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Based on interview and record review, the hospital failed to abide by the provider's agreement that required a hospital to comply with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. Hospital A was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements, in that, 1 of 1 patient (Patient #1) who was under police custody was not appropriately transferred on 11/14/18.

Cross Refer to Tag A409 - §489.24(e)(1) and (2) Appropriate Transfer/Discharge

Based on interview and record review, the hospital did not appropriately transfer 1 of 1 minor patient (Patient #1) who presented in the emergency department (ED) via ambulance on 11/14/18 with a chief complaint of "behavioral problems at school and home with CPS (Child Protective Services) involved..." Patient #1 was discharged and transported by the police officer to Hospital B on the same day. The hospital did not complete and/or provide an appropriate transfer to Hospital B.

Findings included:

On 11/14/2018 at 12:47 PM. Patient #1 (minor) presented in the hospital's ED. The Nursing Triage Note at 12:54 PM indicated the "Chief Complaint was behavioral problems at school and home with CPS involved. Pt refusing to open eyes or respond."

At 13:01 PM a History of Present Illness written by Physician #6, reflected "The patient presents with psychiatric problem. The onset was just prior to arrival. The course/duration of symptoms is constant. Character of symptoms anxious. The degree of symptoms is moderate...There are exacerbating factors including family problems and school...Prior episodes: occasional...Additional history: Pt's (patient) assistant principal states that patient slumped over in the office and they thought she was having a heart attack. Pt was not responsive to nurse's office at school or EMS, but all tests were normal. She states that there has been a couple of incidences of emotional/mental health situations over the past 2 weeks. She reports past violent behaviors that patient has had. Pt has problems at home and CPS has made visits to her home several times recently. Patient's assistant principal is not aware if patient took any drugs or ingested anything. Patient is not responsive to any questions. Review of Systems...Unable to obtain due to: Uncooperative patient."

At 12:54 PM the Physical Examination showed "...Systolic 153 mmHg... Diastolic 95 mmHg...General: Alert, moderate distress... Neurological: patient is following commands but does not respond to any questions. Psychiatric: Mood and affect: Non-communicative, Behavior: Uncooperative."

At 15:44 PM Personnel #7 conducted an assessment indicating "RN Intake Assessment Summary...Patient initially would not verbally respond to ED staff or crisis clinician but began to speak after uncle refused to voluntarily sign her in to an inpatient psychiatric unit. Patient reports SI/HI (suicidal/homicidal ideation) with plan and intent. Patient states she ingested marijuana today to kill self...I want to hang myself...reports self-harm behaviors of burning herself on lip and neck with a lighter...thoughts "stab somebody...my auntie, when we fight...states her aunt also slaps her in the face frequently. Patient mood is depressed. She is withdrawn and affect is flat...Recommendation: Clinician consulted with admin...recommended for inpatient psychiatric treatment. Patient is willing, however guardian is refusing to sign her...Crisis clinician spoke with CPS and law enforcement officer and requested app for detention."

At 17:15 PM the "Notification of Emergency Detention" for Patient Rogers was completed. The notification indicated "Physician #6 completed the Certificate of Medical Examination for Mental Illness stating he observes/believes subject is likely to cause serious harm to self/others ..."

At 18:15 PM Personnel #8 noted "FWPD (Fort Worth Police Department) informing that patient to be discharged to JPS in order for CPS to meet and evaluate patient there, will be treated for behavioral health. Form to be signed by PD upon discharge and PD will receive custody of patient to be transported. Family will drive separate to JPS to given consent."

18:24 PM Personnel #8 noted "Status of discharge: Doctor's order. Departed Room ...at discharge: Ambulatory. Depart Transportation: Law Enforcement/police car ...After care instructions given: Patient. Discharge Comment: DC (discharge) to JPS via police car. ED Discharge Disposition: Home."

18:30 (11/14/18) Personnel #8 noted "FWPD in contact with CPS Case worker, patient to be discharged and transported via PD car to JPS for CPS evaluation and behavioral treatment. Physician #6 notified and patient stable for discharge. Guardians notified and understand plan ..."

In an interview with Personnel #2 on 12/03/18 at 1:00 PM he stated the hospital received an email from Hospital B requesting a copy of Patient #1's ED record. In the email Hospital B mentioned there was a potential "EMTALA" violation. Personnel #2 stated he reviewed the patient's medical record. He stated Physician #5 was aware of this incident. He stated Patient #1's visit was discussed in the Emergency Physician Meeting on 11/285/18. Personnel #2 stated "this should have been a transfer" but the police officer did not want to wait for the completion of the transfer process. Personnel #2 was asked if someone in the ED informed Hospital B that Patient #1 was enroute to their hospital with the FW police. Personnel #2 replied no.

In an interview with Personnel #1 on 12/03/18 at 1:35 PM and by email on 12/10/18, Personnel #1 was requested to provide evidence that the ED on 11/14/18 showed they were in the process of transferring Patient #1. Personnel #1 provided an internal email showing "I researched this and here is what I found BHTC (Behavioral Health Transfer Center) has no record of a transfer being initiated ...the BH Director...provided me with details from their end...Patient is 13...1715...officer wrote APOWW. 1825...officer removed pt from ER and took pt. to Hospital B. But this was initially unknown to Hospital A that they were going to Hospital B. Still nothing documented//unknown to BHTC. Patient later arrived at Hospital B..."