical screening examination was conducted by a MLC, who was not designated qualified medical personnel.

A review of the EMTALA Log revealed that P#4 arrived at the facility via walk-in on 11/8/24 at 6:30 a.m. A review of the Intake Assessment revealed the patient's Chief Complaint was listed as "Cause my mom knows I want to kill myself because I hate myself." P#4's presenting problems were suicide with self-injurious behavior (cutting), body dysmorphia (a mental health condition where a person spends a lot of time worrying about flaws in their appearance), and homicidal ideations (thoughts). The medical record revealed the patient was assessed/evaluated by a Licensed Master Social Work (LMSW), who was not designated as qualified to perform Medical Screening examinations.

A review of the EMTALA Log revealed that P#7 arrived at the facility via walk-in on 12/3/24 at 3:21 p.m. A review of the medical record revealed that P#7's chief complaint was listed as "I have a big drinking problem." Patient #7's presenting problem was alcohol (ETOH) detoxification. He reported drinking a fifth of vodka daily and experiencing withdrawal symptoms including nausea, vomiting, and tremors (shaking). The patient denied suicidal and homicidal ideation, and hallucinations. The medical record revealed the patient was evaluated by a Marriage and Family Therapist. The review failed to reveal documentation that an EMTALA Medical Screening examination was performed by qualified medical personnel.

A review of the EMTALA Log revealed that P#9 arrived at the facility via walk-in on 1/5/25 at 3:12 p.m. A review of the medical record revealed that P#9's chief complaint and presenting problem was listed as" Pt. (patient) presents due to Detox." alcohol (ETOH) detoxification. The patient reported he was going through withdrawal symptoms, including auditory and visual hallucinations, paranoia daily due to lack of sleep, confusion, irritability daily due to urges of cravings, and panic attacks. He reported his last use of alcohol was four days ago. P#9 denied any medical conditions and denied suicidal or homicidal ideations. The medical record revealed the assessment by a Master of Social Work. The review failed to reveal documentation that an EMTALA Medical Screening was conducted by qualified medical personnel.

A review of the EMTALA Log revealed that P#11 arrived at the facility via walk-in on 1/3/25 at 3:00 p.m. A review of the medical record revealed that P#11's Chief Complaint was "Pt. stated "I don't have the will power to live." The presenting Problem was listed as, "Pt. presented seeking an assessment to help with SI (suicidal ideation), depression and substance abuse use." The patient's Psychiatric symptoms stated in part, Poor eye contact, Affect Flat, Dysphoria (very unhappy, or dissatisfied), Thought Process Confused, Judgment and Insight, was poor. The patient's medical history included bipolar disorder (psychiatric illness characterized by both manic and depressive episodes) and schizoaffective disorder (Delusions-fixed beliefs, Hallucinations such as hearing or seeing things that are not there), and Diabetes. Further review revealed the patient reported paranoid ideation, and a history of psychosis (Mental health condition characterized by a disconnection from reality). Review also revealed substance abuse, the patient reported the use of "Amphetamine/Stimulants/ (meth) and last use was "yesterday", and last alcohol intake was "Last night." Review of the summary revealed in part Patient #11, "Precautions: Suicidal and Self-Harm. Level of Suicide ...Moderate/Low ... Pt. reported suicidal ideations with no specific method stating "I'm just tired, I want to try to end it" unable to elaborate. Pt (patient). has history if attempts, cutting on her legs, arm, and torso; last episode 3-4 weeks ago ...Pt. denied HI (homicidal ideation) and AVH (Audio/Visual hallucinations) although pt stated that she was unsure if what if what she is experiencing is some level of paranoia. Pt. reported impaired sleep ...Pt was observed to be confused, nodding out during the assessment, and unable to focus. Further review revealed that an EMTALA Medical Screening Examination was conducted by a Licensed Master Social Worker. The medical record failed to documentation that an EMTALA Medical Screening Examination was conducted by a qualified medical personnel member.

A review of the EMTALA Log revealed that P#17 arrived at the facility on 11/12/24 at 8:21 a.m. A review of the Intake Assessment Report revealed P#17 had a complaint of bizarre behavior and possible hallucinations. The patient was accompanied by his mother. The patient's presenting problems revealed, in part, "Patient is a 14-year-old ... presents voluntarily for walk in assessment due to possible psychosis with delusions. Further review revealed the patient's eye contact was poor, Judgment and insight was poor. The patient denied suicidal and homicidal ideation, or self-harming behaviors. He had a past medical history of asthma and concussion. Further review revealed the MSE was inappropriate because a non-designated person performed the MSE. The medical record failed to reveal evidence that an EMTALA Medical Screening was conducted by a qualified medical personnel member.

During an interview on 3/25/25, at 10:15 a.m. with the Director of Assessments and Referrals (DAR) AA in a conference room, DAR AA stated that her duties as Director include oversight of the facility clinicians and the call center. DAR AA explained that when a patient arrives at the facility by walk-in or by ambulance, they are triaged and placed in an intake room based on their acuity until they can be assessed. She stated that a master-level clinician (MLC), who is a master's prepared mental health counselor or social worker, conducts an initial medical screening examination (MSE) on the patient.

During an interview on 3/25/25 at 11:31 a.m. with Registered Nurse (RN) CC in a conference room, RN CC explained that every patient who presents to the facility requesting treatment should have a medical screening exam (MSE). She added that there are parameters for the MLC to follow, as they do not have medical training and are therefore unable to determine what constitutes an appropriate interpretation of the medical information. RN CC explained that if she is not notified by an MLC that a patient's condition is acute or deteriorating, she would not be aware of it otherwise. RN CC stated that MLCs conduct the MSE. Still, it should be done by an RN because they have clinical experience to determine if a patient requires reassessment, emergency intervention, or transfer based on their vital signs and presentation.

During an interview on 3/26/25 at 9:45 a.m. with the Vice President of Clinical Services (VPCS) EE in a conference room, VPCS EE stated that many medical records failed to reveal that a medical screening examination (MSE) was conducted. He said that the facility staff have not been following the facility's process of documenting or conducting MSEs on patients. He said he was not aware that MSEs were not being conducted prior to the survey. During a follow-up interview on 3/26/25 at 10:35 a.m. with VPCS EE, VPCS EE said that MLCs are not qualified to conduct MSEs and that MSEs should be conducted by an RN or a licensed physician. He added that MLCs do conduct assessments, but to triage and assign acuity levels. When this surveyor asked VPS EE if MLCs are trained to triage and assign acuity levels, he replied that they have not been trained to do so, as they are not medical personnel.

A follow-up interview was conducted on 3/26/25 at 1:46 p.m. with RN EE. RN EE stated that master-level clinicians conduct MSEs, and the MSE is then forwarded to her or a house supervisor for review and signature. She added that there are times when it is not reviewed right away, which defeats the purpose of reviewing the values.

During an interview on 3/26/25 at 2:18 p.m. with Master Level Clinician (MLC) DD in a conference room, MSW DD explained that when patients arrive in the waiting room, she assesses and prioritizes them based on their mental status. She added that one of her responsibilities as a master social worker in intake is to conduct MSEs and initial assessments. She explained that once she completes an MSE, she is supposed to send it to an RN, who will review the assessment and sign it.

A telephone interview was conducted on 3/26/25 at 8:30 p.m. with House Supervisor (HS) KK. She stated that one of her duties as a house supervisor is to respond to medical emergencies and to review and sign medical screening examinations (MSE) sent over by the intake department. HS KK noted that every patient who enters the access/intake department should receive a medical screening exam (MSE). She added that the intake department staff conduct the MSE and forward it to the RN for review and signature. HS KK explained that personnel qualified to conduct medical screening exams include RNs, advanced practitioners, and physicians, and that MLCs are not qualified and lack medical experience.

During an interview on 3/27/25, at 9:54 a.m. with the Medical Director (MD) II in an office, MD II stated that his responsibilities as medical director include overseeing the medical staff, attending medical staff meetings, conducting chart audits to ensure compliance, creating provider schedules, managing outpatient clinics, and seeing approximately 60 patients. He explained that the MSE must be conducted by a qualified medical practitioner (QMP). He added that the facility bylaws stipulate that a QMP must be a registered nurse (RN), advanced practitioner, or physician, and that master-level clinicians are not qualified to conduct an MSE. MD II explained that elements of an MSE include a review of symptoms, pain assessment, physical exam, past and current medical history, medication review, psychological assessment, and vital signs. MD II stated that he was unaware of the MSEs being conducted by MLCs.

During an interview on 4/15/25 at 2:11 p.m. with the Regional Director of Quality (RDQ) MM, in a conference room, RDQ MM stated that she had worked as the Director of Quality at the facility's sister location for four years, was recently promoted to RDQ, and floats between all the facilities. She explained that patient MSEs have been hit or miss in terms of ensuring every patient who enters the facility gets one. She acknowledged that most of the sample patients had not received an MSE. She stated the staff did not recall the specifics of what caused the sample patients not to have an MSE. RDQ MM explained that MSE's are documented on the form titled 'EMTALA Medical Screening' and if that form was not in the record, an MSE was not conducted.

The facility failed to ensure that their own Medical Staff Rules and Regulations and EMTALA policy were followed as evidenced by failing to ensure that all patients who come to the hospital requesting emergency services received an appropriate medical screening examination by a QMP whose scope of responsibilities are approved by the hospital's governing board Medical Staff Rules and Regulations. This failure resulted in inappropriate Medical Screening examinations being conducted by individuals not approved by the hospital's governing board for six (P#1, P#4, P#&, P#9, P#11, and P#17) of 20 sampled patients who presented to the hospital seeking medical assistance for psychiatric complaints.

Based on review of facility policy and procedures, EMTALA Log, Hospital-Wide On-call Calendar, patient census report and interviews with staff, it was determined that the facility failed to provide further medical examination and treatment as required, after inquiring about the individual's method of payment for one (P#7) of 20 sampled patients. P#7 was denied inpatient admission for chemical dependency due to their lack of financial resources. Specifically, P#7 arrived at the facility on 12/3/24 with a complaint of alcohol withdrawal. P#7 reported symptoms of nausea, vomiting, and 'shakes'. It was recommended that P#7 be admitted for inpatient detoxification treatment; however, after speaking to the facility's financial counselor, P#7 expressed an inability to afford the hospitalization. P#7 was discharged with an outpatient referral without further medical assessment.

Findings included:

A review of facilities policy number 21, titled "Emergency Medical Treatment and Active Labor Act (EMTALA) ", last revised on 1/2025, revealed in part the following: "c. The MSE will not be delayed inquiring about a person's ability to pay or perform any insurance verification .... ... if the patient has no insurance, no further questions regarding payment should be asked of the patient until after the medical screening examination has taken place. The Assessment and Referral personnel should not under no circumstances (1) Discuss cost of the service; (2) Ask how the patient will pay for the service; or (3) Make an attempt to collect payment."

A review of the patient census for 12/3/24 revealed a total facility census of 134 patients. Of the 134 patients, 16 patients were on the detoxification/substance abuse unit.

A review of the 'Hospital-Wide On-Call Calendar for December 2024 revealed that on 12/3/24, a nurse practitioner was on call beginning at 5:00 p.m.

A review of the EMTALA Log revealed that P#7 arrived at the facility on 12/3/24 at 3:21 p.m. The ED revealed the patient's complaint was listed as "Psychiatric". The section of the ED Log titled, "Emergency Medical/Psychiatric Condition" documentation revealed "Yes" P#7 had an emergency condition. The patient's disposition was listed as "Referred Out." The Intake Assessment dated 12/3/2024 at 6:29 p.m. was reviewed. The patient's chief complaint was," I have a drinking problem." The section of the medical record titled "Psychiatric Symptoms" revealed the patient's presenting problem was seeking alcohol detox (detoxification-process of removing toxic substances particularly drugs, alcohol from the body), and that his insight was listed as "fair." Psychosocial Assessment: Financial Problems: Yes ..." I've got a lot of bills ...I'm broke most of the time."

Further review of medical record revealed that P#7 reported drinking a fifth of vodka daily and was experiencing withdrawal symptoms, including nausea, vomiting, and shakes. He had a past medical history of depression, anxiety, alcohol abuse, and a suicide attempt in 2021. P#7 had six previous hospital admissions, with the latest one being a year ago for alcohol detox. P#7 denied any current suicidal or homicidal ideations. The section of the medical record titled "LEVEL OF CARE DETERMINATION" revealed, "Symptoms Meet: Criteria for Acute Psychiatric/Chemical dependency Inpatient admission. Acute Inpatient Psychiatric/Chemical Dependency Care: Condition requires a medical monitored detoxification process." Review of the "Summary of Clinical Information" revealed that P#7 was recommended for inpatient detox treatment. After receiving a financial consultation, he expressed an inability to afford services and was referred to an outpatient program. The medical record failed to reveal evidence of outpatient referral information. The facility failed to ensure that their own policy and procedure was followed as evidence by having the financial consult inquire and ask questions about how P#7 would pay for further medical evaluation and treatment. This resulted in P#7, on 12/3/24, not being admitted to the facility's inpatient unit for his Acute Psychiatric/Chemical Dependency, as his condition required medical monitoring for the detoxification process.

During a virtual interview on 8/5/25 at 1:00 p.m., CEO LL explained that financial counseling was conducted on all patients that present to the intake department to be in compliance with the 'no surprise billing act'. Financial counseling was done after an assessment but prior to admission.




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Based on review of the EMTALA Log, medical records, policies and procedures, and staff interviews it was determined that the facility failed to provide an appropriate transfer for four (P#1, P#11, P#13 and P#15) of 20 sampled patients reviewed. Specifically:
1. The facility failed to complete a memo of transfer that included documentation of risks and benefits, confirmation of an accepting physician, nurse to nurse report, mode of transport and confirmation of medical records accompanied the patient for P#1 and P#11.
2. The facility failed to effect an appropriate transfer utilizing qualified personnel and transportation equipment for P#13 when the patient was instructed to go to an acute care ED for evaluation of his elevated blood pressure and for P#15 when he was instructed to go to an acute care ED after a suicide attempt by overdose.

Findings Included:

A review of the EMTALA Log revealed that P#1 arrived at the facility via walk-in on 3/16/25 at 10:15 a.m. A medical record revealed that a master's Level Clinician (MLC) initiated EMTALA Medical Screening (MSE) at 8:09 p.m. P#1's chief complaints were depression and alcohol dependence. P#1 reported suicidal ideation with a plan to overdose on medication. P#1 had a past medical history of cirrhosis (irreversible condition where scar tissue replaces healthy liver tissue, hindering the liver's ability to function correctly, and can lead to liver failure), diabetes (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), hypertension (a condition where the force of blood against artery walls is consistently too high), daily diarrhea, incontinence of urine and feces, and a past suicide attempt by overdose of medication.
Continued review revealed P#1 was placed on high-risk suicide precautions. A consultation with the Medical Director was initiated, and a decision was made to transfer P#1 to an area hospital for medical clearance due to her past medical history.

The medical record failed to include an order to transfer, a completed memorandum of transfer, and documentation that copies of medical records were provided to EMS. There was no documented evidence that Patient #1 medical records were forwarded to the receiving physician and receiving hospital. There was no documentation in the medical record to indicate that the receiving hospital had the required specialized capability that P#1 required. Additionally, there was no documented evidence that the receiving hospital agreed to accept the transfer of P#1 to provide the additional necessary medical intervention for the patient's identified EMC.

A review of the EMTALA Log revealed that P#11 arrived at the facility on 1/13/25 at 3:00 p.m. An Intake Assessment was started by MLC DD on 1/13/25 at 3:48 p.m. A continued review revealed that the EMTALA Medical Screening was started on 1/13/25 at 11:06 p.m. Psychiatrist FF was consulted on 1/14/25 at 12:00 a.m. and determined that P#11 would be admitted as an inpatient for "Acute Psychiatric/Chemical Dependency" but would require a medical clearance at an acute care facility due to emergent medical/physical/psychiatric conditions. The 'Signature of Qualified Medical Personnel Completing MSE' was signed by Registered Nurse (RN) GG on 1/14/25 at 8:40 a.m. The medical record failed to include a memorandum of transfer form or documentation that copies of the medical record were provided to EMS. There was no documented evidence that Patient #11's medical records were forwarded to the receiving physician and receiving hospital. There was no documentation in the medical record to indicate that the receiving hospital had the required specialized capability that Patient #11 required. There was no documented evidence that the receiving hospital agreed to accept the transfer of P#11 to provide the additional necessary medical intervention for the patient's identified EMC. Continued review of the 'A&R Clinical Note' dated 1/14/25 at 10:05 a.m. revealed that P#11 was returned to the facility on 1/14/25 from the acute care facility.

A review of the EMTALA Log revealed that P#13 arrived at the facility on 1/5/25 at 12:05 p.m. An Intake Assessment was initiated 1/5/25 at 3:35 p.m. by MLC KK with a chief complaint of medication needs related to psychosis and blood pressure. P#13 stated that he ran out of his medication, and his psychosis was getting worse. The EMTALA Medical Screening was initiated on 1/5/25 at 6:11 p.m. and the patient's blood pressure was 183/108 mmHg. Continued review revealed that P#13's blood pressure was re-checked after 45 minutes for 166/111.

The nursing supervisor was informed, and P#13 was asked by the nursing supervisor to go to the emergency room (ER) for medical clearance related to his blood pressure. Further review revealed that the MSE was signed by Registered Nurse (RN) GG on 1/6/25 at 7:30 a.m. The record failed to reveal a discharge time. The medical failed to reveal how P#13 was transferred to another hospital. There was no documentation that a memorandum of transfer form was completed. There was no documented evidence in the medical record that the receiving hospital had the required specialized capabilities that this patient required. There was no documented evidence that the receiving hospital agreed to accept the transfer of P#13 to provide the additional necessary medical interventions to evaluate the patient's elevated blood pressure.

A review of the EMTALA Log revealed that P#15 arrived at the facility on 2/17/25 at 11:05 a.m. A review of the 'Triage Information' revealed that P#15 had a previous suicide attempt on 2/16/24 and a history of 'abuse' from 2008 through 2025 and stopped 2/13/25. The document failed to specify the substance. An Intake Assessment revealed that the patient exhibited paranoid ideations. Continued review revealed that at the time of the assessment, P#15 was alert and mood appropriate. He reported no current suicidal or homicidal ideations and no previous suicide attempts. The final disposition revealed that P#15 was sent out for medical clearance. EMTALA Medical Screening was initiated at 2:17 p.m. that revealed the chief complaint of 'Attempted suicide by overdose'. P#15 reported taking 10-15 Abilify (medicine used for depression) pills. The 'Signature of Qualified Medical Personnel Completing MSE' was signed at 3:26 p.m. by a registered nurse. Further review of the 'Disposition' revealed that P#15 was sent out for medical clearance. A review of the 'Memorandum to Transfer (Hospital to Hospital) revealed that P#15 was transported by his mother and partner. No documented evidence in the medical records indicated that portions of the medical record that were available and relevant to transfer were sent with the patient as stated in the facility's transfer policy and procedure. The record failed to reveal a discharge time.

A review of the facility policy titled 'Transfer from Intake Department to another Facility', Policy A&R #19, and last reviewed 1/25 revealed I part:
"I. PROCEDURE
A. Transfer shall be done with the knowledge and consent of the patient/legal guardian following evaluation by a qualified psychiatric/medical examiner or physician.
B. A Psychiatric/Medical Screening Exam, Medical Screening Exam Certification and Consent for Transfer shall accompany the patient being transferred.
C. The transfer shall be completed with knowledge of and arrangements made for acceptance by the receiving facility/physician.
D. A petition shall accompany the patient when transfer is to another facility for acute psychiatric care.
E. All efforts shall be made to complete a certificate to accompany the patient when transfer is to another facility for acute psychiatric care
F. Transportation shall be by ambulance

A review of facility's policy number A&R 15, titled "MEMORANDUM OF TRANSFER" last reviewed on 1/2025 revealed following:
This policy applies to all individuals who are present at RIS for emergency care and/or treatment.
POLICY:
A Memorandum of Transfer will be completed on all patients transferred outside the Hospital's facilities ... Procedure: Responsibilities of Hospital Administration: ...Administration is responsible for the implementation and adherence to the hospital's Transfer Policy & Procedure and Memorandum of Transfer form ...

Transportation for Patient Transfers: Patients transferred to and from another hospital will be transferred by ambulance.
Transfer of Patients with Emergency Medical Conditions:
(A) If a patient at RIS has an emergency medical condition which has not been stabilized or when stabilization of the patient's condition is not possible because RIS does not have the appropriate equipment or staff to correct the underlying condition, transfer shall be carried out as quickly as possible.
Medical Record Requirements:
(A) A Memorandum of Transfer must be completed for every patient transferred and must contain the following information: the patient's full name if known; the patient's ...physical handicap if known; the patient's address and telephone number, if known; the names, addresses and telephone numbers of the transferring and receiving physicians; the time and date on which the patient first presented pr was presented to the transferring physicians; the time and date on which the transferring physician secured a receiving physician; signature, time, and title of the transferring hospital administration who contacted the receiving hospital; a Certification signed by the physician who includes a summary of the risks and medical benefits reasonably expected as a result of the transfer.
(B) (Documentation on the Memorandum of the transfer form). The time and date on which the receiving physician assumed responsibility for the patient; ...type of vehicle and company used for transfer; type of equipment and personnel needed in transfers; name and city to which patient was transported; diagnosis by transferring physician; and attachments ( as noted on the Memorandum of Transfer form) by transferring hospital ...(C) A copy of the Memorandum of Transfer shall be retained by the transferring ...hospitals."

During an interview on 3/25/25, at 11:31 a.m. with Registered Nurse (RN) CC in a conference room, RN CC explained that MLC's can transfer patients out but are required to consult with an RN or shift supervisor first. She said there are occasions when an MLC has transferred a patient out without consulting the RN. She added that the procedure for properly transferring a patient involves initiating a consultation with the RN and a provider to ensure a medical transfer is necessary, then completing a memorandum of transfer and an incident report. She stated that a copy of the patient's medical record should be created, along with all the transfer forms, and sent with the patient. She added that when EMS arrives, whoever is transferring the patient should determine the facility to which the patient is being transferred, contact the command center, and provide a report on the patient to the ED charge nurse.

An interview was conducted with Interim Assistant Chief Nursing Officer (ACNO) GG on 3/27/25 at 9:00 a.m. in the facility's conference room. ACNO GG was not sure why a "Memorandum to transfer" and incident report not done on P#1 or P#11. ACNO GG acknowledged that there was no discharge information in the record for P#13 and P#15 and staff did not recall the reason a transfer was not done for these two patients.
A telephone interview was conducted on 3/27/25 at 11:03 a.m. with Master Level Clinician (MLC) HH. MLC HH stated that if a patient needs to be transferred for medical clearance, she will consult with an RN to ensure the transfer is appropriate. Her responsibility in the transfer process is to make a copy of any relevant documents to send with the patient. The RN's responsibility is to complete the Memorandum of Transfer (MOT) and call to give a report to the receiving hospital's ED charge nurse.

The facility failed to ensure that their policies and procedures were followed as evidenced by failing to ensure that appropriate transfer protocols were followed as stated in the facility's policy and procedure for P#1, P#11, P#13, and P#15.