HospitalInspections.org

During an EMTALA investigation of complaint #42943 completed 12/11/17 to 1/8/18, Tristar Skyline Medical Center was found to be out of compliance with Requirements for the Responsibilities of Medicare Participating Hospitals in Emergency Cases 42 CFR PART 489.20 and 489.24. Based on review of facility policies, review of Medical Staff Bylaws, review of Medical Staff Rules and Regulations, review of Psychiatric On Call Schedules, medical record review, review of Behavioral Unit census records and interview, the facility failed to:

1. Ensure on-call psychiatrists who were available and on-call for duty performed an adequate examination and provided necessary treatment and/or services for all patients who presented to the Emergency Department (ED) with psychiatric signs/symptoms for 30 of 32 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) patient records reviewed who had presented to the ED seeking treatment.

2. Provide patients who presented to the Emergency Department (ED) with an appropriate Medical Screening Examination (MSE) within the capabilities of the hospital's emergency department and ensure patients presenting with psychiatric disorders were assessed by the hospital's on-call psychiatrists in order to determine if an emergency psychiatric condition existed for 30 of 32 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) patient records reviewed who had presented to the ED seeking treatment.

3. Ensure on-call psychiatrists performed an adequate assessment to determine the necessary treatment to stabilize signs/symptoms of psychiatric conditions for 30 of 32 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) patient records reviewed who had presented to the ED seeking treatment.

4. Ensure patients with identified emergency psychiatric conditions were transferred to Hospital A's inpatient psychiatric unit which had the capacity and capability to treat the patient. The hospital failed to minimize the risks to the patient's health by allowing patients with psychiatric conditions to remain in the hospital's ED for extended periods of time without stabilizing treatment while waiting to be transferred to an outside hospital. The failure of the hospital to admit and treat psychiatric patients resulted in an inappropriate transfer for 26 of 32 (#1, #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #24, #25, #26, #27 and #28) patients who had presented to the ED seeking treatment.

Refer to A-2404, A-2406, A-2407 and A-2409.

Based on review of facility policies, Medical Staff Bylaws, Medical Staff Rules and Regulations, Medical Staff On-Call Schedules, medical record review and interview, the facility failed to ensure on-call psychiatrists who were available and on-call for duty performed an adequate examination and provided necessary treatment and/or services for all patients who presented to the Emergency Department (ED) with psychiatric signs/symptoms for 30 of 32 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) patient records reviewed who had presented to the ED seeking treatment.

The findings included:

1. Review of the facilty's "EMTALA [Emergency Medical Treatment and Labor Act] Tennessee Medical Screening Examination and Stabilization Policy revealed, "...To establish guidelines for providing appropriate medical screening examinations ("MSE") and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ("DED")...The MSE must be completed by an individual...qualified to perform such an examination to determine whether an EMC [emergency medical condition) exists...If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity of the facility, or an appropriate transfer as defined by and required by EMTALA. Stabilizing treatment shall be applied in a non-discriminatory manner...no different level of care because of ...payment source or ability, or any other basis prohibited by federal, state or local law..."

Review of the facility's "EMTALA Transfer Policy" revealed, "...To establish guidelines for...providing an appropriate transfer to another facility of an individual with an emergency medical condition ("EMC"), who requests or requires a transfer for further medical care and follow-up to a receiving facility...Transfer of Individuals Who Have Not Been Stabilized...If an individual who has come to the emergency department has an EMC that has not been stabilized, the hospital may transfer the individual only if the transfer is an appropriate transfer...Higher Level of Care...A receiving hospital with specialized capabilities or facilities that are not at the transferring hospital (including...behavioral health units...) must accept an appropriate transfer of an individual with an EMC who requires specialized capabilities or facilities if the hospital has the capacity to treat the individual..."

2. Review of the facility's "MEDICAL STAFF BYLAWS" reviewed 7/19/16 revealed, "...The Medical Staff shall provide services as applicable, to patients admitted or otherwise treated at [Hospital A] which includes the [Hospital A's psychiatric campus]...To provide patients with the quality of care that is commensurate with acceptable standards and available community services...To monitor and enforce compliance with these Bylaws, Rules and Regulations and hospital policies..."

3. Review of the facility's "MEDICAL STAFF RULES AND REGULATIONS" reviewed 7/19/16 revealed, "...EMERGENCY SERVICES...All persons seeking emergency services and care will receive a medical screening examination and evaluation by a physician or a qualified medical person as designated by hospital policy...If the physician on call is requested by the emergency department physician to see an unassigned patient who has presented to the emergency department for treatment or evaluation, the on call physician must respond, regardless of the patient's ability to pay for any service...Patients with conditions whose definitive care is beyond the capabilities of the Hospital shall be referred to the appropriate facility, when in the judgment of the attending Physician the patient's condition permits such a transfer. Patient transfers shall be in accordance with EMTALA regulations..."

4. Review of the facility on-call schedule revealed a psychiatrist was on call 24 hours a day 7 days a week during the time each of the 30 of 32 patients were in the ED.

5. Medical record review revealed Patient #1 presented to the Emergency Department (ED) at Hospital A on 10/21/17 at 7:31 AM for complaint of "...Aggressive behavior, Hallucinations, auditory, schizophrenia..." Patient #1 had out of state Medicaid insurance.

Review of Physician Assistant #1's note dated 10/21/17 at 7:58 AM revealed Physician Assistant #1 initiated a Medical Screening Examination (MSE) which included: a History of Present Illness (HPI), a Risk of Psychiatric Illness, a Review of Systems (ROS), a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...He [Patient #1] is evasive with questions, but upon further discussions with family, they state that he has been having difficulties with voices, commands, and auditory hallucinations. He has been more aggressive recently and is hard to control at home. They attempted to take him to [Hospital A's psychiatric campus], but was instructed to come to the emergency department for medical clearance..." Further review of Physician Assistant #1's note dated 10/21/17 at 4:05 PM revealed, "...Patient is having acute psychosis, with auditory hallucinations. Patient needs completion of psychiatric monitoring and treatment to ensure stabilization...Primary Impression: Acute psychosis ...Secondary Impressions: Auditory hallucinations, Schizophrenia..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #1 on 10/21/17 at 8:00 AM which documented, "...I certify that this person is subject to involuntary care and treatment...Hx [history] of schizophrenia...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Acute psychosis with auditory hallucinations...Treatment may reduce symptoms...Patient needs safe place for treatment..."

A nurse's note dated 10/21/17 at 8:25 AM documented, "...FAMILY IS CONCERNED FOR HIS INCREASE IN AGITATION, DECREASED SLEEP. STATES HE STAYS UP LATE PACING AROUND AND TALKS TO 'THE VOICES.' HIS MOM STATES HE HAS BEEN AGITATED ALTELY [lately] AND HAS BEEN KNOWN TO ATTACK OBJECTS. STATES HIS AUDITORY HALLUCINATIONS SEEM TO GET WORSE WHEN HE IS ANGRY. I NOTED THIS WHEN I TOLD HIM THIS IS A NO SMOKING CAMPUS. HE BECAME IRRITATED AND HIS SPEECH BECAME FASTER AND HE SPOKE VERY ANGRILY WITH NONPERSONS WHEN I LEFT TO GET HIM A NICOTINE PATCH. HE REFUSED THE NICOTINE PATCH, STATING HE 'SWALLOWED A GUN' AND DOESN'T WANT TO TAKE ANY NICOTINE INTO HIS BODY..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...Obtain level of care/service unavailable at this facility. Service: Psych [psychiatry]...Receiving Facility...[Hospital B]...Time of Transfer: 1650 [4:50 PM]...Date: 10/23/17..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #1 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 57 hours and 19 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

6. Medical record review revealed Patient #2 presented to the ED at Hospital A on 9/16/17 at 9:22 PM for complaint of "...Depressed, Suicidal ideation..." Patient #2 had out of state Medicaid insurance.

ED Physician #2's note dated 9/16/17 at 9:48 PM documented ED Physician #2 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #2] brought to emergency department by EMS [emergency medical services] for bizarre behavior, depression and suicidal ideation. Unfortunately the patient is very accelerated, tangential with loose associations and it's very difficult to get a clear history from him. He does state he is suicidal and hopes to kill himself. He is name [has named] several options including lighting himself on fire, stabbing himself, running out in front of traffic, jumping off a building or drowning himself. He has made mention of his girlfriend leaving him and taking his dog but also has mentioned larger social issues such as the government, the military and the devil is being a cause for his frustrations...Focused PE [physical exam]...General/Const [Constitution]...odor of alcohol noted, disheveled with poor hygiene...Psychiatric...Abnormal Mood/Affect...Flight of ideas, Inappropriate, Irritable, Pressured Speech ...Abnormal Thinking/Perception...Suicidal with plan, Judgment abnormal..." Further review of ED Physician #2's note dated 9/16/17 at 11:19 PM revealed, "...Primary Impression: Depression with suicidal ideation...Secondary Impressions: Acute psychosis..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #2 on 9/16/17 at 9:50 PM which documented, "...I certify that this person is subject to involuntary care and treatment ...Depression, tangent thinking, acute mania, suicidal...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Severe depression c [with] SI [suicidal ideation] + plan to kill himself ... Clinical improvement, sx [symptom] reduction...Too high risk + [illegible] for out pt tx [treatment]..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Suicidal ideation...Obtain level of care/service unavailable at this facility. Service: psychiatric services...Receiving Facility...[Hospital B]...Time of Transfer: 0700 [7:00 AM]...Date: 9/20/17..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #2 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 81 hours and 38 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

7. Medical record review revealed Patient #3 presented to the ED at Hospital A on 6/21/17 at 11:11 AM for complaint of "...Hallucinations, auditory, Suicidal ideation..." Patient #3 had TN [Tennessee] Care UHC [United Healthcare] Medicaid insurance.

ED Physician #3's note dated 6/21/17 at 11:25 AM revealed ED Physician #3 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...Patient has a history of schizoaffective disorder...has been out of her psychiatric medications for about 3 weeks. She is now having auditory hallucinations with suicidal content. Her hallucinations instruct her to overdose on her remaining medications..." Further review of ED Physician #3's note dated 6/21/17 at 4:35 PM revealed, "...Primary Impression: Schizoaffective disorder...Secondary Impressions: Auditory hallucinations, Suicidal ideation..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by the ED Physician #3 on 6/21/17 at 2:00 PM which documented, "...I certify that this person is subject to involuntary care and treatment...Pt reports a history of schizoaffective disorder...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Pt presents with auditory hallucinations with suicidal content...Pt needs hospitalization for safety and psychiatric stabilization..."

A nurse's note dated 6/21/17 at 11:12 AM documented, "...PER EMS PT [patient] HAS NOT TAKEN HER PSYCH MEDS [medications] FOR 2 WEEKS, 2 DAYS AGO SHE STARTED HEARING VOICES TO OD [overdose] ON HER PILLS AND KILL HERSELF. PT STATES THAT SHE IS SEEING THE DEVIL..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Psychosis, SI [suicidal ideation]...Obtain level of care/service unavailable at this facility. Service: psych...Receiving Facility...[Hospital B]...Date: 6-24-17...Time: 1610 [4:10 PM]..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #3 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 76 hours and 59 minutes.

8. Medical record review revealed Patient #4 presented to the ED at Hospital A on 2/17/17 at 1:54 PM for complaint of " ...Depressed ..." Patient #4 had TN Care Bluecare Medicaid insurance.

ED Physician #4's note dated 2/17/17 at 2:11 PM documented ED Physician #4 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...HAS BEEN OFF MEDS FOR ABOUT 6 WEEKS AND HAVING SI CURRENTLY. HX OF THE SAME WITH ATTEMPTS MORE THAN ONCE IN THE PAST..." Further review of ED Physician #4's note dated 2/17/17 at 4:38 PM revealed, "...WILL NEED PSYCH EVAL [evaluation] AND 6404 SINCE DANGER TO SELF...Primary Impression...Adjustment disorder with depressed mood..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #4 on 2/17/17 at 2:15 PM which documented, "...I certify that this person is subject to involuntary care and treatment...HISTORY OF DEPRESSION...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Deterioration due to mental illness to point of inability to care [for] self, at significant risk to health...Treatment likely to prove beneficial in symptom reduction...Condition is likely to deteriorate further without treatment...Adequate evaluation requires a secure setting..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Depression, SI...Obtain level of care/service unavailable at this facility. Service: Psychiatric Care...Receiving Facility...[Hospital B]...Time of Transfer: 1022 [10:22 AM]...Date: 2-20-17 [2/21/17]..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #4 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 92 hours and 28 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

9. Medical record review revealed Patient #5 presented to the ED at Hospital A on 2/20/17 at 1:16 PM for complaint of " ...Suicidal ideation ..." Patient #5 had TN Care Bluecare Medicaid insurance.

ED Physician #5's note dated 2/20/17 at 1:34 PM documented ED Physician #5 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #5] requesting heroin detox [detoxification]. Is also suicidal - states she wants to blow her brains out with a gun..." Further review of ED Physician #5's note dated 2/20/17 at 2:37 PM revealed, "...Will require psychiatric evaluation...Primary Impression: Suicidal ideation..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #5 on 2/20/17 at 1:30 PM which documented, "...I certify that this person is subject to involuntary care and treatment...Previous psychiatric hospitalizations...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Suicidal ideation with a well-formed plan for self harm as follows: Using firearm...Habitual use of drugs to the point of deterioration or death...In my opinion, the patient is at continued risk of self-harm in not placed under involuntary committment [commitment]...Condition is likely to deteriorate further without treatment...Treatment likely to prove beneficial in symptom reduction...Inability to contract for safety..."

A nurse's note dated 2/20/17 at 1:21 PM documented, "...PT VERBALIZES MULTIPLE DRUG USE HISTORY, PT STATES SUICIDAL IDEATION, STATES 'I DONT WANNA LIVE ANYMORE'..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: SI...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital B]...Time of Transfer: 1025 [10:25 AM]...Date: 2/24/17..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #5 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 94 hours and 9 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

10. Medical record review revealed Patient #6 presented to the ED at Hospital A on 5/19/17 at 7:07 PM for complaint of " ...Suicidal ideation ..." Patient #6 had TN Care UHC Medicaid insurance.

ED Physician #6's note dated 5/19/17 at 7:27 PM documented ED Physician #6 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #6] WITH HX OF BIPOLAR DISORDER WHO PRESENTS WITH SUICIDAL IDEATION WITH PLANS TO OVERDOSE WITH MEDICATION..." Further review of a physician's note dated 5/19/17 at 10:19 PM revealed, "...Primary Impression: Suicidal ideation..." Further review of ED Physician #6's note dated 5/23/17 at 4:36 AM revealed, "...Pt unable to go to [Hospital B] 2/2 [secondary to] PICC [peripherally inserted central catheter] which was initially not conveyed to us, now pt on list for [Hospital A psychiatric campus] in am [AM]..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by Licensed Professional Counselor #1 on 5/19/17 at 2:15 PM which documented, "...I certify that this person is subject to involuntary care and treatment...History of psychiatric hospitalizations at [Hospital D], [Hospital E] & [Hospital A's psychiatric campus]...current diagnosis of Schizophrenia & Mood Disorder NOS [not otherwise specified]...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Patient has SI w/ plan to OD on medication, slit wrists, or walk into traffic...Patient has continued access to lethal means...In my opinion patient poses an imminent threat to self if not placed under an involuntary commitment...Treatment likely to prove beneficial in symptom reduction...Current presentation places self & others at too high risk of injury..."

A nurse's note dated 5/19/17 at 7:10 PM documented, "...PER EMS, PT HERE WITH SI, NEEDS CLEARANCE FOR [Hospital A's psychiatric campus]...PT HAS PLAN TO OVERDOSE WITH PILLS...PICC LINE TO LEFT AC [antecubital]..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Suicidal ideation...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital B]...Time of Transfer: 0225 [2:25 AM]...Date: 5/23/17..." Further review of an "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Suicidal...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital A's psychiatric campus]...Time of Transfer: 1300 [1:00 PM]...Date: 5/24/17..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #6 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 113 hours and 53 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

11. Medical record review revealed Patient #7 presented to the ED at Hospital A on 9/28/17 at 5:37 PM for complaint of " ...Altered mental status ..." Patient #7 was uninsured.

ED Physician #7's note dated 9/28/17 at 8:20 PM documented ED Physician #7 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #7] was seen earlier today by mobile crisis for unclear reason, was cleared home with his mother, and mother later called EMS for continued altered mental status...EXAM...NEURO [neurological]...Questionably intoxicated on marijuana with giggles and perseveration on the connectedness of life...PSYCH...Poor insight and judgment...Speaking to visual hallucinations when left alone in the room which is not consistent with simple marijuana intoxication..." Further review of ED Physician #7's note dated 9/28/17 at 11:37 PM revealed, "...Primary Impression: Acute psychosis...Secondary Impressions: Marijuana use..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #7 on 9/28/17 at 6:00 PM which documented, "...I certify that this person is subject to involuntary care and treatment...no reported psychiatric diagnosis...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...acute psychosis...Would benefit from psychiatric care including symptom reduction...Unable to treat as an outpatient..."

A nurse's note dated 9/28/17 at 6:50 PM documented, "...MOTHER STATES 'HE IS JUST NOT RIGHT, HE WAS ADMITTED TO AN ER ON TUESDAY, EVALUATED BY MOBILE CRISIS AND SENT TO [Hospital B] AND THE PSYCHIATRIST EVALUATED HIM THERE AND SENT HIM HOME STATING THAT HE JUST NEEDED TO DETOX [detoxify] FROM POT, BUT I KNOW SOMETHING IS JUST OFF WITH HIM'..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by ED Physician #8 revealed, "...MEDICAL CONDITION: Diagnosis: Acute psychosis...Obtain level of care/service unavailable at this facility. Service: Psychiatry...Receiving Facility...[Hospital B]...Time of Transfer: 2200 [10:00 PM]...Date: 10/1/17..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #7 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 76 hours and 23 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

12. Medical record review revealed Patient #8 presented to the ED at Hospital A on 7/17/17 at 5:13 PM for complaint of "...I want to detox from alcohol..." Patient #8 was uninsured.

ED Physician #8's note dated 7/17/17 at 5:40 PM documented ED Physician #8 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #8] states he needs help to get off alcohol because he is afraid that he will die if he does not stop drinking...He has been to rehabilitation recently and just started drinking again about 3 weeks ago..." Further review of a physician's note dated 7/17/17 at 8:00 PM revealed, "...case manager spoke with the patient about options for outpatient detox. After this the patient stated he wanted to lay down on the railroad tracks or walk into traffic if he was discharged from the ED today..." Further review of ED Physician #8's note dated 7/17/17 at 8:30 PM revealed, "...the patient is now extremely agitated and has been threatening multiple staff members..." Further review of a physician's note dated 7/18/17 at 12:36 AM revealed, "...Primary Impression: Depression...Secondary Impressions: Alcohol abuse, Suicidal ideation..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #8 on 7/17/17 at 8:00 PM which documented, "...I certify that this person is subject to involuntary care and treatment...Active symptoms of psychiatric disorder as noted: suicidal ideation, depression...Reported history of behaviors clinically indicative of a psychiatric disorder...Reported or clinically suspected substance dependence...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Suicidal ideation with well-formed plan for self harm as follows: Walking into active traffic or lay on railroad tracks...In my opinion, the patient is at continued risk of harm to others if not placed under involuntary commitment...Condition is likely to deteriorate further without treatment ...Treatment likely to prove beneficial in symptom reduction...Adequate evaluation requires a secure setting..."

A nurse's note dated 7/17/17 at 5:30 PM documented, "...PT IS ALCOHOLIC, DRINKS BEER EVERY DAY AND TIRED OF LIVING THIS WAY, HAS HAD SI, WENT THROUGH 30 DAY REHAB [rehabilitation] IN THE PAST AND RELAPSED, STATES HE HAS HAD A LOT TO DRINK TODAY..." Further review of a nurse's note dated 7/17/17 at 5:36 PM revealed, "...SUICIDE ASSESSMENT...PATIENT SAYS THAT HE WISHES HE WAS NEVER BORN...PATIENT STATED THAT HE LOST HIS JOB RECENTLY..."

Review of the Emergency Notes revealed the following: "...07/17/17 2003 [8:03 PM]...MD ASKED ME TO GIVE RESOURCES TO THIS PATIENT FOR SUBSTANCE ABUSE. I WALKED UP TO HIS BEDSIDE AND HE WAS ON HIS PHONE WITH A NURSE AT ANOTHER [Hospital A's corporation] FACILITY WHERE HIS SIGNIFICANT OTHER IS LOCATED. THE NURSE ON THE PHONE WAS GIVING INSTRUCTION THAT THEY DO NOT HAVE PHONES IN THE ROOM AND HIS SIGNIFICANT OTHER WAS GIVEN HIS MESSAGE. THIS MAN SCREAMED OUT AT THE NURSE (I HEARD ALL THIS COMMOTION AS HE HAD HIS PHONE ON SPEAKER). HE SCREAMED THAT SHE WAS VIOLATING HIS CIVIL RIGHTS AND CURSED HER WITH A 'FUCK YOU! I KNOW MY RIGHTS AND ILL [I'll] HAVE YOU REPORTED. I AM A SECURITY GUARD AT DILLARD AND I KNOW WHO TO CALL!' I WAS AT HIS BEDSIDE WHEN HE GOT OFF THE PHONE-AND HE WAS VERY ANGRY WITH THE ANSWER HE GOT FROM ANOTHER FACILITY. HE IMMEDIATELY STARTED BEING BELLIGERENT WITH ME. HE ASKED ME 'WHAT THE HELL DO YOU WANT?' I TRIED TO RE-DIRECT AND SPOKE OF A POSITIVE ANSWER FOR HIS NEEDS OF FINDING A DETOX BED FOR HIS SUBSTANCE ABUSE. HE HAS TOLD MD THAT HE WAS NOT SUICIDAL AND WAS NOT HOMICIDAL. NOW, HE WANTS TO 'LAY ON THE RAILROAD TRACKS' OR JUMP INTO TRAFFIC! HE SAID I HAVE NO PLACE TO GO AND NOW 'SHE-(SIGNIFICANT OTHER) IS GOING TO GET A PLACE FOR HER PROBLEM SO I AM SUICIDAL. I DON'T WANT TO LEAVE NOW. IF I LEAVE I WILL HURT MYSELF!' I LET MD KNOW. HER PLANS WILL BE TO COMPLETE AN [a] 6404 AND WILL KNOWLEDGE THAT IT WILL BE RESCINDED WITH PLANS FROM MOBILE CRISIS. SECURITY AWARE AND NURSES AWARE...07/17/17 2028 [8:28 PM]...THIS PATIENT IS NOW DEMANDING TO LEAVE AND IS CALLING 'SOMEONE' TO COME PICK HIM UP. SECURITY NOTIFIED. THIS PATIENT AGGRESSIVE AT BEDSIDE. THREATENING TO NOW 'LEAVE, AND SO WHATEVER HE NEEDS TO DO TO GET OUT OF HERE' BODY LANGUAGE AGGRESSIVE WITH FINGERS GOING INTO A FIST, AND OPENING THE FIST FOR US TO SEE THE INTENT. MD AWARE. HE TORE HIS GOWN OFF AND THREW IN THE FLOOR, DEMANDED HIS PHONE. DEMANDED HIS RIGHTS BE 'UPHELD'...07/18/17 0425 [4:25 AM] THIS PATIENT IS NOW MEDICALLY CLEARED AND READY FOR PSYCH PROCESS TO BEGIN...HE IS ASKING WHY HE IS HERE. I WILL DISCUSS THIS CASE WITH MD..."

Rreview of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Suicidal Ideation...Obtain level of care/service unavailable at this facility. Service: Psychiatric Care...Receiving Facility...[Hospital B]...Time of Transfer: 0425 [4:25 AM]...Date: 7-21-17..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #8 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 83 hours and 12 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

13. Medical record review revealed Patient #9 presented to the ED at Hospital A on 7/16/17 at 5:25 AM for complaint of "...PSYCH..." Patient #9 was uninsured.

ED Physician #7's note dated 7/16/17 at 5:41 PM documented ED Physician #7 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #9] with known anxiety disorder and major depressive disorder reports weeks of worsening depressed mood, especially bad in the last few days with suicidal ideation including a plan to shoot herself or record car [wreck her]...PSYCH...Tearful, actively suicidal...Marginal insight and judgment..." Further review of ED Physician #7's note dated 7/17/17 at 6:00 AM revealed, "Additional Medical History...Anxiety, depression, hypothyroidism, cavernous hemangioma, seizures, hypertension, chronic pain, migraines, fibromyalgia...6404 was filed by myself for suicidal ideation. She has already been evaluated by mobile crisis who feels that she needs inpatient treatment...Primary Impression: Suicidal ideation...Secondary Impressions: Migraine..."

A Certificate of Need for Emergency Involuntary Admission (6404) was not present in the patient's medical record.

A nurse's note dated 7/16/17 at 5:28 AM documented, "...SENT FROM [Hospital A's psychiatric campus] FOR CLEARANCE AND PLACEMENT..." Further review of a nurse's note dated 7/16/17 at 5:49 AM revealed, "...SUICIDE ASSESSMENT...PT STATES SHES BEEN HAVING THESE THOUGHTS FOR ABOUT A WEEK...PT STATES SHE HAS PLANS 'DIFFERENT OPTIONS' BUT HAS BEEN TRYING TO FIGHT THEM OFF..."

Rreview of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: SI...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital B]...Time of Transfer: 1646 [4:46 PM]...Date: 7-19-17..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #9 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 59 hours and 21 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

14. Medical record review revealed Patient #10 presented to the ED at Hospital A on 10/13/17 at 10:06 PM for complaint of "...bipolar disorder..." Patient #10 was uninsured.

ED Physician #9's note dated 10/13/17 at 10:57 PM documented ED Physician #9 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #10] presents today with issues with bipolar disorder. Family member is here and says he has been delusional. He has been giving his money away to people. this has made him homeless. He also sent them a note saying he is suicidal..." Further review of ED Physician #9's note dated 10/14/17 at 12:37 AM revealed, "...history of bipolar. off meds. delusional, destructive behavior. evidence of psychosis...Primary Impression: Bipolar disorder..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #9 on 10/14/17 at 12:35 AM which documented, "...I certify that this person is subject to involuntary care and treatment...Active symptoms of psychiatric disorder as noted: suicidal ideation, depression...bipolar history off meds...delusional behavior, psychosis, giving away money, reckless behavior...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...worsening psychosis 2/2 [secondary to] bipolar with delusional and paranoid behavior...In my opinion, the patient is at continued risk of h

Based on review of facility policies, Medical Staff Bylaws, Medical Staff Rules and Regulations, Medical Staff On-Call Schedules, medical record review and interview, the facility failed to provide patients who presented to the Emergency Department (ED) with an appropriate Medical Screening Examination (MSE) within the capabilities of the hospital's emergency department and ensure patients presenting with psychiatric disorders were assessed by the hospital's on-call psychiatrists in order to determine if an emergency psychiatric condition existed for 30 of 32 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) patient records reviewed who had presented to the ED seeking treatment.

The findings included:

1. Review of the facilty's "EMTALA [Emergency Medical Treatment and Labor Act] Tennessee Medical Screening Examination and Stabilization Policy revealed, "...To establish guidelines for providing appropriate medical screening examinations ("MSE") and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ("DED")...The MSE must be completed by an individual...qualified to perform such an examination to determine whether an EMC [emergency medical condition) exists ...If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity of the facility, or an appropriate transfer as defined by and required by EMTALA. Stabilizing treatment shall be applied in a non-discriminatory manner...no different level of care because of...payment source or ability, or any other basis prohibited by federal, state or local law..."

Review of the facility's "EMTALA Transfer Policy" revealed, "...To establish guidelines for...providing an appropriate transfer to another facility of an individual with an emergency medical condition ("EMC"), who requests or requires a transfer for further medical care and follow-up to a receiving facility ...Transfer of Individuals Who Have Not Been Stabilized...If an individual who has come to the emergency department has an EMC that has not been stabilized, the hospital may transfer the individual only if the transfer is an appropriate transfer...Higher Level of Care...A receiving hospital with specialized capabilities or facilities that are not at the transferring hospital (including...behavioral health units...) must accept an appropriate transfer of an individual with an EMC who requires specialized capabilities or facilities if the hospital has the capacity to treat the individual..."

2. Review of the facility's "MEDICAL STAFF BYLAWS" reviewed 7/19/16 revealed, "...The Medical Staff shall provide services as applicable, to patients admitted or otherwise treated at [Hospital A] which includes the [Hospital A's psychiatric campus]...To provide patients with the quality of care that is commensurate with acceptable standards and available community services...To monitor and enforce compliance with these Bylaws, Rules and Regulations and hospital policies..."

3. Review of the facility's "MEDICAL STAFF RULES AND REGULATIONS" reviewed 7/19/16 revealed, "...EMERGENCY SERVICES...All persons seeking emergency services and care will receive a medical screening examination and evaluation by a physician or a qualified medical person as designated by hospital policy...If the physician on call is requested by the emergency department physician to see an unassigned patient who has presented to the emergency department for treatment or evaluation, the on call physician must respond, regardless of the patient's ability to pay for any service...Patients with conditions whose definitive care is beyond the capabilities of the Hospital shall be referred to the appropriate facility, when in the judgment of the attending Physician the patient's condition permits such a transfer. Patient transfers shall be in accordance with EMTALA regulations..."

4. Review of the facility on-call schedule revealed a psychiatrist was on call 24 hours a day 7 days a week during the time each of the 30 of 32 patients were in the ED.

5. Medical record review revealed Patient #1 presented to the Emergency Department (ED) at Hospital A on 10/21/17 at 7:31 AM for complaint of "...Aggressive behavior, Hallucinations, auditory, schizophrenia..." Patient #1 had out of state Medicaid insurance.

Physician Assistant #1's note dated 10/21/17 at 7:58 AM documented Physician Assistant #1 initiated a Medical Screening Examination (MSE) which included: a History of Present Illness (HPI), a Risk of Psychiatric Illness, a Review of Systems (ROS), a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...He [Patient #1] is evasive with questions, but upon further discussions with family, they state that he has been having difficulties with voices, commands, and auditory hallucinations. He has been more aggressive recently and is hard to control at home. They attempted to take him to [Hospital A's psychiatric campus], but was instructed to come to the emergency department for medical clearance..." Further review of Physician Assistant #1's note dated 10/21/17 at 4:05 PM revealed, "...Patient is having acute psychosis, with auditory hallucinations. Patient needs completion of psychiatric monitoring and treatment to ensure stabilization...Primary Impression: Acute psychosis ...Secondary Impressions: Auditory hallucinations, Schizophrenia..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #1 on 10/21/17 at 8:00 AM which documented, "...I certify that this person is subject to involuntary care and treatment...Hx [history] of schizophrenia...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Acute psychosis with auditory hallucinations...Treatment may reduce symptoms...Patient needs safe place for treatment..."

A nurse's note dated 10/21/17 at 8:25 AM documented, "...FAMILY IS CONCERNED FOR HIS INCREASE IN AGITATION, DECREASED SLEEP. STATES HE STAYS UP LATE PACING AROUND AND TALKS TO 'THE VOICES.' HIS MOM STATES HE HAS BEEN AGITATED ALTELY [lately] AND HAS BEEN KNOWN TO ATTACK OBJECTS. STATES HIS AUDITORY HALLUCINATIONS SEEM TO GET WORSE WHEN HE IS ANGRY. I NOTED THIS WHEN I TOLD HIM THIS IS A NO SMOKING CAMPUS. HE BECAME IRRITATED AND HIS SPEECH BECAME FASTER AND HE SPOKE VERY ANGRILY WITH NONPERSONS WHEN I LEFT TO GET HIM A NICOTINE PATCH. HE REFUSED THE NICOTINE PATCH, STATING HE 'SWALLOWED A GUN' AND DOESN'T WANT TO TAKE ANY NICOTINE INTO HIS BODY..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...Obtain level of care/service unavailable at this facility. Service: Psych [psychiatry]...Receiving Facility...[Hospital B]...Time of Transfer: 1650 [4:50 PM]...Date: 10/23/17..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #1 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 57 hours and 19 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

6. Medical record review revealed Patient #2 presented to the ED at Hospital A on 9/16/17 at 9:22 PM for complaint of " ...Depressed, Suicidal ideation..." Patient #2 had out of state Medicaid insurance.

ED Physician #2's note dated 9/16/17 at 9:48 PM documented ED Physician #2 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #2] brought to emergency department by EMS [emergency medical services] for bizarre behavior, depression and suicidal ideation. Unfortunately the patient is very accelerated, tangential with loose associations and it's very difficult to get a clear history from him. He does state he is suicidal and hopes to kill himself. He is name [has named] several options including lighting himself on fire, stabbing himself, running out in front of traffic, jumping off a building or drowning himself. He has made mention of his girlfriend leaving him and taking his dog but also has mentioned larger social issues such as the government, the military and the devil is being a cause for his frustrations...Focused PE [physical exam]...General/Const [Constitution]...odor of alcohol noted, disheveled with poor hygiene...Psychiatric...Abnormal Mood/Affect...Flight of ideas, Inappropriate, Irritable, Pressured Speech ...Abnormal Thinking/Perception...Suicidal with plan, Judgment abnormal..." Further review of ED Physician #2's note dated 9/16/17 at 11:19 PM revealed, "...Primary Impression: Depression with suicidal ideation...Secondary Impressions: Acute psychosis..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #2 on 9/16/17 at 9:50 PM which documented, "...I certify that this person is subject to involuntary care and treatment ...Depression, tangent thinking, acute mania, suicidal...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Severe depression c [with] SI [suicidal ideation] + plan to kill himself ... Clinical improvement, sx [symptom] reduction...Too high risk + [illegible] for out pt tx [treatment]..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Suicidal ideation...Obtain level of care/service unavailable at this facility. Service: psychiatric services...Receiving Facility...[Hospital B]...Time of Transfer: 0700 [7:00 AM]...Date: 9/20/17..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #2 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 81 hours and 38 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

7. Medical record review revealed Patient #3 presented to the ED at Hospital A on 6/21/17 at 11:11 AM for complaint of "...Hallucinations, auditory, Suicidal ideation..." Patient #3 had TN [Tennessee] Care UHC [United Healthcare] Medicaid insurance.

ED Physician #3's note dated 6/21/17 at 11:25 AM documented ED Physician #3 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...Patient has a history of schizoaffective disorder...has been out of her psychiatric medications for about 3 weeks. She is now having auditory hallucinations with suicidal content. Her hallucinations instruct her to overdose on her remaining medications..." Further review of ED Physician #3's note dated 6/21/17 at 4:35 PM revealed, "...Primary Impression: Schizoaffective disorder...Secondary Impressions: Auditory hallucinations, Suicidal ideation..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by the ED Physician #3 on 6/21/17 at 2:00 PM which documented, "...I certify that this person is subject to involuntary care and treatment...Pt reports a history of schizoaffective disorder...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Pt presents with auditory hallucinations with suicidal content...Pt needs hospitalization for safety and psychiatric stabilization..."

A nurse's note dated 6/21/17 at 11:12 AM documented, "...PER EMS PT [patient] HAS NOT TAKEN HER PSYCH MEDS [medications] FOR 2 WEEKS, 2 DAYS AGO SHE STARTED HEARING VOICES TO OD [overdose] ON HER PILLS AND KILL HERSELF. PT STATES THAT SHE IS SEEING THE DEVIL..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Psychosis, SI [suicidal ideation]...Obtain level of care/service unavailable at this facility. Service: psych...Receiving Facility...[Hospital B]...Date: 6-24-17...Time: 1610 [4:10 PM]..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #3 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 76 hours and 59 minutes.

8. Medical record review revealed Patient #4 presented to the ED at Hospital A on 2/17/17 at 1:54 PM for complaint of " ...Depressed ..." Patient #4 had TN Care Bluecare Medicaid insurance.

ED Physician #4's note dated 2/17/17 at 2:11 PM documented ED Physician #4 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...HAS BEEN OFF MEDS FOR ABOUT 6 WEEKS AND HAVING SI CURRENTLY. HX OF THE SAME WITH ATTEMPTS MORE THAN ONCE IN THE PAST..." Further review of ED Physician #4's note dated 2/17/17 at 4:38 PM revealed, "...WILL NEED PSYCH EVAL [evaluation] AND 6404 SINCE DANGER TO SELF...Primary Impression...Adjustment disorder with depressed mood..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #4 on 2/17/17 at 2:15 PM which documented, "...I certify that this person is subject to involuntary care and treatment...HISTORY OF DEPRESSION...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Deterioration due to mental illness to point of inability to care [for] self, at significant risk to health...Treatment likely to prove beneficial in symptom reduction...Condition is likely to deteriorate further without treatment...Adequate evaluation requires a secure setting..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Depression, SI...Obtain level of care/service unavailable at this facility. Service: Psychiatric Care...Receiving Facility...[Hospital B]...Time of Transfer: 1022 [10:22 AM]...Date: 2-20-17 [2/21/17]..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #4 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 92 hours and 28 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

9. Medical record review revealed Patient #5 presented to the ED at Hospital A on 2/20/17 at 1:16 PM for complaint of " ...Suicidal ideation ..." Patient #5 had TN Care Bluecare Medicaid insurance.

ED Physician #5's note dated 2/20/17 at 1:34 PM documented ED Physician #5 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #5] requesting heroin detox [detoxification]. Is also suicidal - states she wants to blow her brains out with a gun..." Further review of ED Physician #5's note dated 2/20/17 at 2:37 PM revealed, "...Will require psychiatric evaluation...Primary Impression: Suicidal ideation..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #5 on 2/20/17 at 1:30 PM which documented, "...I certify that this person is subject to involuntary care and treatment...Previous psychiatric hospitalizations...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Suicidal ideation with a well-formed plan for self harm as follows: Using firearm...Habitual use of drugs to the point of deterioration or death...In my opinion, the patient is at continued risk of self-harm in not placed under involuntary committment [commitment]...Condition is likely to deteriorate further without treatment...Treatment likely to prove beneficial in symptom reduction...Inability to contract for safety..."

A nurse's note dated 2/20/17 at 1:21 PM documented, "...PT VERBALIZES MULTIPLE DRUG USE HISTORY, PT STATES SUICIDAL IDEATION, STATES 'I DONT WANNA LIVE ANYMORE'..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: SI...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital B]...Time of Transfer: 1025 [10:25 AM]...Date: 2/24/17..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #5 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 94 hours and 9 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

10. Medical record review revealed Patient #6 presented to the ED at Hospital A on 5/19/17 at 7:07 PM for complaint of " ...Suicidal ideation ..." Patient #6 had TN Care UHC Medicaid insurance.

ED Physician #6's note dated 5/19/17 at 7:27 PM rdocumented ED Physician #6 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #6] WITH HX OF BIPOLAR DISORDER WHO PRESENTS WITH SUICIDAL IDEATION WITH PLANS TO OVERDOSE WITH MEDICATION..." Further review of a physician's note dated 5/19/17 at 10:19 PM revealed, "...Primary Impression: Suicidal ideation..." Further review of ED Physician #6's note dated 5/23/17 at 4:36 AM revealed, "...Pt unable to go to [Hospital B] 2/2 [secondary to] PICC [peripherally inserted central catheter] which was initially not conveyed to us, now pt on list for [Hospital A psychiatric campus] in am [AM]..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by Licensed Professional Counselor #1 on 5/19/17 at 2:15 PM which documented, "...I certify that this person is subject to involuntary care and treatment...History of psychiatric hospitalizations at [Hospital D], [Hospital E] & [Hospital A's psychiatric campus]...current diagnosis of Schizophrenia & Mood Disorder NOS [not otherwise specified]...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Patient has SI w/ plan to OD on medication, slit wrists, or walk into traffic...Patient has continued access to lethal means...In my opinion patient poses an imminent threat to self if not placed under an involuntary commitment...Treatment likely to prove beneficial in symptom reduction...Current presentation places self & others at too high risk of injury..."

A nurse's note dated 5/19/17 at 7:10 PM documented, "...PER EMS, PT HERE WITH SI, NEEDS CLEARANCE FOR [Hospital A's psychiatric campus]...PT HAS PLAN TO OVERDOSE WITH PILLS...PICC LINE TO LEFT AC [antecubital]..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Suicidal ideation...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital B]...Time of Transfer: 0225 [2:25 AM]...Date: 5/23/17..." Further review of an "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Suicidal...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital A's psychiatric campus]...Time of Transfer: 1300 [1:00 PM]...Date: 5/24/17..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #6 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 113 hours and 53 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

11. Medical record review revealed Patient #7 presented to the ED at Hospital A on 9/28/17 at 5:37 PM for complaint of " ...Altered mental status ..." Patient #7 was uninsured.

ED Physician #7's note dated 9/28/17 at 8:20 PM documented ED Physician #7 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #7] was seen earlier today by mobile crisis for unclear reason, was cleared home with his mother, and mother later called EMS for continued altered mental status...EXAM...NEURO [neurological]...Questionably intoxicated on marijuana with giggles and perseveration on the connectedness of life...PSYCH...Poor insight and judgment...Speaking to visual hallucinations when left alone in the room which is not consistent with simple marijuana intoxication..." Further review of ED Physician #7's note dated 9/28/17 at 11:37 PM revealed, "...Primary Impression: Acute psychosis...Secondary Impressions: Marijuana use..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #7 on 9/28/17 at 6:00 PM which documented, "...I certify that this person is subject to involuntary care and treatment...no reported psychiatric diagnosis...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...acute psychosis...Would benefit from psychiatric care including symptom reduction...Unable to treat as an outpatient..."

A nurse's note dated 9/28/17 at 6:50 PM documented, "...MOTHER STATES 'HE IS JUST NOT RIGHT, HE WAS ADMITTED TO AN ER ON TUESDAY, EVALUATED BY MOBILE CRISIS AND SENT TO [Hospital B] AND THE PSYCHIATRIST EVALUATED HIM THERE AND SENT HIM HOME STATING THAT HE JUST NEEDED TO DETOX [detoxify] FROM POT, BUT I KNOW SOMETHING IS JUST OFF WITH HIM'..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by ED Physician #8 revealed, "...MEDICAL CONDITION: Diagnosis: Acute psychosis...Obtain level of care/service unavailable at this facility. Service: Psychiatry...Receiving Facility...[Hospital B]...Time of Transfer: 2200 [10:00 PM]...Date: 10/1/17..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #7 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 76 hours and 23 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

12. Medical record review revealed Patient #8 presented to the ED at Hospital A on 7/17/17 at 5:13 PM for complaint of "...I want to detox from alcohol..." Patient #8 was uninsured.

ED Physician #8's note dated 7/17/17 at 5:40 PM documented ED Physician #8 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #8] states he needs help to get off alcohol because he is afraid that he will die if he does not stop drinking...He has been to rehabilitation recently and just started drinking again about 3 weeks ago..." Further review of a physician's note dated 7/17/17 at 8:00 PM revealed, "...case manager spoke with the patient about options for outpatient detox. After this the patient stated he wanted to lay down on the railroad tracks or walk into traffic if he was discharged from the ED today..." Further review of ED Physician #8's note dated 7/17/17 at 8:30 PM revealed, "...the patient is now extremely agitated and has been threatening multiple staff members..." Further review of a physician's note dated 7/18/17 at 12:36 AM revealed, "...Primary Impression: Depression...Secondary Impressions: Alcohol abuse, Suicidal ideation..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #8 on 7/17/17 at 8:00 PM which documented, "...I certify that this person is subject to involuntary care and treatment...Active symptoms of psychiatric disorder as noted: suicidal ideation, depression...Reported history of behaviors clinically indicative of a psychiatric disorder...Reported or clinically suspected substance dependence...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Suicidal ideation with well-formed plan for self harm as follows: Walking into active traffic or lay on railroad tracks...In my opinion, the patient is at continued risk of harm to others if not placed under involuntary commitment...Condition is likely to deteriorate further without treatment ...Treatment likely to prove beneficial in symptom reduction...Adequate evaluation requires a secure setting..."

A nurse's note dated 7/17/17 at 5:30 PM documented, "...PT IS ALCOHOLIC, DRINKS BEER EVERY DAY AND TIRED OF LIVING THIS WAY, HAS HAD SI, WENT THROUGH 30 DAY REHAB [rehabilitation] IN THE PAST AND RELAPSED, STATES HE HAS HAD A LOT TO DRINK TODAY..." Further review of a nurse's note dated 7/17/17 at 5:36 PM revealed, "...SUICIDE ASSESSMENT...PATIENT SAYS THAT HE WISHES HE WAS NEVER BORN...PATIENT STATED THAT HE LOST HIS JOB RECENTLY..."

Review of the Emergency Notes revealed the following: "...07/17/17 2003 [8:03 PM]...MD ASKED ME TO GIVE RESOURCES TO THIS PATIENT FOR SUBSTANCE ABUSE. I WALKED UP TO HIS BEDSIDE AND HE WAS ON HIS PHONE WITH A NURSE AT ANOTHER [Hospital A's corporation] FACILITY WHERE HIS SIGNIFICANT OTHER IS LOCATED. THE NURSE ON THE PHONE WAS GIVING INSTRUCTION THAT THEY DO NOT HAVE PHONES IN THE ROOM AND HIS SIGNIFICANT OTHER WAS GIVEN HIS MESSAGE. THIS MAN SCREAMED OUT AT THE NURSE (I HEARD ALL THIS COMMOTION AS HE HAD HIS PHONE ON SPEAKER). HE SCREAMED THAT SHE WAS VIOLATING HIS CIVIL RIGHTS AND CURSED HER WITH A 'FUCK YOU! I KNOW MY RIGHTS AND ILL [I'll] HAVE YOU REPORTED. I AM A SECURITY GUARD AT DILLARD AND I KNOW WHO TO CALL!' I WAS AT HIS BEDSIDE WHEN HE GOT OFF THE PHONE-AND HE WAS VERY ANGRY WITH THE ANSWER HE GOT FROM ANOTHER FACILITY. HE IMMEDIATELY STARTED BEING BELLIGERENT WITH ME. HE ASKED ME 'WHAT THE HELL DO YOU WANT?' I TRIED TO RE-DIRECT AND SPOKE OF A POSITIVE ANSWER FOR HIS NEEDS OF FINDING A DETOX BED FOR HIS SUBSTANCE ABUSE. HE HAS TOLD MD THAT HE WAS NOT SUICIDAL AND WAS NOT HOMICIDAL. NOW, HE WANTS TO 'LAY ON THE RAILROAD TRACKS' OR JUMP INTO TRAFFIC! HE SAID I HAVE NO PLACE TO GO AND NOW 'SHE-(SIGNIFICANT OTHER) IS GOING TO GET A PLACE FOR HER PROBLEM SO I AM SUICIDAL. I DON'T WANT TO LEAVE NOW. IF I LEAVE I WILL HURT MYSELF!' I LET MD KNOW. HER PLANS WILL BE TO COMPLETE AN [a] 6404 AND WILL KNOWLEDGE THAT IT WILL BE RESCINDED WITH PLANS FROM MOBILE CRISIS. SECURITY AWARE AND NURSES AWARE...07/17/17 2028 [8:28 PM]...THIS PATIENT IS NOW DEMANDING TO LEAVE AND IS CALLING 'SOMEONE' TO COME PICK HIM UP. SECURITY NOTIFIED. THIS PATIENT AGGRESSIVE AT BEDSIDE. THREATENING TO NOW 'LEAVE, AND SO WHATEVER HE NEEDS TO DO TO GET OUT OF HERE' BODY LANGUAGE AGGRESSIVE WITH FINGERS GOING INTO A FIST, AND OPENING THE FIST FOR US TO SEE THE INTENT. MD AWARE. HE TORE HIS GOWN OFF AND THREW IN THE FLOOR, DEMANDED HIS PHONE. DEMANDED HIS RIGHTS BE 'UPHELD'...07/18/17 0425 [4:25 AM] THIS PATIENT IS NOW MEDICALLY CLEARED AND READY FOR PSYCH PROCESS TO BEGIN...HE IS ASKING WHY HE IS HERE. I WILL DISCUSS THIS CASE WITH MD..."

Rreview of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Suicidal Ideation...Obtain level of care/service unavailable at this facility. Service: Psychiatric Care...Receiving Facility...[Hospital B]...Time of Transfer: 0425 [4:25 AM]...Date: 7-21-17..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #8 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 83 hours and 12 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

13. Medical record review revealed Patient #9 presented to the ED at Hospital A on 7/16/17 at 5:25 AM for complaint of "...PSYCH..." Patient #9 was uninsured.

ED Physician #7's note dated 7/16/17 at 5:41 PM documented ED Physician #7 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #9] with known anxiety disorder and major depressive disorder reports weeks of worsening depressed mood, especially bad in the last few days with suicidal ideation including a plan to shoot herself or record car [wreck her]...PSYCH...Tearful, actively suicidal...Marginal insight and judgment..." Further review of ED Physician #7's note dated 7/17/17 at 6:00 AM revealed, "Additional Medical History...Anxiety, depression, hypothyroidism, cavernous hemangioma, seizures, hypertension, chronic pain, migraines, fibromyalgia...6404 was filed by myself for suicidal ideation. She has already been evaluated by mobile crisis who feels that she needs inpatient treatment...Primary Impression: Suicidal ideation...Secondary Impressions: Migraine..."

A Certificate of Need for Emergency Involuntary Admission (6404) was not present in the patient's medical record.

A nurse's note dated 7/16/17 at 5:28 AM documented, "...SENT FROM [Hospital A's psychiatric campus] FOR CLEARANCE AND PLACEMENT..." Further review of a nurse's note dated 7/16/17 at 5:49 AM revealed, "...SUICIDE ASSESSMENT...PT STATES SHES BEEN HAVING THESE THOUGHTS FOR ABOUT A WEEK...PT STATES SHE HAS PLANS 'DIFFERENT OPTIONS' BUT HAS BEEN TRYING TO FIGHT THEM OFF..."

Rreview of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: SI...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital B]...Time of Transfer: 1646 [4:46 PM]...Date: 7-19-17..."

There was no documentation the on-call psychiatrist had performed an assessment of Patient #9 or provided stabilizing treatment of the patient's psychiatric issue while the patient was in Hospital A's ED for 59 hours and 21 minutes. There was no documentation why the patient was not admitted to the hospital's psychiatric unit.

14. Medical record review revealed Patient #10 presented to the ED at Hospital A on 10/13/17 at 10:06 PM for complaint of "...bipolar disorder..." Patient #10 was uninsured.

ED Physician #9's note dated 10/13/17 at 10:57 PM documented ED Physician #9 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #10] presents today with issues with bipolar disorder. Family member is here and says he has been delusional. He has been giving his money away to people. this has made him homeless. He also sent them a note saying he is suicidal..." Further review of ED Physician #9's note dated 10/14/17 at 12:37 AM revealed, "...history of bipolar. off meds. delusional, destructive behavior. evidence of psychosis...Primary Impression: Bipolar disorder..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #9 on 10/14/17 at 12:35 AM which documented, "...I certify that this person is subject to involuntary care and treatment...Active symptoms of psychiatric disorder as noted: suicidal ideation, depression...bipolar history off meds...delusional behavior, psychosis, giving away money, reckless behavior...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...worsening psychosis 2/2 [se

Based on review of facility policies, Medical Staff Bylaws, Medical Staff Rules and Regulations, Medical Staff On-Call Schedules, medical record review and interview, the facility failed to ensure on-call psychiatrists performed an adequate assessment to determine the necessary treatment to stabilize signs/symptoms of psychiatric conditions for 30 of 32 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) patient records reviewed who had presented to the ED seeking treatment.

The findings included:

1. Review of the facilty's "EMTALA [Emergency Medical Treatment and Labor Act] Tennessee Medical Screening Examination and Stabilization Policy revealed, "...To establish guidelines for providing appropriate medical screening examinations ("MSE") and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ("DED")...The MSE must be completed by an individual...qualified to perform such an examination to determine whether an EMC [emergency medical condition) exists ...If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity of the facility, or an appropriate transfer as defined by and required by EMTALA. Stabilizing treatment shall be applied in a non-discriminatory manner...no different level of care because of...payment source or ability, or any other basis prohibited by federal, state or local law..."

Review of the facility's "EMTALA Transfer Policy" revealed, "...To establish guidelines for...providing an appropriate transfer to another facility of an individual with an emergency medical condition ("EMC"), who requests or requires a transfer for further medical care and follow-up to a receiving facility ...Transfer of Individuals Who Have Not Been Stabilized...If an individual who has come to the emergency department has an EMC that has not been stabilized, the hospital may transfer the individual only if the transfer is an appropriate transfer...Higher Level of Care...A receiving hospital with specialized capabilities or facilities that are not at the transferring hospital (including...behavioral health units...) must accept an appropriate transfer of an individual with an EMC who requires specialized capabilities or facilities if the hospital has the capacity to treat the individual..."

2. Review of the facility's "MEDICAL STAFF BYLAWS" reviewed 7/19/16 revealed, "...The Medical Staff shall provide services as applicable, to patients admitted or otherwise treated at [Hospital A] which includes the [Hospital A's psychiatric campus]...To provide patients with the quality of care that is commensurate with acceptable standards and available community services...To monitor and enforce compliance with these Bylaws, Rules and Regulations and hospital policies..."

3. Review of the facility's "MEDICAL STAFF RULES AND REGULATIONS" reviewed 7/19/16 revealed, "...EMERGENCY SERVICES...All persons seeking emergency services and care will receive a medical screening examination and evaluation by a physician or a qualified medical person as designated by hospital policy...If the physician on call is requested by the emergency department physician to see an unassigned patient who has presented to the emergency department for treatment or evaluation, the on call physician must respond, regardless of the patient's ability to pay for any service...Patients with conditions whose definitive care is beyond the capabilities of the Hospital shall be referred to the appropriate facility, when in the judgment of the attending Physician the patient's condition permits such a transfer. Patient transfers shall be in accordance with EMTALA regulations..."

4. Review of the facility on-call schedule revealed a psychiatrist was on call 24 hours a day 7 days a week during the time each of the 30 of 32 patients were in the ED.

5. Medical record review revealed Patient #1 presented to the Emergency Department (ED) at Hospital A on 10/21/17 at 7:31 AM for complaint of "...Aggressive behavior, Hallucinations, auditory, schizophrenia..." Patient #1 had out of state Medicaid insurance.

Physician Assistant #1's note dated 10/21/17 at 7:58 AM documented Physician Assistant #1 initiated a Medical Screening Examination (MSE) which included: a History of Present Illness (HPI), a Risk of Psychiatric Illness, a Review of Systems (ROS), a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...He [Patient #1] is evasive with questions, but upon further discussions with family, they state that he has been having difficulties with voices, commands, and auditory hallucinations. He has been more aggressive recently and is hard to control at home. They attempted to take him to [Hospital A's psychiatric campus], but was instructed to come to the emergency department for medical clearance..." Further review of Physician Assistant #1's note dated 10/21/17 at 4:05 PM revealed, "...Patient is having acute psychosis, with auditory hallucinations. Patient needs completion of psychiatric monitoring and treatment to ensure stabilization...Primary Impression: Acute psychosis ...Secondary Impressions: Auditory hallucinations, Schizophrenia..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #1 on 10/21/17 at 8:00 AM which documented, "...I certify that this person is subject to involuntary care and treatment...Hx [history] of schizophrenia...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Acute psychosis with auditory hallucinations...Treatment may reduce symptoms...Patient needs safe place for treatment..."

A nurse's note dated 10/21/17 at 8:25 AM documented, "...FAMILY IS CONCERNED FOR HIS INCREASE IN AGITATION, DECREASED SLEEP. STATES HE STAYS UP LATE PACING AROUND AND TALKS TO 'THE VOICES.' HIS MOM STATES HE HAS BEEN AGITATED ALTELY [lately] AND HAS BEEN KNOWN TO ATTACK OBJECTS. STATES HIS AUDITORY HALLUCINATIONS SEEM TO GET WORSE WHEN HE IS ANGRY. I NOTED THIS WHEN I TOLD HIM THIS IS A NO SMOKING CAMPUS. HE BECAME IRRITATED AND HIS SPEECH BECAME FASTER AND HE SPOKE VERY ANGRILY WITH NONPERSONS WHEN I LEFT TO GET HIM A NICOTINE PATCH. HE REFUSED THE NICOTINE PATCH, STATING HE 'SWALLOWED A GUN' AND DOESN'T WANT TO TAKE ANY NICOTINE INTO HIS BODY..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...Obtain level of care/service unavailable at this facility. Service: Psych [psychiatry]...Receiving Facility...[Hospital B]...Time of Transfer: 1650 [4:50 PM]...Date: 10/23/17..."

There was no documentation the on-call psychiatrist performed an assessment of Patient #1 to determine the treatment necessary to stabilize the patient's psychiatric condition while Patient #1 was in the ED 57 hours and 19 minutes awaiting placement/transfer to an inpatient psychiatric facility.

6. Medical record review revealed Patient #2 presented to the ED at Hospital A on 9/16/17 at 9:22 PM for complaint of " ...Depressed, Suicidal ideation..." Patient #2 had out of state Medicaid insurance.

ED Physician #2's note dated 9/16/17 at 9:48 PM documented ED Physician #2 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #2] brought to emergency department by EMS [emergency medical services] for bizarre behavior, depression and suicidal ideation. Unfortunately the patient is very accelerated, tangential with loose associations and it's very difficult to get a clear history from him. He does state he is suicidal and hopes to kill himself. He is name [has named] several options including lighting himself on fire, stabbing himself, running out in front of traffic, jumping off a building or drowning himself. He has made mention of his girlfriend leaving him and taking his dog but also has mentioned larger social issues such as the government, the military and the devil is being a cause for his frustrations...Focused PE [physical exam]...General/Const [Constitution]...odor of alcohol noted, disheveled with poor hygiene...Psychiatric...Abnormal Mood/Affect...Flight of ideas, Inappropriate, Irritable, Pressured Speech ...Abnormal Thinking/Perception...Suicidal with plan, Judgment abnormal..." Further review of ED Physician #2's note dated 9/16/17 at 11:19 PM revealed, "...Primary Impression: Depression with suicidal ideation...Secondary Impressions: Acute psychosis..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #2 on 9/16/17 at 9:50 PM which documented, "...I certify that this person is subject to involuntary care and treatment ...Depression, tangent thinking, acute mania, suicidal...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Severe depression c [with] SI [suicidal ideation] + plan to kill himself ... Clinical improvement, sx [symptom] reduction...Too high risk + [illegible] for out pt tx [treatment]..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Suicidal ideation...Obtain level of care/service unavailable at this facility. Service: psychiatric services...Receiving Facility...[Hospital B]...Time of Transfer: 0700 [7:00 AM]...Date: 9/20/17..."

There was no documentation the on-call psychiatrist performed an assessment of Patient #2 to determine the treatment necessary to stabilize the patient's psychiatric condition while Patient #2 was in the ED 81 hours and 38 minutes awaiting placement/transfer to an inpatient psychiatric facility.

7. Medical record review revealed Patient #3 presented to the ED at Hospital A on 6/21/17 at 11:11 AM for complaint of "...Hallucinations, auditory, Suicidal ideation..." Patient #3 had TN [Tennessee] Care UHC [United Healthcare] Medicaid insurance.

ED Physician #3's note dated 6/21/17 at 11:25 AM documented ED Physician #3 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...Patient has a history of schizoaffective disorder...has been out of her psychiatric medications for about 3 weeks. She is now having auditory hallucinations with suicidal content. Her hallucinations instruct her to overdose on her remaining medications..." Further review of ED Physician #3's note dated 6/21/17 at 4:35 PM revealed, "...Primary Impression: Schizoaffective disorder...Secondary Impressions: Auditory hallucinations, Suicidal ideation..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by the ED Physician #3 on 6/21/17 at 2:00 PM which documented, "...I certify that this person is subject to involuntary care and treatment...Pt reports a history of schizoaffective disorder...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Pt presents with auditory hallucinations with suicidal content...Pt needs hospitalization for safety and psychiatric stabilization..."

A nurse's note dated 6/21/17 at 11:12 AM documented, "...PER EMS PT [patient] HAS NOT TAKEN HER PSYCH MEDS [medications] FOR 2 WEEKS, 2 DAYS AGO SHE STARTED HEARING VOICES TO OD [overdose] ON HER PILLS AND KILL HERSELF. PT STATES THAT SHE IS SEEING THE DEVIL..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Psychosis, SI [suicidal ideation]...Obtain level of care/service unavailable at this facility. Service: psych...Receiving Facility...[Hospital B]...Date: 6-24-17...Time: 1610 [4:10 PM]..."

There was no documentation the on-call psychiatrist performed an assessment of Patient #3 to determine the treatment necessary to stabilize the patient's psychiatric condition while Patient #3 was in the ED 76 hours and 59 minutes awaiting placement/transfer to an inpatient psychiatric facility.

8. Medical record review revealed Patient #4 presented to the ED at Hospital A on 2/17/17 at 1:54 PM for complaint of " ...Depressed ..." Patient #4 had TN Care Bluecare Medicaid insurance.

ED Physician #4's note dated 2/17/17 at 2:11 PM documented ED Physician #4 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...HAS BEEN OFF MEDS FOR ABOUT 6 WEEKS AND HAVING SI CURRENTLY. HX OF THE SAME WITH ATTEMPTS MORE THAN ONCE IN THE PAST..." Further review of ED Physician #4's note dated 2/17/17 at 4:38 PM revealed, "...WILL NEED PSYCH EVAL [evaluation] AND 6404 SINCE DANGER TO SELF...Primary Impression...Adjustment disorder with depressed mood..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #4 on 2/17/17 at 2:15 PM which documented, "...I certify that this person is subject to involuntary care and treatment...HISTORY OF DEPRESSION...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Deterioration due to mental illness to point of inability to care [for] self, at significant risk to health...Treatment likely to prove beneficial in symptom reduction...Condition is likely to deteriorate further without treatment...Adequate evaluation requires a secure setting..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Depression, SI...Obtain level of care/service unavailable at this facility. Service: Psychiatric Care...Receiving Facility...[Hospital B]...Time of Transfer: 1022 [10:22 AM]...Date: 2-20-17 [2/21/17]..."

There was no documentation the on-call psychiatrist performed an assessment of Patient #4 to determine the treatment necessary to stabilize the patient's psychiatric condition while Patient #4 was in the ED 92 hours and 28 minutes awaiting placement/transfer to an inpatient psychiatric facility.

9. Medical record review revealed Patient #5 presented to the ED at Hospital A on 2/20/17 at 1:16 PM for complaint of " ...Suicidal ideation ..." Patient #5 had TN Care Bluecare Medicaid insurance.

ED Physician #5's note dated 2/20/17 at 1:34 PM documented ED Physician #5 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #5] requesting heroin detox [detoxification]. Is also suicidal - states she wants to blow her brains out with a gun..." Further review of ED Physician #5's note dated 2/20/17 at 2:37 PM revealed, "...Will require psychiatric evaluation...Primary Impression: Suicidal ideation..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #5 on 2/20/17 at 1:30 PM which documented, "...I certify that this person is subject to involuntary care and treatment...Previous psychiatric hospitalizations...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Suicidal ideation with a well-formed plan for self harm as follows: Using firearm...Habitual use of drugs to the point of deterioration or death...In my opinion, the patient is at continued risk of self-harm in not placed under involuntary committment [commitment]...Condition is likely to deteriorate further without treatment...Treatment likely to prove beneficial in symptom reduction...Inability to contract for safety..."

A nurse's note dated 2/20/17 at 1:21 PM documented, "...PT VERBALIZES MULTIPLE DRUG USE HISTORY, PT STATES SUICIDAL IDEATION, STATES 'I DONT WANNA LIVE ANYMORE'..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: SI...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital B]...Time of Transfer: 1025 [10:25 AM]...Date: 2/24/17..."

There was no documentation the on-call psychiatrist performed an assessment of Patient #5 to determine the treatment necessary to stabilize the patient's psychiatric condition while Patient #5 was in the ED 94 hours and 9 minutes awaiting placement/transfer to an inpatient psychiatric facility.

10. Medical record review revealed Patient #6 presented to the ED at Hospital A on 5/19/17 at 7:07 PM for complaint of " ...Suicidal ideation ..." Patient #6 had TN Care UHC Medicaid insurance.

ED Physician #6's note dated 5/19/17 at 7:27 PM documented ED Physician #6 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #6] WITH HX OF BIPOLAR DISORDER WHO PRESENTS WITH SUICIDAL IDEATION WITH PLANS TO OVERDOSE WITH MEDICATION..." Further review of a physician's note dated 5/19/17 at 10:19 PM revealed, "...Primary Impression: Suicidal ideation..." Further review of ED Physician #6's note dated 5/23/17 at 4:36 AM revealed, "...Pt unable to go to [Hospital B] 2/2 [secondary to] PICC [peripherally inserted central catheter] which was initially not conveyed to us, now pt on list for [Hospital A psychiatric campus] in am [AM]..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by Licensed Professional Counselor #1 on 5/19/17 at 2:15 PM which documented, "...I certify that this person is subject to involuntary care and treatment...History of psychiatric hospitalizations at [Hospital D], [Hospital E] & [Hospital A's psychiatric campus]...current diagnosis of Schizophrenia & Mood Disorder NOS [not otherwise specified]...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Patient has SI w/ plan to OD on medication, slit wrists, or walk into traffic...Patient has continued access to lethal means...In my opinion patient poses an imminent threat to self if not placed under an involuntary commitment...Treatment likely to prove beneficial in symptom reduction...Current presentation places self & others at too high risk of injury..."

A nurse's note dated 5/19/17 at 7:10 PM documented, "...PER EMS, PT HERE WITH SI, NEEDS CLEARANCE FOR [Hospital A's psychiatric campus]...PT HAS PLAN TO OVERDOSE WITH PILLS...PICC LINE TO LEFT AC [antecubital]..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Suicidal ideation...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital B]...Time of Transfer: 0225 [2:25 AM]...Date: 5/23/17..." Further review of an "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Suicidal...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital A's psychiatric campus]...Time of Transfer: 1300 [1:00 PM]...Date: 5/24/17..."

There was no documentation the on-call psychiatrist performed an assessment of Patient #6 to determine the treatment necessary to stabilize the patient's psychiatric condition while Patient #6 was in the ED 113 hours and 53 minutes awaiting placement/transfer to an inpatient psychiatric facility.

11. Medical record review revealed Patient #7 presented to the ED at Hospital A on 9/28/17 at 5:37 PM for complaint of " ...Altered mental status ..." Patient #7 was uninsured.

ED Physician #7's note dated 9/28/17 at 8:20 PM documented ED Physician #7 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #7] was seen earlier today by mobile crisis for unclear reason, was cleared home with his mother, and mother later called EMS for continued altered mental status...EXAM...NEURO [neurological]...Questionably intoxicated on marijuana with giggles and perseveration on the connectedness of life...PSYCH...Poor insight and judgment...Speaking to visual hallucinations when left alone in the room which is not consistent with simple marijuana intoxication..." Further review of ED Physician #7's note dated 9/28/17 at 11:37 PM revealed, "...Primary Impression: Acute psychosis...Secondary Impressions: Marijuana use..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #7 on 9/28/17 at 6:00 PM which documented, "...I certify that this person is subject to involuntary care and treatment...no reported psychiatric diagnosis...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...acute psychosis...Would benefit from psychiatric care including symptom reduction...Unable to treat as an outpatient..."

A nurse's note dated 9/28/17 at 6:50 PM documented, "...MOTHER STATES 'HE IS JUST NOT RIGHT, HE WAS ADMITTED TO AN ER ON TUESDAY, EVALUATED BY MOBILE CRISIS AND SENT TO [Hospital B] AND THE PSYCHIATRIST EVALUATED HIM THERE AND SENT HIM HOME STATING THAT HE JUST NEEDED TO DETOX [detoxify] FROM POT, BUT I KNOW SOMETHING IS JUST OFF WITH HIM'..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by ED Physician #8 revealed, "...MEDICAL CONDITION: Diagnosis: Acute psychosis...Obtain level of care/service unavailable at this facility. Service: Psychiatry...Receiving Facility...[Hospital B]...Time of Transfer: 2200 [10:00 PM]...Date: 10/1/17..."

There was no documentation the on-call psychiatrist performed an assessment of Patient #7 to determine the treatment necessary to stabilize the patient's psychiatric condition while Patient #7 was in the ED 76 hours and 23 minutes awaiting placement/transfer to an inpatient psychiatric facility.

12. Medical record review revealed Patient #8 presented to the ED at Hospital A on 7/17/17 at 5:13 PM for complaint of "...I want to detox from alcohol..." Patient #8 was uninsured.

ED Physician #8's note dated 7/17/17 at 5:40 PM documented ED Physician #8 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #8] states he needs help to get off alcohol because he is afraid that he will die if he does not stop drinking...He has been to rehabilitation recently and just started drinking again about 3 weeks ago..." Further review of a physician's note dated 7/17/17 at 8:00 PM revealed, "...case manager spoke with the patient about options for outpatient detox. After this the patient stated he wanted to lay down on the railroad tracks or walk into traffic if he was discharged from the ED today..." Further review of ED Physician #8's note dated 7/17/17 at 8:30 PM revealed, "...the patient is now extremely agitated and has been threatening multiple staff members..." Further review of a physician's note dated 7/18/17 at 12:36 AM revealed, "...Primary Impression: Depression...Secondary Impressions: Alcohol abuse, Suicidal ideation..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #8 on 7/17/17 at 8:00 PM which documented, "...I certify that this person is subject to involuntary care and treatment...Active symptoms of psychiatric disorder as noted: suicidal ideation, depression...Reported history of behaviors clinically indicative of a psychiatric disorder...Reported or clinically suspected substance dependence...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Suicidal ideation with well-formed plan for self harm as follows: Walking into active traffic or lay on railroad tracks...In my opinion, the patient is at continued risk of harm to others if not placed under involuntary commitment...Condition is likely to deteriorate further without treatment ...Treatment likely to prove beneficial in symptom reduction...Adequate evaluation requires a secure setting..."

A nurse's note dated 7/17/17 at 5:30 PM documented, "...PT IS ALCOHOLIC, DRINKS BEER EVERY DAY AND TIRED OF LIVING THIS WAY, HAS HAD SI, WENT THROUGH 30 DAY REHAB [rehabilitation] IN THE PAST AND RELAPSED, STATES HE HAS HAD A LOT TO DRINK TODAY..." Further review of a nurse's note dated 7/17/17 at 5:36 PM revealed, "...SUICIDE ASSESSMENT...PATIENT SAYS THAT HE WISHES HE WAS NEVER BORN...PATIENT STATED THAT HE LOST HIS JOB RECENTLY..."

Review of the Emergency Notes revealed the following: "...07/17/17 2003 [8:03 PM]...MD ASKED ME TO GIVE RESOURCES TO THIS PATIENT FOR SUBSTANCE ABUSE. I WALKED UP TO HIS BEDSIDE AND HE WAS ON HIS PHONE WITH A NURSE AT ANOTHER [Hospital A's corporation] FACILITY WHERE HIS SIGNIFICANT OTHER IS LOCATED. THE NURSE ON THE PHONE WAS GIVING INSTRUCTION THAT THEY DO NOT HAVE PHONES IN THE ROOM AND HIS SIGNIFICANT OTHER WAS GIVEN HIS MESSAGE. THIS MAN SCREAMED OUT AT THE NURSE (I HEARD ALL THIS COMMOTION AS HE HAD HIS PHONE ON SPEAKER). HE SCREAMED THAT SHE WAS VIOLATING HIS CIVIL RIGHTS AND CURSED HER WITH A 'FUCK YOU! I KNOW MY RIGHTS AND ILL [I'll] HAVE YOU REPORTED. I AM A SECURITY GUARD AT DILLARD AND I KNOW WHO TO CALL!' I WAS AT HIS BEDSIDE WHEN HE GOT OFF THE PHONE-AND HE WAS VERY ANGRY WITH THE ANSWER HE GOT FROM ANOTHER FACILITY. HE IMMEDIATELY STARTED BEING BELLIGERENT WITH ME. HE ASKED ME 'WHAT THE HELL DO YOU WANT?' I TRIED TO RE-DIRECT AND SPOKE OF A POSITIVE ANSWER FOR HIS NEEDS OF FINDING A DETOX BED FOR HIS SUBSTANCE ABUSE. HE HAS TOLD MD THAT HE WAS NOT SUICIDAL AND WAS NOT HOMICIDAL. NOW, HE WANTS TO 'LAY ON THE RAILROAD TRACKS' OR JUMP INTO TRAFFIC! HE SAID I HAVE NO PLACE TO GO AND NOW 'SHE-(SIGNIFICANT OTHER) IS GOING TO GET A PLACE FOR HER PROBLEM SO I AM SUICIDAL. I DON'T WANT TO LEAVE NOW. IF I LEAVE I WILL HURT MYSELF!' I LET MD KNOW. HER PLANS WILL BE TO COMPLETE AN [a] 6404 AND WILL KNOWLEDGE THAT IT WILL BE RESCINDED WITH PLANS FROM MOBILE CRISIS. SECURITY AWARE AND NURSES AWARE...07/17/17 2028 [8:28 PM]...THIS PATIENT IS NOW DEMANDING TO LEAVE AND IS CALLING 'SOMEONE' TO COME PICK HIM UP. SECURITY NOTIFIED. THIS PATIENT AGGRESSIVE AT BEDSIDE. THREATENING TO NOW 'LEAVE, AND SO WHATEVER HE NEEDS TO DO TO GET OUT OF HERE' BODY LANGUAGE AGGRESSIVE WITH FINGERS GOING INTO A FIST, AND OPENING THE FIST FOR US TO SEE THE INTENT. MD AWARE. HE TORE HIS GOWN OFF AND THREW IN THE FLOOR, DEMANDED HIS PHONE. DEMANDED HIS RIGHTS BE 'UPHELD'...07/18/17 0425 [4:25 AM] THIS PATIENT IS NOW MEDICALLY CLEARED AND READY FOR PSYCH PROCESS TO BEGIN...HE IS ASKING WHY HE IS HERE. I WILL DISCUSS THIS CASE WITH MD..."

Rreview of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Suicidal Ideation...Obtain level of care/service unavailable at this facility. Service: Psychiatric Care...Receiving Facility...[Hospital B]...Time of Transfer: 0425 [4:25 AM]...Date: 7-21-17..."

There was no documentation the on-call psychiatrist performed an assessment of Patient #8 to determine the treatment necessary to stabilize the patient's psychiatric condition while Patient #8 was in the ED 83 hours and 12 minutes awaiting placement/transfer to an inpatient psychiatric facility.

13. Medical record review revealed Patient #9 presented to the ED at Hospital A on 7/16/17 at 5:25 AM for complaint of "...PSYCH..." Patient #9 was uninsured.

ED Physician #7's note dated 7/16/17 at 5:41 PM documented ED Physician #7 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #9] with known anxiety disorder and major depressive disorder reports weeks of worsening depressed mood, especially bad in the last few days with suicidal ideation including a plan to shoot herself or record car [wreck her]...PSYCH...Tearful, actively suicidal...Marginal insight and judgment..." Further review of ED Physician #7's note dated 7/17/17 at 6:00 AM revealed, "Additional Medical History...Anxiety, depression, hypothyroidism, cavernous hemangioma, seizures, hypertension, chronic pain, migraines, fibromyalgia...6404 was filed by myself for suicidal ideation. She has already been evaluated by mobile crisis who feels that she needs inpatient treatment...Primary Impression: Suicidal ideation...Secondary Impressions: Migraine..."

A Certificate of Need for Emergency Involuntary Admission (6404) was not present in the patient's medical record.

A nurse's note dated 7/16/17 at 5:28 AM documented, "...SENT FROM [Hospital A's psychiatric campus] FOR CLEARANCE AND PLACEMENT..." Further review of a nurse's note dated 7/16/17 at 5:49 AM revealed, "...SUICIDE ASSESSMENT...PT STATES SHES BEEN HAVING THESE THOUGHTS FOR ABOUT A WEEK...PT STATES SHE HAS PLANS 'DIFFERENT OPTIONS' BUT HAS BEEN TRYING TO FIGHT THEM OFF..."

Rreview of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: SI...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital B]...Time of Transfer: 1646 [4:46 PM]...Date: 7-19-17..."

There was no documentation the on-call psychiatrist performed an assessment of Patient #9 to determine the treatment necessary to stabilize the patient's psychiatric condition while Patient #9 was in the ED 59 hours and 21 minutes awaiting placement/transfer to an inpatient psychiatric facility.

14. Medical record review revealed Patient #10 presented to the ED at Hospital A on 10/13/17 at 10:06 PM for complaint of "...bipolar disorder..." Patient #10 was uninsured.

ED Physician #9's note dated 10/13/17 at 10:57 PM documented ED Physician #9 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #10] presents today with issues with bipolar disorder. Family member is here and says he has been delusional. He has been giving his money away to people. this has made him homeless. He also sent them a note saying he is suicidal..." Further review of ED Physician #9's note dated 10/14/17 at 12:37 AM revealed, "...history of bipolar. off meds. delusional, destructive behavior. evidence of psychosis...Primary Impression: Bipolar disorder..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #9 on 10/14/17 at 12:35 AM which documented, "...I certify that this person is subject to involuntary care and treatment...Active symptoms of psychiatric disorder as noted: suicidal ideation, depression...bipolar history off meds...delusional behavior, psychosis, giving away money, reckless behavior...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...worsening psychosis 2/2 [secondary to] bipolar with delusional and paranoid behavior...In my opinion, the patient is at continued risk of harm to others if not placed under involuntary commitment...Treatment likely to prove beneficial in symptom reduction...Adequate evaluation requires a secure setting..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) re

Based on review of facility policies, Medical Staff Bylaws, Medical Staff Rules and Regulations, Medical Staff On-Call Schedules, medical record review and interview, the hospital failed to ensure patients with identified emergency psychiatric conditions were transferred to Hospital A's inpatient psychiatric unit which had the capacity and capability to treat the patient. The hospital failed to minimize the risks to the patient's health by allowing patients with psychiatric conditions to remain in the hospital's ED for extended periods of time without stabilizing treatment while waiting to be transferred to an outside hospital. The failure of the hospital to admit and treat psychiatric patients resulted in an inappropriate transfer for 26 of 32 (#1, #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #24, #25, #26, #27 and #28) patients who had presented to the ED seeking treatment.

The findings included:

1. Review of the facilty's "EMTALA [Emergency Medical Treatment and Labor Act] Tennessee Medical Screening Examination and Stabilization Policy revealed, "...To establish guidelines for providing appropriate medical screening examinations ("MSE") and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ("DED")...The MSE must be completed by an individual...qualified to perform such an examination to determine whether an EMC [emergency medical condition) exists ...If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity of the facility, or an appropriate transfer as defined by and required by EMTALA. Stabilizing treatment shall be applied in a non-discriminatory manner...no different level of care because of...payment source or ability, or any other basis prohibited by federal, state or local law..."

Review of the facility's "EMTALA Transfer Policy" revealed, "...To establish guidelines for...providing an appropriate transfer to another facility of an individual with an emergency medical condition ("EMC"), who requests or requires a transfer for further medical care and follow-up to a receiving facility ...Transfer of Individuals Who Have Not Been Stabilized...If an individual who has come to the emergency department has an EMC that has not been stabilized, the hospital may transfer the individual only if the transfer is an appropriate transfer...Higher Level of Care...A receiving hospital with specialized capabilities or facilities that are not at the transferring hospital (including...behavioral health units...) must accept an appropriate transfer of an individual with an EMC who requires specialized capabilities or facilities if the hospital has the capacity to treat the individual..."

2. Review of the facility's "MEDICAL STAFF BYLAWS" reviewed 7/19/16 revealed, "...The Medical Staff shall provide services as applicable, to patients admitted or otherwise treated at [Hospital A] which includes the [Hospital A's psychiatric campus]...To provide patients with the quality of care that is commensurate with acceptable standards and available community services...To monitor and enforce compliance with these Bylaws, Rules and Regulations and hospital policies..."

3. Review of the facility's "MEDICAL STAFF RULES AND REGULATIONS" reviewed 7/19/16 revealed, "...EMERGENCY SERVICES...All persons seeking emergency services and care will receive a medical screening examination and evaluation by a physician or a qualified medical person as designated by hospital policy...If the physician on call is requested by the emergency department physician to see an unassigned patient who has presented to the emergency department for treatment or evaluation, the on call physician must respond, regardless of the patient's ability to pay for any service...Patients with conditions whose definitive care is beyond the capabilities of the Hospital shall be referred to the appropriate facility, when in the judgment of the attending Physician the patient's condition permits such a transfer. Patient transfers shall be in accordance with EMTALA regulations..."

4. Review of the facility on-call schedule revealed a psychiatrist was on call 24 hours a day 7 days a week during the time each of the 30 of 32 patients were in the ED.

5. Medical record review revealed Patient #1 presented to the Emergency Department (ED) at Hospital A on 10/21/17 at 7:31 AM for complaint of "...Aggressive behavior, Hallucinations, auditory, schizophrenia..." Patient #1 had out of state Medicaid insurance.

Physician Assistant #1's note dated 10/21/17 at 7:58 AM documented Physician Assistant #1 initiated a Medical Screening Examination (MSE) which included: a History of Present Illness (HPI), a Risk of Psychiatric Illness, a Review of Systems (ROS), a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...He [Patient #1] is evasive with questions, but upon further discussions with family, they state that he has been having difficulties with voices, commands, and auditory hallucinations. He has been more aggressive recently and is hard to control at home. They attempted to take him to [Hospital A's psychiatric campus], but was instructed to come to the emergency department for medical clearance..." Further review of Physician Assistant #1's note dated 10/21/17 at 4:05 PM revealed, "...Patient is having acute psychosis, with auditory hallucinations. Patient needs completion of psychiatric monitoring and treatment to ensure stabilization...Primary Impression: Acute psychosis ...Secondary Impressions: Auditory hallucinations, Schizophrenia..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #1 on 10/21/17 at 8:00 AM which documented, "...I certify that this person is subject to involuntary care and treatment...Hx [history] of schizophrenia...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Acute psychosis with auditory hallucinations...Treatment may reduce symptoms...Patient needs safe place for treatment..."

A nurse's note dated 10/21/17 at 8:25 AM documented, "...FAMILY IS CONCERNED FOR HIS INCREASE IN AGITATION, DECREASED SLEEP. STATES HE STAYS UP LATE PACING AROUND AND TALKS TO 'THE VOICES.' HIS MOM STATES HE HAS BEEN AGITATED ALTELY [lately] AND HAS BEEN KNOWN TO ATTACK OBJECTS. STATES HIS AUDITORY HALLUCINATIONS SEEM TO GET WORSE WHEN HE IS ANGRY. I NOTED THIS WHEN I TOLD HIM THIS IS A NO SMOKING CAMPUS. HE BECAME IRRITATED AND HIS SPEECH BECAME FASTER AND HE SPOKE VERY ANGRILY WITH NONPERSONS WHEN I LEFT TO GET HIM A NICOTINE PATCH. HE REFUSED THE NICOTINE PATCH, STATING HE 'SWALLOWED A GUN' AND DOESN'T WANT TO TAKE ANY NICOTINE INTO HIS BODY..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...Obtain level of care/service unavailable at this facility. Service: Psych [psychiatry]...Receiving Facility...[Hospital B]...Time of Transfer: 1650 [4:50 PM]...Date: 10/23/17..."

Review of the Psychiatric Unit census revealed the census was: 19 (10 vacancies) on Acute-Side B, 14 (5 vacancies) on Acute-Side A and 11 (11 vacancies) on Mood and Stress Disorder Unit on 10/21/17; 23 (6 vacancies) on Acute-Side B, 17 (2 vacancies) on Acute-Side A and 8 (14 vacancies) on Mood and Stress Disorder Unit on 10/22/17; and 21 (8 vacancies) on Acute-Side B, 17 (2 vacancies) on Acute-Side A and 8 (14 vacancies) on Mood and Stress Disorder Unit on 10/23/17.

There was no documentation the patient was referred to Hospital A's psychiatric campus for possible admission while he remained in the ED 57 hours and 19 minutes.

6. Medical record review revealed Patient #2 presented to the ED at Hospital A on 9/16/17 at 9:22 PM for complaint of " ...Depressed, Suicidal ideation..." Patient #2 had out of state Medicaid insurance.

ED Physician #2's note dated 9/16/17 at 9:48 PM documented ED Physician #2 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #2] brought to emergency department by EMS [emergency medical services] for bizarre behavior, depression and suicidal ideation. Unfortunately the patient is very accelerated, tangential with loose associations and it's very difficult to get a clear history from him. He does state he is suicidal and hopes to kill himself. He is name [has named] several options including lighting himself on fire, stabbing himself, running out in front of traffic, jumping off a building or drowning himself. He has made mention of his girlfriend leaving him and taking his dog but also has mentioned larger social issues such as the government, the military and the devil is being a cause for his frustrations...Focused PE [physical exam]...General/Const [Constitution]...odor of alcohol noted, disheveled with poor hygiene...Psychiatric...Abnormal Mood/Affect...Flight of ideas, Inappropriate, Irritable, Pressured Speech ...Abnormal Thinking/Perception...Suicidal with plan, Judgment abnormal..." Further review of ED Physician #2's note dated 9/16/17 at 11:19 PM revealed, "...Primary Impression: Depression with suicidal ideation...Secondary Impressions: Acute psychosis..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #2 on 9/16/17 at 9:50 PM which documented, "...I certify that this person is subject to involuntary care and treatment ...Depression, tangent thinking, acute mania, suicidal...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Severe depression c [with] SI [suicidal ideation] + plan to kill himself ... Clinical improvement, sx [symptom] reduction...Too high risk + [illegible] for out pt tx [treatment]..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Suicidal ideation...Obtain level of care/service unavailable at this facility. Service: psychiatric services...Receiving Facility...[Hospital B]...Time of Transfer: 0700 [7:00 AM]...Date: 9/20/17..."

Review of the Psychiatric Unit census revealed the census was: 23 (6 vacancies) on Acute-Side B, 13 (6 vacancies) on Acute-Side A and 10 (12 vacancies) on Mood and Stress Disorder Unit on 9/16/17; 23 (6 vacancies) on Acute-Side B, 17 (2 vacancies) on Acute-Side A and 8 (14 vacancies) on Mood and Stress Disorder Unit on 9/17/17; 17 (12 vacancies) on Acute-Side B, 13 (6 vacancies) on Acute-Side A and 12 (10 vacancies) on Mood and Stress Disorder Unit on 9/18/17; 12 (17 vacancies) on Acute-Side B, 15 (4 vacancies) on Acute-Side A and 13 (9 vacancies) on Mood and Stress Disorder Unit on 9/19/17; and 15 (14 vacancies) on Acute-Side B, 17 (2 vacancies) on Acute-Side A and 11 (11 vacancies) on Mood and Stress Disorder Unit on 9/20/17.

There was no documentation the patient was referred to Hospital A's psychiatric campus for possible admission while he remained in the ED 81 hours and 38 minutes.

7. Medical record review revealed Patient #4 presented to the ED at Hospital A on 2/17/17 at 1:54 PM for complaint of " ...Depressed ..." Patient #4 had TN Care Bluecare Medicaid insurance.

ED Physician #4's note dated 2/17/17 at 2:11 PM documented ED Physician #4 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...HAS BEEN OFF MEDS FOR ABOUT 6 WEEKS AND HAVING SI CURRENTLY. HX OF THE SAME WITH ATTEMPTS MORE THAN ONCE IN THE PAST..." Further review of ED Physician #4's note dated 2/17/17 at 4:38 PM revealed, "...WILL NEED PSYCH EVAL [evaluation] AND 6404 SINCE DANGER TO SELF...Primary Impression...Adjustment disorder with depressed mood..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #4 on 2/17/17 at 2:15 PM which documented, "...I certify that this person is subject to involuntary care and treatment...HISTORY OF DEPRESSION...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Deterioration due to mental illness to point of inability to care [for] self, at significant risk to health...Treatment likely to prove beneficial in symptom reduction...Condition is likely to deteriorate further without treatment...Adequate evaluation requires a secure setting..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Depression, SI...Obtain level of care/service unavailable at this facility. Service: Psychiatric Care...Receiving Facility...[Hospital B]...Time of Transfer: 1022 [10:22 AM]...Date: 2-20-17 [2/21/17]..."

Review of the Psychiatric Unit census revealed the census was: 12 (17 vacancies) on Acute-Side B, 8 (11 vacancies) on Acute-Side A and 8 (14 vacancies) on Mood and Stress Disorder Unit on 2/17/17; 11 (18 vacancies) on Acute-Side B, 10 (9 vacancies) on Acute-Side A and 12 (10 vacancies) on Mood and Stress Disorder Unit on 2/18/17; 14 (15 vacancies) on Acute-Side B, 13 (6 vacancies) on Acute-Side A and 14 (8 vacancies) on Mood and Stress Disorder Unit on 2/19/17; and 12 (17 vacancies) on Acute-Side B, 15 (4 vacancies) on Acute-Side A and 16 (6 vacancies) on Mood and Stress Disorder Unit on 2/20/17.

There was no documentation the patient was referred to Hospital A's psychiatric campus for possible admission while he remained in the ED 92 hours and 28 minutes.

8. Medical record review revealed Patient #5 presented to the ED at Hospital A on 2/20/17 at 1:16 PM for complaint of " ...Suicidal ideation ..." Patient #5 had TN Care Bluecare Medicaid insurance.

ED Physician #5's note dated 2/20/17 at 1:34 PM documented ED Physician #5 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #5] requesting heroin detox [detoxification]. Is also suicidal - states she wants to blow her brains out with a gun..." Further review of ED Physician #5's note dated 2/20/17 at 2:37 PM revealed, "...Will require psychiatric evaluation...Primary Impression: Suicidal ideation..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #5 on 2/20/17 at 1:30 PM which documented, "...I certify that this person is subject to involuntary care and treatment...Previous psychiatric hospitalizations...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Suicidal ideation with a well-formed plan for self harm as follows: Using firearm...Habitual use of drugs to the point of deterioration or death...In my opinion, the patient is at continued risk of self-harm in not placed under involuntary committment [commitment]...Condition is likely to deteriorate further without treatment...Treatment likely to prove beneficial in symptom reduction...Inability to contract for safety..."

A nurse's note dated 2/20/17 at 1:21 PM documented, "...PT VERBALIZES MULTIPLE DRUG USE HISTORY, PT STATES SUICIDAL IDEATION, STATES 'I DONT WANNA LIVE ANYMORE'..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: SI...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital B]...Time of Transfer: 1025 [10:25 AM]...Date: 2/24/17..."

Review of the Psychiatric Unit census revealed the census was: 12 (17 vacancies) on Acute-Side B, 15 (4 vacancies) on Acute-Side A and 16 (6 vacancies) on Mood and Stress Disorder Unit on 2/20/17; 21 (8 vacancies) on Acute-Side B, 12 (7 vacancies) on Acute-Side A and 17 (5 vacancies) on Mood and Stress Disorder Unit on 2/21/17; 19 (10 vacancies) on Acute-Side B, 10 (9 vacancies) on Acute-Side A and 16 (6 vacancies) on Mood and Stress Disorder Unit on 2/22/17; 16 (13 vacancies) on Acute-Side B, 12 (7 vacancies) on Acute-Side A and 5 (17 vacancies) on Mood and Stress Disorder Unit on 2/23/17; and 15 (14 vacancies) on Acute-Side B, 9 (10 vacancies) on Acute-Side A and 10 (12 vacancies) on Mood and Stress Disorder Unit on 2/24/17.

There was no documentation the patient was referred to Hospital A's psychiatric campus for possible admission while she remained in the ED 94 hours and 9 minutes.

9. Medical record review revealed Patient #6 presented to the ED at Hospital A on 5/19/17 at 7:07 PM for complaint of " ...Suicidal ideation ..." Patient #6 had TN Care UHC Medicaid insurance.

ED Physician #6's note dated 5/19/17 at 7:27 PM documented ED Physician #6 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #6] WITH HX OF BIPOLAR DISORDER WHO PRESENTS WITH SUICIDAL IDEATION WITH PLANS TO OVERDOSE WITH MEDICATION..." Further review of a physician's note dated 5/19/17 at 10:19 PM revealed, "...Primary Impression: Suicidal ideation..." Further review of ED Physician #6's note dated 5/23/17 at 4:36 AM revealed, "...Pt unable to go to [Hospital B] 2/2 [secondary to] PICC [peripherally inserted central catheter] which was initially not conveyed to us, now pt on list for [Hospital A psychiatric campus] in am [AM]..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by Licensed Professional Counselor #1 on 5/19/17 at 2:15 PM which documented, "...I certify that this person is subject to involuntary care and treatment...History of psychiatric hospitalizations at [Hospital D], [Hospital E] & [Hospital A's psychiatric campus]...current diagnosis of Schizophrenia & Mood Disorder NOS [not otherwise specified]...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Patient has SI w/ plan to OD on medication, slit wrists, or walk into traffic...Patient has continued access to lethal means...In my opinion patient poses an imminent threat to self if not placed under an involuntary commitment...Treatment likely to prove beneficial in symptom reduction...Current presentation places self & others at too high risk of injury..."

A nurse's note dated 5/19/17 at 7:10 PM documented, "...PER EMS, PT HERE WITH SI, NEEDS CLEARANCE FOR [Hospital A's psychiatric campus]...PT HAS PLAN TO OVERDOSE WITH PILLS...PICC LINE TO LEFT AC [antecubital]..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Suicidal ideation...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital B]...Time of Transfer: 0225 [2:25 AM]...Date: 5/23/17..." Further review of an "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Suicidal...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital A's psychiatric campus]...Time of Transfer: 1300 [1:00 PM]...Date: 5/24/17..."

Review of the Psychiatric Unit census revealed the census was: 13 (16 vacancies) on Acute-Side B, 8 (11 vacancies) on Acute-Side A and 9 (13 vacancies) on Mood and Stress Disorder Unit on 5/19/17; 18 (11 vacancies) on Acute-Side B, 9 (10 vacancies) on Acute-Side A and 7 (15 vacancies) on Mood and Stress Disorder Unit on 5/20/17; 23 (6 vacancies) on Acute-Side B, 13 (6 vacancies) on Acute-Side A and 8 (14 vacancies) on Mood and Stress Disorder Unit on 5/21/17; 21 (8 vacancies) on Acute-Side B, 13 (6 vacancies) on Acute-Side A and 8 (14 vacancies) on Mood and Stress Disorder Unit on 5/22/17; and 25 (4 vacancies) on Acute-Side B, 14 (5 vacancies) on Acute-Side A and 8 (14 vacancies) on Mood and Stress Disorder Unit on 5/23/17.

Patient #6 was initially declined at Hospital A's psychiatric campus due to MD staffing, but Hospital A's psychiatric campus had beds available each of the 5 days Patient#6 was in the ED. Patient #6 was admitted to Hospital A's psychiatric campus after being declined by Hospital B due to the patient having a PICC line while she remained in the ED 113 hours and 53 minutes.

10. Medical record review revealed Patient #7 presented to the ED at Hospital A on 9/28/17 at 5:37 PM for complaint of " ...Altered mental status ..." Patient #7 was uninsured.

ED Physician #7's note dated 9/28/17 at 8:20 PM documented ED Physician #7 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #7] was seen earlier today by mobile crisis for unclear reason, was cleared home with his mother, and mother later called EMS for continued altered mental status...EXAM...NEURO [neurological]...Questionably intoxicated on marijuana with giggles and perseveration on the connectedness of life...PSYCH...Poor insight and judgment...Speaking to visual hallucinations when left alone in the room which is not consistent with simple marijuana intoxication..." Further review of ED Physician #7's note dated 9/28/17 at 11:37 PM revealed, "...Primary Impression: Acute psychosis...Secondary Impressions: Marijuana use..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #7 on 9/28/17 at 6:00 PM which documented, "...I certify that this person is subject to involuntary care and treatment...no reported psychiatric diagnosis...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...acute psychosis...Would benefit from psychiatric care including symptom reduction...Unable to treat as an outpatient..."

A nurse's note dated 9/28/17 at 6:50 PM documented, "...MOTHER STATES 'HE IS JUST NOT RIGHT, HE WAS ADMITTED TO AN ER ON TUESDAY, EVALUATED BY MOBILE CRISIS AND SENT TO [Hospital B] AND THE PSYCHIATRIST EVALUATED HIM THERE AND SENT HIM HOME STATING THAT HE JUST NEEDED TO DETOX [detoxify] FROM POT, BUT I KNOW SOMETHING IS JUST OFF WITH HIM'..."

Review of the "Emergency Medical Condition (EMC) Identified" transfer form signed by ED Physician #8 revealed, "...MEDICAL CONDITION: Diagnosis: Acute psychosis...Obtain level of care/service unavailable at this facility. Service: Psychiatry...Receiving Facility...[Hospital B]...Time of Transfer: 2200 [10:00 PM]...Date: 10/1/17..."

Review of the Psychiatric Unit census revealed the census was: 21 (8 vacancies) on Acute-Side B, 12 (7 vacancies) on Acute-Side A and 11 (11 vacancies) on Mood and Stress Disorder Unit on 9/28/17; 24 (5 vacancies) on Acute-Side B, 12 (7 vacancies) on Acute-Side A and 9 (13 vacancies) on Mood and Stress Disorder Unit on 9/29/17; 24 (5 vacancies) on Acute-Side B, 12 (7 vacancies) on Acute-Side A and 12 (10 vacancies) on Mood and Stress Disorder Unit on 9/30/17; and 24 (5 vacancies) on Acute-Side B, 14 (5 vacancies) on Acute-Side A and 12 (10 vacancies) on Mood and Stress Disorder Unit on 10/1/17.

There was no documentation the patient was referred to Hospital A's psychiatric campus for possible admission while he remained in the ED 76 hours and 23 minutes.

11. Medical record review revealed Patient #8 presented to the ED at Hospital A on 7/17/17 at 5:13 PM for complaint of "...I want to detox from alcohol..." Patient #8 was uninsured.

ED Physician #8's note dated 7/17/17 at 5:40 PM documented ED Physician #8 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #8] states he needs help to get off alcohol because he is afraid that he will die if he does not stop drinking...He has been to rehabilitation recently and just started drinking again about 3 weeks ago..." Further review of a physician's note dated 7/17/17 at 8:00 PM revealed, "...case manager spoke with the patient about options for outpatient detox. After this the patient stated he wanted to lay down on the railroad tracks or walk into traffic if he was discharged from the ED today..." Further review of ED Physician #8's note dated 7/17/17 at 8:30 PM revealed, "...the patient is now extremely agitated and has been threatening multiple staff members..." Further review of a physician's note dated 7/18/17 at 12:36 AM revealed, "...Primary Impression: Depression...Secondary Impressions: Alcohol abuse, Suicidal ideation..."

A Certificate of Need for Emergency Involuntary Admission (6404) was completed by ED Physician #8 on 7/17/17 at 8:00 PM which documented, "...I certify that this person is subject to involuntary care and treatment...Active symptoms of psychiatric disorder as noted: suicidal ideation, depression...Reported history of behaviors clinically indicative of a psychiatric disorder...Reported or clinically suspected substance dependence...poses an immediate substantial likelihood of serious harm...there is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment...Suicidal ideation with well-formed plan for self harm as follows: Walking into active traffic or lay on railroad tracks...In my opinion, the patient is at continued risk of harm to others if not placed under involuntary commitment...Condition is likely to deteriorate further without treatment ...Treatment likely to prove beneficial in symptom reduction...Adequate evaluation requires a secure setting..."

A nurse's note dated 7/17/17 at 5:30 PM documented, "...PT IS ALCOHOLIC, DRINKS BEER EVERY DAY AND TIRED OF LIVING THIS WAY, HAS HAD SI, WENT THROUGH 30 DAY REHAB [rehabilitation] IN THE PAST AND RELAPSED, STATES HE HAS HAD A LOT TO DRINK TODAY..." Further review of a nurse's note dated 7/17/17 at 5:36 PM revealed, "...SUICIDE ASSESSMENT...PATIENT SAYS THAT HE WISHES HE WAS NEVER BORN...PATIENT STATED THAT HE LOST HIS JOB RECENTLY..."

Review of the Emergency Notes revealed the following: "...07/17/17 2003 [8:03 PM]...MD ASKED ME TO GIVE RESOURCES TO THIS PATIENT FOR SUBSTANCE ABUSE. I WALKED UP TO HIS BEDSIDE AND HE WAS ON HIS PHONE WITH A NURSE AT ANOTHER [Hospital A's corporation] FACILITY WHERE HIS SIGNIFICANT OTHER IS LOCATED. THE NURSE ON THE PHONE WAS GIVING INSTRUCTION THAT THEY DO NOT HAVE PHONES IN THE ROOM AND HIS SIGNIFICANT OTHER WAS GIVEN HIS MESSAGE. THIS MAN SCREAMED OUT AT THE NURSE (I HEARD ALL THIS COMMOTION AS HE HAD HIS PHONE ON SPEAKER). HE SCREAMED THAT SHE WAS VIOLATING HIS CIVIL RIGHTS AND CURSED HER WITH A 'FUCK YOU! I KNOW MY RIGHTS AND ILL [I'll] HAVE YOU REPORTED. I AM A SECURITY GUARD AT DILLARD AND I KNOW WHO TO CALL!' I WAS AT HIS BEDSIDE WHEN HE GOT OFF THE PHONE-AND HE WAS VERY ANGRY WITH THE ANSWER HE GOT FROM ANOTHER FACILITY. HE IMMEDIATELY STARTED BEING BELLIGERENT WITH ME. HE ASKED ME 'WHAT THE HELL DO YOU WANT?' I TRIED TO RE-DIRECT AND SPOKE OF A POSITIVE ANSWER FOR HIS NEEDS OF FINDING A DETOX BED FOR HIS SUBSTANCE ABUSE. HE HAS TOLD MD THAT HE WAS NOT SUICIDAL AND WAS NOT HOMICIDAL. NOW, HE WANTS TO 'LAY ON THE RAILROAD TRACKS' OR JUMP INTO TRAFFIC! HE SAID I HAVE NO PLACE TO GO AND NOW 'SHE-(SIGNIFICANT OTHER) IS GOING TO GET A PLACE FOR HER PROBLEM SO I AM SUICIDAL. I DON'T WANT TO LEAVE NOW. IF I LEAVE I WILL HURT MYSELF!' I LET MD KNOW. HER PLANS WILL BE TO COMPLETE AN [a] 6404 AND WILL KNOWLEDGE THAT IT WILL BE RESCINDED WITH PLANS FROM MOBILE CRISIS. SECURITY AWARE AND NURSES AWARE...07/17/17 2028 [8:28 PM]...THIS PATIENT IS NOW DEMANDING TO LEAVE AND IS CALLING 'SOMEONE' TO COME PICK HIM UP. SECURITY NOTIFIED. THIS PATIENT AGGRESSIVE AT BEDSIDE. THREATENING TO NOW 'LEAVE, AND SO WHATEVER HE NEEDS TO DO TO GET OUT OF HERE' BODY LANGUAGE AGGRESSIVE WITH FINGERS GOING INTO A FIST, AND OPENING THE FIST FOR US TO SEE THE INTENT. MD AWARE. HE TORE HIS GOWN OFF AND THREW IN THE FLOOR, DEMANDED HIS PHONE. DEMANDED HIS RIGHTS BE 'UPHELD'...07/18/17 0425 [4:25 AM] THIS PATIENT IS NOW MEDICALLY CLEARED AND READY FOR PSYCH PROCESS TO BEGIN...HE IS ASKING WHY HE IS HERE. I WILL DISCUSS THIS CASE WITH MD..."

Rreview of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: Suicidal Ideation...Obtain level of care/service unavailable at this facility. Service: Psychiatric Care...Receiving Facility...[Hospital B]...Time of Transfer: 0425 [4:25 AM]...Date: 7-21-17..."

Review of the Psychiatric Unit census revealed the census was: 7 (22 vacancies) on Acute-Side B, 8 (11 vacancies) on Acute-Side A, 8 (6 vacancies) on Mood and Stress Disorder Unit and 14 (2 vacancies) on Dual Diagnosis Unit on 7/17/17; 10 (19 vacancies) on Acute-Side B, 7 (12 vacancies) on Acute-Side A, 8 (14 vacancies) on Mood and Stress Disorder Unit and 14 (2 vacancies) on Dual Diagnosis Unit on 7/18/17; 11 (18 vacancies) on Acute-Side B, 11 (8 vacancies) on Acute-Side A, 10 (12 vacancies) on Mood and Stress Disorder Unit and 11 (5 vacancies) on Dual Diagnosis Unit on 7/19/17; 10 (19 vacancies) on Acute-Side B, 13 (6 vacancies) on Acute-Side A, 10 (12 vacancies) on Mood and Stress Disorder Unit and 11 (5 vacancies) on Dual Diagnosis Unit on 7/20/17; and 11 (18 vacancies) on Acute-Side B, 14 (5 vacancies) on Acute-Side A, 10 (12 vacancies) on Mood and Stress Disorder Unit and 11 (5 vacancies) on Dual Diagnosis Unit on 7/21/17.

There was no documentation the patient was referred to Hospital A's psychiatric campus for possible admission while he remained in the ED 83 hours and 12 minutes.

12. Medical record review revealed Patient #9 presented to the ED at Hospital A on 7/16/17 at 5:25 AM for complaint of "...PSYCH..." Patient #9 was uninsured.

ED Physician #7's note dated 7/16/17 at 5:41 PM documented ED Physician #7 initiated a MSE which included: a HPI, a Risk of Psychiatric Illness, a ROS, a Past Medical History, a physical exam, and lab results interpretation. The physician's note revealed, "...[Patient #9] with known anxiety disorder and major depressive disorder reports weeks of worsening depressed mood, especially bad in the last few days with suicidal ideation including a plan to shoot herself or record car [wreck her]...PSYCH...Tearful, actively suicidal...Marginal insight and judgment..." Further review of ED Physician #7's note dated 7/17/17 at 6:00 AM revealed, "Additional Medical History...Anxiety, depression, hypothyroidism, cavernous hemangioma, seizures, hypertension, chronic pain, migraines, fibromyalgia...6404 was filed by myself for suicidal ideation. She has already been evaluated by mobile crisis who feels that she needs inpatient treatment...Primary Impression: Suicidal ideation...Secondary Impressions: Migraine..."

A Certificate of Need for Emergency Involuntary Admission (6404) was not present in the patient's medical record.

A nurse's note dated 7/16/17 at 5:28 AM documented, "...SENT FROM [Hospital A's psychiatric campus] FOR CLEARANCE AND PLACEMENT..." Further review of a nurse's note dated 7/16/17 at 5:49 AM revealed, "...SUICIDE ASSESSMENT...PT STATES SHES BEEN HAVING THESE THOUGHTS FOR ABOUT A WEEK...PT STATES SHE HAS PLANS 'DIFFERENT OPTIONS' BUT HAS BEEN TRYING TO FIGHT THEM OFF..."

Rreview of the "Emergency Medical Condition (EMC) Identified" transfer form signed by a physician (illegible signature) revealed, "...MEDICAL CONDITION: Diagnosis: SI...Obtain level of care/service unavailable at this facility. Service: Psych...Receiving Facility...[Hospital B]...Time of Transfer: 1646 [4:46 PM]...Date: 7-19-17..."

Review of the Psychiatric Unit census revealed the census was: 9 (20 vacancies) on Acute-Side B, 8 (11 vacancies) on Acute-Side A and 9 (13 vacancies) on Mood and Stress Disorder Uni