The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

COTEAU DES PRAIRIES HEALTH CARE SYSTEM 205 ORCHARD DR SISSETON, SD 57262 July 10, 2012
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
Based on record review, interview, and policy review, the hospital failed to comply with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. The hospital failed to:
*Provide appropriate medical screening for 3 of 20 sampled patients (1, 13, and 16) that presented to the emergency department (ED) for treatment.
*Arrange appropriate transfers for 7 of 20 sampled psychiatric patients (1, 4, 8, 9, 15, 16, and 19) who had attempted suicide.
*Document the risks associated with a transfer for one of six sampled patients (6) transferred to another healthcare facility.
*Complete the certificate of transfer and consent form for two of six sampled patients (2 and 12) transferred to another healthcare facility.
*Appropriately complete the certification of qualified mental health professional or physician certification form for three of seven sampled patients (2, 9, and 14) evaluated for involuntary/voluntary commitment to a mental health facility.
Findings include:

1. Review of patients 1, 13, and 16's medical records revealed the medical screening examination did not include alcohol levels or drug screening when suicide had been attempted by overdosing on prescription medications and/or alcohol. Refer to C2406, findings 1 through 4.

2. Review of patients 1, 4, 8, 9, 15, 16, and 19's medical records revealed a mental health evaluation and appropriate transfer arrangements for mental health services and/or treatment were not provided to patients after stabilizing their medical symptoms brought about by attempted suicide. Refer to C2407, findings 1 through 9.

3. Review of patient 6's medical record revealed on 6/20/12 she had presented on prescription medications.

Review of patient 6's transfer certification form revealed the risks associated with the transfer had not been documented. Refer to C2409, finding 1.

4. Review of patients 2, 9, and 14's certification of qualified mental health professional or physician certification form (qualified mental health professional form) revealed the physician had not documented the patients' names, dates, and times the personal examinations had taken place. That form was the legal documentation an individual with a serious emotional disturbance was a fit subject for interventions and detention at an appropriate facility to receive mental health services. Refer to C2409, findings 2 through 4.
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
Based on record review, interview, and policy review, the provider failed to ensure patients received an appropriate medical screening examination (exam) within the capability of the hospital's emergency department for three of three sampled patients (1, 13 and 16) with an emergency medical psychiatric condition. Findings include:

1. Review of patient 1's medical record revealed on 7/9/12 she had presented to the emergency department (ED) after attempting suicide with her prescription medications Paroxetine and Topamax.

Review of patient 1's nurses notes dated 7/9/12 at 7:43 a.m. at the time of her discharge revealed:
*"Patient hallucinating at the time of discharge thinks that her daughter _____ (daughter's name) is under the stand in her room staff and police officer tried to explain to the PT (patient) there was no one in the room with us PT not ok with that answer."
*The patient had been provided discharge instructions, a medication list, and all questions had been answered. The patient had signed the aftercare instructions.
*The patient was discharged to the police department and left with a police officer.

Interview on 7/10/12 at 12:50 p.m. with the director of nursing (DON) revealed:
*The staff had documented the patient was hallucinating at the time of her discharge.
*The ED physician should have been notified regarding the patient's hallucinations. However she thought the patient's hallucinations were fabricated, and she was stable at the time of her discharge.
*The Tribal police had asked to be called, so they could pick the patient up at discharge.
*The patient had been transferred to jail and Indian Health Services (IHS) law enforcement would be responsible for arranging mental health services.

Review of patient 1's history and physical report dated 7/18/12 revealed:
*The patient diagnosis was intentional overdose of Paroxetine and Topamax.
*She was upset and had taken thirty Paroxetine and about ten Topamax.
*She would be admitted to the hospital for observation and worked up accordingly.
*Her Tylenol level was zero, salicylate level was low, and her blood alcohol was zero.

Review of patient 1's laboratory (lab) summary sheet dated 7/9/12 revealed the urinalysis was positive for THC-Cannabinoid.

Review of the ED mental health assessment form signed 7/9/12 by physician B revealed patient 1 did not have suicidal ideations, a suicide plan, and was not potentially violent.

Review of patient 1's discharge summary dated 7/9/12 revealed discharge instructions stated "She is to followup and get some counseling as needed." The patient was stable and had been instructed to continue her medications as before.

2. Review and interview of patient 13's medical record with the DON on 7/10/12 at 1:45 p.m. confirmed:
*On 5/2/12 the patient had presented to the ED accompanied by city police for self-inflicted knife wounds to his chest. The patient was discharged that same day into police custody and escorted to jail.
*Physician assistant (PA) D's emergency room note indicated the patient was very drunk, sad, and could not get over the loss of his daughter last October.
*PA D had not requested laboratory workup for an alcohol level or drug screening on admission or prior to the patient's discharge.
*PA D did not document on the patient's mental status at the time of the patient's discharge.
*PA D had documented the patient's left chest had six to seven light abrasions or scratches, the patient had stated his knife was very dull, and he would choose a sharper one next time or a gun.

3. Review of patient 16's medical record revealed:
*On 3/31/12 he was accompanied to the ED by Tribal police for attempted suicide. The patient had cut himself five times on his right forearm and had blood on his lips.
*He stated he had been taking Wellbutrin for three years, and other medications for depression, but had stopped taking them lately.
*He was seen at IHS for counseling a month ago after getting out of jail.
*He had stated he would kill himself after being released from jail.
*He wanted to go to the "Spirit world to be with his daughters mom who got killed a few years ago."
*He was discharged into Tribal police custody and they would arrange for him to be evaluated Monday.
*There were no physician's orders found in the medical record.
*There were no laboratory reports for alcohol or drug screening.

Interview on 7/10/12 at 2:55 p.m. with the DON regarding patient 16 revealed:
*The physician had not ordered a drug screen, an alcohol level, or written an order for discharge.
*Arrangements should have been made to transfer the patient to another healthcare facility for mental health services/treatment.
*The patient had been seen in the ED on a Saturday and would be in jail until Monday or until mental health services could be arranged.

Review of the provider's 9/14/11 Medical Screening Exam policy revealed "When an individual comes to the ER of the hospital and a request is made for emergency care, the hospital must provide an appropriate medical screening exam, and if applicable, ancillary services routinely available to the ER to determine whether an emergency medical condition exists..."
VIOLATION: STABILIZING TREATMENT Tag No: C2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview, and policy review, the provider failed to ensure:
*Patients that attempted suicide were provided mental health evaluations and transferred appropriately when their medical symptoms brought about by the attempt were stabilized for seven of seven reviewed psychiatric patients' charts (1, 4, 8, 9, 15, 16, and 19).
*Medical care was administered for identified injuries for one of one reviewed patient (4) chart.
*Interventions for pain had been administered to one of one sampled patient (4) during their emergency department (ED) visit.
Findings include:

1. Review of patient 1's medical record revealed:
*On 7/9/12 at 1:19 a.m. she had presented to the emergency department (ED) and was admitted for observation.
*She was discharged on [DATE] at 7:43 a.m. into the custody of law enforcement.
*She had attempted suicide by overdosing on her prescription medications Paroxetine 20 milligrams (mg) and Topamax 100 mg. Paroxetine was prescribed for depression and Topamax for seizure disorders.
*She had taken thirty tablets of each medication about one and on half hours ago.
*She had been having trouble at home and did not want to talk about it or her situation.
*There was no documentation in the patient's medical record she had been offered treatment at another healthcare facility that specialized in mental health services.

Review of patient 1's nurses notes dated 7/9/12 at 7:43 a.m. documented at the time of her discharge revealed:
*"Patient hallucinating at the time of discharge thinks that her daughter _____ (daughter's name) is under the stand in her room staff and police officer tried to explain to the PT (patient) there was no one in the room with us PT not ok with that answer."
*The patient had been provided discharge instructions, a medication list, and all questions had been answered. The patient had signed the aftercare instructions.
*The patient was discharged into policy custody and left with a police officer.

Interview on 7/10/12 at 12:50 p.m. with the DON revealed:
*The staff had documented the patient was hallucinating at the time of her discharge.
*The ED physician should have been notified regarding the patient's hallucinations. However she thought the patient's hallucinations were fabricated, and she was stable at the time of her discharge.
*Tribal police had asked to be called, so they could pick the patient up at discharge.
*The patient had been transferred to jail and law enforcement would get her into IHS mental health for treatment.

Review of patient 1's history and physical report dated 7/9/12 revealed:
*The patient's diagnosis was intentional overdose of Paroxetine and Topamax.
*She was upset and had taken thirty Paroxetine and about ten Topamax.
*She would be admitted to the hospital for observation and worked up accordingly.
*Her Tylenol level was zero, salicylate level was low, and her blood alcohol was zero.

Review of patient 1's lab summary sheet dated 7/9/12 revealed the urinalysis was positive for THC-Cannabinoid.

Comparison of the patient's nurses notes and the physician's history and physical report revealed conflicting information regarding the quantity of pills she had taken.

Review of the ED mental health assessment form signed on 7/9/12 at 3:30 a.m. by physician B revealed the patient did not have suicidal ideations, a suicide plan, or was potentially violent.

Review of patient 1's discharge summary dated 7/9/12 revealed discharge instructions stated "She is to followup and get some counseling as needed." The patient was stable and had been instructed to continue her medications as before.

2. Review of patient 8's medical record revealed on 6/19/12 at 1:00 a.m. an IHS Tribal police had accompanied the patient to the ED for an intentional overdose with alcohol and prescription medications. The patient had drank a traveler of vodka, taken ten Diazepam 5 milligram (mg) tablets, and eight Ibuprofen 800 mg tablets. The patient stated "There was nothing to live for" and his son and son-in-law had informed him his wife was unfaithful. Patient 8 was discharged that same day at 7:00 a.m. and escorted to jail by IHS Tribal police.

Review of patient 8's emergency room note dated 6/19/12 completed by PA-C A revealed:
*The patient had been brought in by law enforcement, had taken a "bunch of pills," and had drank a traveler of vodka. He was able to ambulate with help and was talking.
*Two vials of medicine had been found that contained Diazepam 5 mg and Motrin 800 mg. The time the patient had taken the medications was not clear, but the son thought maybe a couple of hours ago.
*Previous medical history included removal of 6 feet of intestines but was not sure why, he had shot himself with a 9 millimeter in the past, and had a couple overdose attempts previously.
*The patient had been receiving psychiatric care at IHS and was currently under police custody.
*The patient's ED course included intravenous infusions with normal saline, poison control was contacted, he was monitored with telemetry, denied pain, and complained of an upset stomach that was treated with Protonix.
*The patient's plan included eating breakfast, remaining in police custody, holding his coumadin, continue his Zantac, and avoid any NSAIDS. The patient verbalized understanding and satisfaction with that plan.

Review of patient 8's emergency room assessment completed by registered nurse (RN) B revealed:
*He was alert and oriented to person, place, and time; his stomach was upset; and he was moved to hospital room 109 for telemetry monitoring.
*He stated he had been in treatment for depression for about six years.
*He drank alcohol to "Escape" and had stated "I just want to be gone and not live anymore."

Review of patient 8's lab summary form revealed lab samples had been drawn on 6/19/12 at 1:27 a.m. for hematology, coagulation, and chemistry. Abnormal results identified included:
* Ethyl alcohol level - High at 87 milligrams per deciliter (mg/dl), normal range was 0.0 - 80.0 mg/dl.
*Salicylate level was low at 2.5 mg/dl and acetaminophen level was low at 2.5 mg/dl.
*No further testing for ethyl alcohol was completed prior to the patient's discharge on 6/19/12 at 7:00 a.m.
*Drug screening had not been conducted for controlled or illegal substances.

Interview on 7/9/12 at 3:20 p.m. with the IHS chief of police regarding patient 8 revealed:
*Patients attempting suicide and under police custody for protection were released if the hospital made arrangements for higher level of care at a mental health facility.
*"It was the expectation the hospital provide proper care. Patients should not be put in jail but should receive care at a mental health facility."

Interview on 7/9/12 at 4:25 p.m. with PA-C A revealed the police officer accompanying patient 8 had informed him the patient was under police custody and would be kept for 72 hours in their care. The patient would be held in jail until a mental health evaluation could be conducted by a mental health professional from IHS mental health services. PA-C A revealed because of past experiences he had assumed that mental health evaluation would have been arranged by Tribal police. PA-C A revealed he had not requested the patient be transferred to a facility that provided mental health care, it was not in his scope of practice to complete a mental health evaluation, and a physician would have to be called in for that. PA-C A revealed the patient had not received a mental health evaluation at the hospital, was medically stable at the time of his discharge, and was going to a safe environment.

Interview on 7/9/12 at 5:00 p.m. with physician C regarding patient 8 revealed:
*On the morning of 6/19/12 she had been briefed by PA-C A on patient 8. There was nothing outstanding about that briefing that she could remember.
*She did not know why the patient had not been transferred to a facility that could have provided mental health care.
*When a patient comes to the ED in police custody they are returned to the custody of the police.
*If a patient came to the ED department under a court ordered 24 hour or 72 hour hold then she would get involved.
*The hospital policies were lacking and did not reflect procedures regarding patients not under mental illness holds. The different types of court ordered holds were confusing and there was confusion about what being in custody meant.

Interview on 7/9/12 at 6:30 p.m. with IHS Tribal police officer D regarding patient 8 revealed:
*He had accompanied the patient to the ED on 6/19/12 after the patient had overdosed on alcohol and pills.
*The patient had stated "I took enough pills to kill myself." The patient was upset about allegations of his wife cheating.
*About a year ago he had responded to the police call when the patient had shot himself in the chest.
*He had stayed at the hospital with the patient. The patient had attempted suicide and was under protective police custody. Patients may walk out of the hospital if the police did not maintain custody. The hospital staff stated they cannot prevent a patient from leaving if they wanted to go. If the police officer felt the patient was a danger to themselves they would go to jail until arrangements were made by the police with a mental health professional.
*There was no recommendation or an arrangement made by the hospital for the patient to be evaluated at a mental health facility or be transferred to a mental health facility.

Interview on 7/10/12 at 1:21 and review of patient 8's medical record with the DON revealed:
*The patient should have stayed in the hospital until a mental health evaluation and transfer had been arranged.
*The patient should have had a urine drug screen completed during his ED visit.
*The patient's mental health status should have been evaluated and documented in the medical record prior to his discharge.
*There were no physician's orders for observation admission or discharge documented for the patient.
*The provider did not have a policy for obtaining medical holds for patients with psychiatric emergencies. The policy for treating psychiatric patient was outdated and needed revision.

3. Review of patient 9's medical record revealed:
*On 6/13/12 at 6:48 a.m. she had been accompanied by a police officer to the ED and was discharged back to her job that same day at 8:28 a.m.
*She was having martial problems over money, had phoned her mother, and told her she wanted to kill herself instead of getting a divorce.
*The ED intake notes indicated she denied wanting to kill herself, and she just wanted to talk to someone.

Review of the emergency room note dated 6/13/12 by physician B regarding patient 9 revealed:
*She was very depressed, under financial stresses, and was not suicidal.
*She was provided a prescription of fourteen pills for Pristiq 50 mg (antidepressant) once a day and an appointment with physician B in ten days for follow-up management.

Review of patient 9's medical record revealed:
*On 6/13/12 at 1:00 p.m. a police officer had accompanied her back to the ED. She was transferred that same day at 4:53 p.m. to a mental health unit at another healthcare facility.
*She had been at work and was threatening to kill herself after her husband had asked her to go stay with her father.
*The police officer reported the patient had told her sister she would kill herself after work.
*The sister had signed a commitment form, the police had brought her back to the hospital for a mental health evaluation, and would transfer her to a mental health unit.

Review of patient 9's certification of qualified mental health professional or physician certificate form revealed the name of the patient, date, and year of the patient's personal examination had not been completed. The patient's name, date, and year had been left blank in the certification section on that form. Physician B had signed that form on 6/13/12.

Interview on 7/10/12 at 1:35 p.m. and review of patient 9's medical record with the DON revealed:
*The patient might not have been stable the first time she had been discharged earlier that day, and she should not have been discharged .
*The physician should have documented the patient's name, date, and year on the certification of qualified mental health professional or physician certificate.

4. Review of patient 15's medical record revealed:
*She had (MDS) dated [DATE] at 10:36 p.m. after intentionally ingesting approximately seven Zyprexa 2.5 mg tablets about one half hour prior to admit.
*She had been receiving counseling at IHS every couple of weeks but her "husband" did not think it was working, and she was having problems with depression.
*PA D's plan included her going to Tribal jail and letting law enforcement set-up her treatment program on Monday.

Interview on 7/10/12 at 2:52 p.m. with the DON regarding patient 15 revealed:
*She had (MDS) dated [DATE] (Friday) and would be in jail until 4/16/12 (Monday) or until mental health treatment could be arranged.
*There was no documentation PA D had requested a physician be called to complete a mental health evaluation or transferred the patient to a healthcare facility that provided psychiatric services.

5. Review of patient 16's medical record revealed:
*On 3/31/12 he was accompanied to the ED by Tribal police for an attempted suicide. The patient had cut himself five times on his right forearm and had blood on his lips.
*He stated he had been taking Wellbutrin for three years, and other medications for depression, but had stopped taking them lately.
*He was seen at IHS for counseling a month ago after getting out of jail.
*He wanted to go to the "Spirit world to be with his daughters mom who got killed a few years ago."
*He stated he would kill himself after being released from jail.
*He was discharged into Tribal police custody and they would arrange for him to be evaluated Monday (4/2/12).
*There were no physician orders found in the medical record.
*There were no laboratory reports for alcohol or drug screening.

Review of patient 16's emergency room note dated 3/31/12 completed by physician E revealed:
*The patient had attempted suicide by cutting himself on the right forearm.
*He was not taking his Wellbutrin, because he had run out of the medication.
*Approximately two months ago he was counseled at IHS for depression, and would hang himself when released from jail.
*He had suggested to him his alcohol was contributing to his depression and thinking, he needed to dry out, and be evaluated by mental health in several days. The Tribal police concurred with the plan and would take him into custody until Monday and have him evaluated.
*Diagnoses included chronic depression and off medications, recurrent alcohol abuse, family issues, and the death of his wife. The cutting was a call for help, but the patient was at a higher risk of suicide.

Interview on 7/10/12 at 2:55 p.m. with the DON regarding patient 16 revealed:
*The physician had not ordered drug screening, an alcohol level, or written an order for discharge.
*Arrangements should have been made to transfer the patient to another healthcare facility for treatment.
*The patient had been seen in the ED on a Saturday and would be in jail until Monday or until mental health services could be arranged.

6. Review of patient 19's medical record dated 2/17/12 revealed:
*The patient was accompanied by the city police to the ED at 12:45 p.m. for a mental hold and assessment.*The patient had been drinking, was depressed, and had self-inflicted razor blade cuts to his left forearm and left neck.
*The patient had been discharged into city police custody and escorted to jail.

Review of the emergency room note dated 2/17/12 by physician G revealed:
*The patient was at risk for harming himself.
*The police officer had started the petition and the hold.
*He had spoken with Yankton State Mental Hospital admissions, and it was preferred the qualified mental health examination and paperwork be performed when the patient was no longer intoxicated and/or was sober.

Interview on 7/10/12 at 2:05 p.m. with the DON regarding patient 19 confirmed:
*He had not been held at the hospital for the mental health evaluation. He had been discharged into policy custody and escorted to jail.
*He had returned with police later that day at 8:20 p.m., had been evaluated by physician G, and had been transferred to another healthcare facility for mental health services.

7. Review of patient 4's ED record revealed:
*On 6/29/12 at 5:24 p.m. she had presented to the ED and had been discharged that same day at 5:39 p.m.
*During a fight with her boyfriend she had jumped from a moving vehicle traveling approximately 45 miles per hour.
*She had hit her head but denied loss of consciousness and denied alcohol usage.
*Road rashes were noted to the right flank and midback, lower left quadrate of her abdomen, right elbow and forearm, and left wrist.
*Her pain level was 10 of 10 in her left wrist and right great toe.
*A police officer accompanied the patient during the ED stay.

Review of patient's 4's emergency room note dated 6/29/12 completed by physician assistant (PA) D revealed:
*She had jumped from a moving car last night about 12:30 a.m.(midnight).
*Injuries included bruises on her thigh; tenderness, swelling, and an inability to move her right great toe; abrasion to the right forearm; and her left forearm was "quite" swollen and tender to touch.
*The plan was to keep the abrasions clean, apply Polysporin, and Ibuprofen or Tylenol as needed for pain. If there was no improvement within 48-72 hours the patient needed to be rechecked.

Review of patient 4's radiology reports dated 6/29/12 revealed:*The abdominal computed tomography was negative.
*The right great toe was negative for acute fracture or dislocation.
*The right forearm had no definite acute fractures or dislocation.
*A nondisplaced fracture at the base of the styloid process of the left ulna.

Review of patient 4's emergency room assessment completed by registered nurse (RN) B revealed:
*She had informed the patient there were no broken bones.
*She had asked RN B to wash her right forearm and elbow since she had not done that herself.
*RN B had asked her if she was going home to shower, and the patient stated "Yes." RN B informed the patient to wash with soap, apply Vaseline to keep scab soft, gave her 4 x 4 gauze pads, Kling wrap, told her to use Neosporin on her abrasions, and apply ice to her left arm.
*RN B did not cleanse the patient's injuries nor apply dressings.
*She had requested a sling for her left arm but RN B informed her not to use her arm, hold it up if she wanted to, but it was not broken.
*She had complained her pain was a "10/10" on a 1 to 10 scale.
*No documentation was found in the medical record pain medication had been administered by the nursing staff during the patient's ED visit.

Review of patient 4's physician's orders dated 6/29/12 revealed no pain medications had been ordered or administered during the patient's ED visit.

Interview on 7/10/12 at 1:05 p.m. with the DON regarding patient 4 confirmed:
*RN B should have cleansed the patient's wounds, applied ointment, and guaze bandages.
*RN B did not give the patient a sling for her forearm.
*The patient did not receive pain medications during her ED visit.

8. Interview on 7/9/12 at 12:46 p.m. with the medical director revealed:
*The hospital had received many complaints from IHS that patients' with mental health emergencies were being discharged to jail instead of being transferred to a facility that provided mental health services.
*Because of those complaints about two months ago the hospital had established a committee to review all ED mental health admissions monthly. His review of those medical records included a review for the appropriateness of the transfer or a return to policy custody.
*Committee members included the medical director, DON, and assistant DON. Representatives from IHS, Tribal Council, and Tribal police were invited to those monthly committee meeting.
*Patients that had attempted suicide should not have been released into law enforcement custody and escorted to jail. An appropriate transfer to receive mental health services was more beneficial for patients with mental health issues. If patients were violent and presented a harm to staff or had attempted to elope then jail placement might have been the best option.

9. Review of the provider's emergency management of psychiatric patients policy issued July 1995 (no update) revealed for suicidal patients:
*"Treat the emergency condition brought about by the attempt.
*Maintain and airway.
*Treat for shock
*Carry out gastric lavage as necessary.
*Prevent further self-injury - a patient who has made a suicidal gesture may do so again.
*Admit to observation unit or transfer to Psychiatric Unit."

Review of the provider's EMTALA policy revised 5/20/12 revealed:
*Patients presenting to the ED with an emergency medical condition must be provided within the staff and facilities available medical examinations, treatments required to stabilize the medical condition, or transfer of the patient to another medical facility.
*Stabilize means "To provide such medical treatment of the emergency medical condition may be necessary to assure within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during transfer of an individual from a facility or to deliver a newborn."
*"If the individual has an emergency medical condition which has not been stabilized, the hospital may not transfer the individual unless":
-The patient or individual responsible for the patient request in writing transfer to another medical facility.
-A physician signs a certification based on information available at the time of the transfer the medical benefits at another medical facility outweigh the increased risks to the individual.
-A physician is not in the ED and a practitioner signs the certification which must be countersigned by a qualified medical person.
*"Any transfer must be "an appropriate transfer" in whom the transferring hospital has provided the medical treatment within its capacity which minimized the risk to the individual's health.."
*"An appropriate transfer is a transfer in which the receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer of the individual to provide appropriate medical treatment.
VIOLATION: DELAY IN EXAMINATION OR TREATMENT Tag No: C2408
Based on record review, interview, and policy review, the provider failed to ensure a delay in obtaining a mental health evaluation and a transfer to a facility specializing in mental health occurred for one of one psychiatric patient (8) with a history or attempted suicide. Findings include:

1. Review of patient 8's medical record revealed on 6/19/12 at 1:00 a.m. an Indian Health Service (IHS) Tribal police had accompanied the patient to the ED for an intentional overdose with alcohol and prescription medications. The patient had drank a traveler of vodka, taken ten Diazepam 5 milligram (mg) tablets, and eight Ibuprofen 800 mg tablets. The patient stated "There was nothing to live for," and his son and son-in-law had informed him his wife was unfaithful. Patient 8 was discharged that same day at 7:00 a.m. accompanied by the IHS Tribal police officer and escorted to jail.

Review of patient 8's emergency room note dated 6/19/12 completed by physician assistant-certified (PA-C) A revealed:
*The patient had been brought in by law enforcement, had taken a "bunch of pills," and had drank a traveler of vodka. He was able to ambulate with help and was talking.
*Two vials of medicine had been found that contained Diazepam 5 mg and Motrin 800 mg. The time the patient had taken the medications was not clear, but the son thought maybe a couple of hours ago.
*Previous medical history included removal of six feet of intestines but was not sure why, he had shot himself with a 9 millimeter in the past, and had a couple overdose attempts previously.
*He had been receiving psychiatric care at IHS and was currently under police custody.

Interview on 7/9/12 at 1:55 p.m. with Tribal officer B regarding patient 8 revealed:
*He remembered patient 8 had been taken to the ED for attempting suicide with alcohol and drugs.
*He was responsible for transporting him in the afternoon around 2:00 p.m. to another healthcare facility for mental health services.

Interview on 7/9/12 at 3:20 p.m. with the IHS chief of police regarding patient 8 revealed:
*Patients attempting suicide and were under police custody for protection would be released if the hospital made arrangements for higher level of care at a mental health facility.
*It was the expectation the hospital provide proper care. Patients should not be put in jail but should receive care at a mental health facility.

Interview on 7/9/12 at 4:25 p.m. with PA-C A revealed the police officer accompanying patient 8 had informed him the patient was under policy custody and would be kept for 72 hours in their care. The patient would be held in jail until a mental health evaluation could be conducted by a mental health professional from IHS mental health professionals. PA-C A revealed because of past experiences he had assumed that mental health evaluation would be arranged by Tribal police. PA-C A revealed he had not requested the patient be transferred to a facility that provided mental health care, it was not in his scope of practice to complete a mental health evaluation, and the on-call physician would have to be called in for that. PA-C A revealed the patient did not received a mental health evaluation at the hospital, was medically stable at the time of his discharge, and was going to a safe environment.

Interview on 7/9/12 at 6:30 p.m. with IHS tribal police officer D regarding patient 8 revealed:
*He had accompanied him to the ED on 6/19/12 after he had overdosed on alcohol and pills.
*He had stated "I took enough pills to kill myself." He was upset about allegations of his wife cheating.
*About a year ago he had responded to the police call when the patient had shot himself in the chest.
*He had stayed at the hospital with the patient. He had attempted suicide and was under protective police custody. Patients may walk out of the hospital if the police did not maintain custody. The hospital staff stated they could not prevent a patient from leaving if they wanted to go. If the police officer felt the patient was a danger to themselves they would go to jail until arrangements were made by the police with a mental health professional.
*There was no recommendation or arrangements made by the hospital for the patient to be evaluated at a mental health facility or be transferred to a mental health facility.

Interview on 7/10/12 at 1:21 p.m. and review of patient 8's medical record with the DON revealed:
*The patient should have stayed in the hospital until a mental health evaluation and transfer had been arranged.
*He should have had a urine drug screen completed during his ED visit.
*His mental health status should have been evaluated and documented in the medical record prior to his discharge.
*There were no physician's orders for observation admission or discharge documented for him.
*The provider did not have a policy for obtaining medical holds for patients with psychiatric emergencies. The policy for treating psychiatric patients was outdated and needed revision.
*The provider had requested IHS Tribal police share their policies on managing patients with mental illness and commitment procedures, but they had not provided that information.

Review of the provider's emergency management of psychiatric patients dated July 1995 revealed treatment of suicidal patients included:
*"Treat the emergency condition that brought about by the attempt.
*Maintain and airway.
*Treat for shock.
*Carry out gastric lavage as necessary.
*Prevent further self injury - a patient who has made a suicidal gesture may do so again.
*Admit to observation unit or transfer to Psychiatric Unit."
VIOLATION: APPROPRIATE TRANSFER Tag No: C2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview, and policy review, the provider failed to ensure:
*The risks associated with a transfer had been identified and documented for one of one psychiatric patient (6) transfer by family in a private car to another healthcare facility for mental health services.
*The transfer certification and consent form was completed for two of two sampled patients (2 and 12) upon transfer to another healthcare facility for mental health services.
*Physicians completing the certification of qualified mental health professional or physician certification form (qualified mental health professional form) documented the patient name, date, and time the personal examination had taken place for three of three sampled patients (2, 9, and 14) who were involuntarily/voluntarily committed to mental health facilities.
Findings include:

1. Review of patient 6's medical record revealed:
*She had (MDS) dated [DATE] after an attempted suicide of prescription medications metformin, Lisinopril, and alcohol.
*She had been admitted for observation and transferred on 6/21/12 per family members via private car to another healthcare facility for mental health follow-up.
*The release of responsibility authorization/certification for transfer form indicated the benefit of the transfer was to receive a mental health evaluation. There were no risks of the transfer documented on that form.
*An ED mental health assessment form had been signed by physician D on 6/20/12 at 1:30 p.m. that indicated the patient had suicidal ideation, it was unknown if there was a suicide plan, and she was not potentially violent. No further evaluation of her mental status by the physician had been documented during the patient's stay or at the time of the patient's discharge.

Interview on 7/10/12 at 1:20 p.m. with the DON regarding patient 6 revealed:
*She had been transferred to another healthcare facility for mental health follow-up on 6/21/12 at 10:56 a.m.
*The risks should have been documented on the release of responsibility authorization/certification for transfer form.

Review of the provider's EMTALA policy dated 5/20/12 revealed "The hospital has met the requirements of the law if the individual is informed that the transfer of the individual is necessary. The individual or a person acting on the individual's behalf is informed of the risks and benefits" of the transfer when patients are not stable or refuses to consent to the transfer.

2. Review of patient 2's medical record revealed:
*On 7/7/12 at 1:17 a.m. he had been accompanied to the ED by police under a 24 hour mental hold order.
*He was transferred on 7/7/12 at 12:29 p.m. to a treatment program at another healthcare facility.
*He had argued with his father and had threaten to walk out into traffic.
*His diagnoses included possible suicidal ideas and drug abuse.
*There was no certificate of transfer documentation in the medical record.

Review of patient 2's certification of qualified mental heath professional or physician certificate form revealed:
*The physician should have documented the name of the patient, date, and year he had completed the patient personal examination.
*The patient's name, date, and year had been left blank in the certification section of that form.
*The qualified mental health professional completing the patient's personal examination had not signed that certification section.
*The section documenting examination findings had been signed by physician B, but that signature was not dated.

Interview and review of patient 2's medical record on 7/10/12 at 12:05 p.m. with the DON revealed:
*The certification of qualified mental health professional or physician certificate had not been completed appropriately by physician B. The physician should have documented the name of the patient and the date and year he had completed the patient's personal examination.
*He had been transferred to another healthcare facility, and the physician should have completed the transfer certification and consent paperwork.

3. Review of patient 9's medical record dated 6/13/12 revealed:
*A police officer had accompanied her back to the ED at 1:00 p.m. She was transferred at 4:53 p.m. to another healthcare facility for mental health unit for follow-up.
*She had been at work and was threatening to kill herself after her husband had asked her to go stay with her father.
*The police officer reported she had told her sister she would kill herself after work.
*The sister had signed a commitment form, the police had brought her back to the hospital for a mental health evaluation, and would transfer her to a mental health unit.

Review of patient 9's certification of qualified mental health professional or physician certificate revealed the physician should have documented the name of the patient, date, and year of the patient's personal examination he had completed. The patient's name, date, and year had been left blank of in the certification section on that form. Physician B had signed that form on 6/13/12.

Interview on 9/10/12 at 1:35 p.m. and review of patient 9's medical record with the DON revealed:
*The physician should have document the patient's name, date, and year on the certification of qualified mental health professional or physician certificate form.

4. Review and interview of patient 12's medical record with the DON on 7/10/12 at 1:43 p.m. revealed:
*He had arrived to the ED in the custody of police after threatening to kill himself. He was under a 24 hour court ordered hold.
*He reported he had a shotgun in his pickup.
*Physician C had not documented an order for discharge or transfer of the patient.
*There was no certificate of transfer or consent form for transfer in the medical record.

5. Review and interview of patient 14's medical record revealed:
*The was accompanied to the ED by police on 4/25/12 at 3:29 p.m. after he reported to them he had suicidal thoughts and requested voluntarily commitment to a psychiatric facility.
*The urinalysis laboratory report dated 4/25/12 was positive for opiates. He had admitted to using Tylenol with codeine last weekend when shown the laboratory reports.
*The laboratory chemistry report dated 4/25/12 revealed a high alcohol level of 85; the normal range being 0-80 mg/dl.

Review of patient 14's nursing documentation on 4/25/12 at 5:40 p.m. revealed:
*PA F had contacted the Yankton mental health services, and they would accept the patient pending the certified medical professional results.
*The "Patient was discharged to jail with police officer to probably be transported to Yankton in AM."

Review of patient 14's physician progress notes completed by PA F on 4/25/12 at 6:18 p.m. revealed:
*He had active warrants and had turned himself in to law enforcement. At that time he started talking about having suicidal thoughts.
*His plan included cutting his neck or wrists, or choking himself. He had attempted four to five times in the past (three times with pills).
*He was having relationship problems with his girlfriend and trouble finding a place to stay because of self-choking.
*There was no documentation the physician had been notified to complete a certification of qualified mental health professional or physician certificate. The certificate could not be found in the patient's medical record.
*He had been accepted for inpatient psychiatric services on 4/27/12 in Yankton. Law enforcement would arrange transportation and time of transfer.

Interview on 7/10/12 at 2:50 p.m. with the DON regarding patient 14 confirmed:
*The certification of qualified mental health professional or physician certificate completed by a physician could not be located in the patient's medical.
*The patient had been taken to jail by law enforcement and would be transported on 4/27/12 for inpatient psychiatric treatment as arranged by PA F.

Review of the provider's policies and procedure's manual revealed there was not a policy or guidelines for the legal documentation completed by a qualified mental health professional or physician when an individual with a serious emotional disturbance was brought in for a mental health evaluation prior to detention at an appropriate facility to receive mental health services.